Cystectomy: What it is, why it’s done and what to expect

A cystectomy is the complete surgical removal of the bladder. It is used primarily to treat bladder cancer. But it can also be used to treat prostate cancer and urethral cancer, as well as gynecologic cancers and colorectal cancers that have spread to the bladder, in some instances. It is used to resolve complications stemming from other cancer treatments, too.

But can you really live happily without a bladder? If so, how do you urinate? And, how does a cystectomy affect your sex life? Read on to learn the answers to these and other questions I often hear from my patients.

What happens during a cystectomy?

That depends on which type you’re having and whether it will be performed using a minimally invasive method or through open surgery.

With a simple cystectomy, only the bladder is removed. With a partial cystectomy, only a part of it is removed. With a radical cystectomy, though, nearby lymph nodes are removed, too. Men will often have their prostate gland and seminal vesicles removed as well. That’s because there’s a high chance that the section of urethra which passes through the prostate will already be involved at the time the bladder is removed, and it’s a potential site for recurrence later on. Women may have their ovaries, fallopian tubes, uterus or other structures removed, too.

Depending on the stage and type of cancer you’re being treated for, a cystectomy may be part of a larger operation called a total pelvic exenteration. That’s a procedure in which additional organs and structures are removed from your pelvis, such as parts of your colon, vagina and tailbone.

What are cystectomies normally used to treat?

All bladder cancers — including urothelial carcinoma (the most common), squamous cell carcinoma and adenocarcinoma — can be treated with a radical cystectomy.

It can also be used to treat locally advanced or recurrent prostate cancer, as well as bladder fistulas (abnormal holes) and other complications of prior treatments.

Having your bladder removed seems pretty extreme. Are there any alternatives?

Sometimes, yes. But not everyone is a good candidate for those.

Intravesical therapy, in which the bladder’s inner lining is repeatedly washed with a medicated solution called Bacillus Calmette-Géurin (BCG), can be used for some cancers that haven’t invaded nearby muscles, commonly called muscle-invasive bladder cancer. Once that’s happened, though, the gold standard of treatment is a systemic therapy like chemotherapy or immunotherapy, followed by a radical cystectomy.

There’s also a “trimodal” treatment plan that involves a procedure called Trans-Urethral Resection of a Bladder Tumor (TURBT), followed by chemotherapy and radiation therapy. But it’s not ideal for all patients. It really depends on the type and stage of your cancer, as well as the tumor’s characteristics and your bladder function.

How do you urinate after a cystectomy?

After your bladder is gone, surgeons will create a new way for urine to leave your body. There are three options.

Ileal conduit

A small piece of small intestine is used to connect the tubes that drain urine from each kidney to an opening on the surface of your abdominal wall called a stoma. Urine will drain continuously into a collection pouch worn outside your body. This is by far the most commonly used option.

Neobladder

A larger section of your small intestine is used to create a pouch inside the pelvis where urine can collect. It’s hooked up to the ureters on one side and the urethra on the other, so urine will still exit your body in the conventional way. This option most closely resembles normal urination, but it still doesn’t function quite the same, so you’ll need to follow a timed schedule to void your urine until you relearn your body’s signals.

Indiana pouch

A reservoir is created inside the abdomen using part of the large intestine. It’s connected to your skin via a stoma and must be emptied several times a day with a catheter. This option is very rarely used.

Can you still have sex after a cystectomy?

Yes. You can still have an active and fulfilling sex life after a cystectomy. However, your sexual function is likely going to be different, especially if you’re a male. The nerves that control erections are wrapped around the prostate gland. So, even if you get a nerve-sparing cystectomy, it’s going to have an effect. If you already have baseline erectile dysfunction, this procedure could be just enough to tip you over the edge, where you can’t get a spontaneous erection anymore.

For women, it depends on whether you’re having adjacent organs removed. If the anterior wall of your vagina is taken out during a radical cystectomy or a TPE, for instance, penetrative sex may no longer be an option. The vaginal vault will simply not be long enough to accommodate a penis.

For some of our patients, this is not a problem, as retaining sexual function is not high on their priority list. But if it is for you, there are options available. They include implants and injections for men and reconstruction for women. If you’re a patient at UT MD Anderson, you can discuss these options with Run Wang, M.D., a urologist here who specializes in regaining sexual function after cancer treatment, or Kristin Rojas, M.D., a gynecologic oncologist who specializes in female sexual dysfunction.

What are the risks and benefits of a cystectomy?

The main risks of cystectomy are:

• Infection of the urinary tract or surgical incision
• Leakage from the urinary reconstruction or bowel connections
• Bowel complications, such as an ileus or obstruction
• Blood clots, including a deep vein thrombosis or embolism

Despite these risks, cystectomy offers the best chance of a cure for many people with bladder cancer. When performed at the right time, it can be life-saving. And, if only minimal disease remains at the time your bladder is removed, there’s a > 80% chance you will still be alive five years later.

How long does it take to recover from a cystectomy?

You can expect to remain in the hospital for between three and seven days afterward. The exact amount of time depends on how long it takes your intestines to “wake up.” They kind of go on strike when they’re manipulated in this way, so it takes them a few days to recover. You’ll need to stay in the hospital until that happens, generally until you start passing gas and stool again.

If you have a desk job, you can usually return to work in about three or four weeks. But if your job involves manual labor, you’ll need between six and 12 weeks to fully recover. Most patients are 80% to 90% back to their baseline by the 12-week follow-up visit.

What’s the one thing you should know about cystectomies?

Cystectomies are major surgeries, but they can also be life-saving. And while I’ve never met a patient who was excited to hear they needed one, you can live happily for decades without a bladder if your cystectomy is done right.

Here at UT MD Anderson, our bladder cancer specialists perform multiple cystectomies a week. So, our surgeons are very experienced.

We also have a whole team of specialized providers to help you, including ostomy nurses who work with you before and after the surgery, clinical nurses who are very familiar with these procedures and know what to look for in case of a problem, and internal medicine specialists to help you manage any other health conditions you might have. So, it’s very worthwhile to come to a place like UT MD Anderson for your cystectomy.

Kelly Bree, M.D., is a urologist at UT MD Anderson with a special interest in sexual function after cystectomy.

Request an appointment at UT MD Anderson online or call 1-877-632-6789.