Urination After Removal of Cancerous Bladder
A diagnosis of bladder cancer, which is often very fast-growing, frequently leads to surgical removal of the organ. But without the bladder to perform the job of holding urine, the kidneys must be connected directly to a hole in the patient's skin, with a clumsy external bag that collects urine.
Three new reconstructive techniques, however, are allowing some cystectomy (bladder removal) patients a better postsurgical quality of life.
In the first, known as an ileal conduit, the surgeon cuts out a small section of the person’s intestine, creates a sac from it, and connects the kidneys to it. The urine is then routed through the sac to a hole (called a stoma) in the skin, where it collects in a small bag.
In the second reconstructive technique, known as a continent diversion, the doctor adds a valve to the newly created internal sac. After urine collects inside the sac, the patient pushes a catheter through the stoma and valve and draws off the urine.
The third procedure involves constructing a neobladder, which is also made from a section of intestine. The surgeon proceeds by removing a length of intestine; he then cuts it open, lays it flat, and sews it into the shape of a pouch. The surgical team sews the tubes from the kidneys (ureters) onto one end of the neobladder, and attaches it to the other end of the tube (urethra) that normally connects the bladder with the outside. In this scenario, the neobladder works rather like the original bladder, filling with urine until it is expelled through the urethra through the body’s normal external opening.
The neobladder, since it’s made of intestinal tissue, can’t exactly duplicate the way the bladder works. A bladder has muscle in its walls that expels the urine, but intestinal tissue does not. So patients are incontinent at first. Over the course of about six months, they gradually learn to use other muscles, in the pelvis area, to expel the urine. They must practice pelvic exercises daily to hold and control the flow of urine from the neobladder. Following surgery, patients must pass urine about every two hours during the day and every three hours at night. But with the muscle exercises, these times trend more toward the normal range.
An added bonus for patients requiring cystectomy is a new robotic-surgery technique that makes do with a smaller incision, leads to less blood loss, and produces fewer postsurgical complications. In traditional bladder removal, the surgeon must open a large incision, from below the bellybutton to the pelvic bone. Quite a lot of blood is lost, and a high risk of complications ensues.
Indeed, researchers say that up to 50 percent of patients undergoing open surgery for bladder cancer experience some sort of complication. Use of the surgical robot, however, reduces these problems. Moreover, for a man, the robot helps the surgeon spare the nerves that control erection.
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