Reconstructing Urinary Function After Bladder Removal
Froedtert & the Medical College of Wisconsin offer patients with bladder cancer a unique team-based approach to bladder surgery. The surgical care team includes a fellowship-trained cancer surgeon and a fellowship-trained reconstructive surgeon who is skilled in a variety of techniques for restoring urinary function. The specialists carefully coordinate treatment to help ensure each patient achieves the best outcome — cancer control with successful reconstruction.
The reconstructive surgeon works with each patient to explain options, understand preferences and set realistic expectations. In general, there are three ways to reconstruct urinary function following bladder removal:
A urinary conduit provides a simple means for bringing urine outside the body. First, the surgeon detaches a short segment of the small bowel from the rest of the intestines. The ureters are surgically attached to one end of the bowel segment, and the other end is brought out through an opening made in the lower abdomen. The patient wears a urostomy bag, which must be emptied periodically. Urinary conduit is the most common urinary reconstruction. In general, a urinary conduit is the best option for elderly patients or those with significant health issues.
A neo bladder is a “new bladder” constructed using the patient’s own tissue. First, the surgeon takes a segment of the small bowel (approximately 22 inches) and fashions it into a spherical pouch. The ureters and the urethra are then attached to the pouch. Urine flows from the kidneys, through the ureters, to the “new bladder” and is expelled normally through the urethra. With a neo bladder, patients do not feel the same urge to urinate as they are used to.
As the bladder fills, the patient will experience a sensation like bowel cramping. Expelling urine requires a combination of relaxing the pelvic muscles and slightly straining the abdominal muscles. Almost all patients are incontinent following surgery. As a patient builds up the strength of his or her pelvic muscles with Kegel exercises and works on extending the time between urinations, the neo bladder will expand.
After about one year, more than 80 percent of patients are able to regain daytime continence. Reestablishing nighttime continence can take a few years, with approximately two-thirds of patients able to achieve complete nighttime dryness. In general, younger and healthier patients are the best candidates for this reconstruction.
A neo bladder is not possible for patients whose cancer has spread to the urethra or ureters. In addition, patients with chronic kidney disease are not good candidates for the procedure.
This reconstruction creates a urine “reservoir” that the patient drains with a catheter. First, the surgeon constructs the reservoir using a portion of the large bowel. Next, the ureters are attached to the reservoir. The terminal portion of the small bowel is then used to form a channel from the reservoir to an opening created in the lower abdomen. The patient inserts a catheter into the opening to drain the urine. Most patients need to drain their reservoir pouch every four to six hours. At first, patients may need to drain it more frequently, but many are eventually able to reduce frequency to four times a day.
Potential problems include difficulty inserting the catheter and leaking. In addition, the pouch needs to be rinsed periodically to prevent mucus build-up. Like the neo bladder reconstruction, the catheter pouch is more suitable for younger and healthier patients, and chronic kidney disease rules out this option. In addition, patients with colitis and colonic polyps are not good candidates for a catheter pouch.