Radical Cystectomy – Male Conduit

What does this procedure involve?

Removal of your bladder, prostate and local lymph nodes. The urine is then diverted into a section of bowel which is brought to the skin surface as a stoma (ileal conduit, also known as a urostomy).

What are the alternatives?

Radical radiotherapy – if, for any reason, a decision has been made that you should not undergo surgery
BCG instillation into the bladder – only indicated for high-grade non-muscle invasive cancer; not for muscle-invasive disease
Radical cystectomy with formation of a neobladder or construction of a catheterisable pouch – radical bladder removal but without an external urostomy
Systemic chemotherapy – drugs given by mouth or into your bloodstream; sometimes used before radiotherapy or radical cystectomy

What happens on the day of the procedure?

Your urologist (or a member of their team) will briefly review your history and medications, and will discuss the surgery again with you to confirm your consent.

An anaesthetist will see you to discuss the options of a general anaesthetic or spinal anaesthetic. The anaesthetist will also discuss pain relief after the procedure with you.

We may provide you with a pair of TED stockings to wear, and we may give you a heparin injection to thin your blood. These help to prevent blood clots from developing and passing into your lungs. Your medical team will decide whether you need to continue these after you go home.

Some urology units admit you the day before your procedure to administer laxatives to clear your bowel; others will admit you on the day of surgery and will not use laxatives. Your urologist will advise on which protocol will be used.

Will I have any say in where my urostomy is sited?

Before your procedure we will arrange for you to see a Stoma Nurse Specialist. Their job is to help you decide on the ideal site for your stoma. They will then mark this on the skin of your abdomen. The surgeon needs to see this mark during the procedure, so it is important not to wash it off. If you wish, we will give you the opportunity to meet someone who already has a urostomy.

Details of the procedure

We use a general anaesthetic for the procedure
Your anaesthetist may also use an epidural or spinal anaesthetic to minimise any post-operative pain
You will usually be given an injection of antibiotics before the procedure, after you have been checked for any allergies
We normally perform the procedure through an incision in your lower abdomen (tummy) or using a laparoscopic (keyhole) approach with or without robotic assistance
We will remove your bladder, prostate, seminal vesicles (sperm sacs) and, if necessary, your urethra (waterpipe)
We may be able to preserve the nerves which control your erections but this is not always possible; you should discuss this with your urologist before the procedure
We stitch the ureters (the tubes which drain urine from the kidneys to the bladder) to a separated piece of small bowel and bring this out on the surface of the abdomen as a urostomy (usually an ileal conduit)
We re-join the ends of the small bowel from which the urostomy has been made
We close the wound with stitches or staples
We normally place one or more drains where the bladder has been removed and leave two small splints in the ureters, protruding from the end of your urostomy (pictured)
We attach a drainage bag to your urostomy
The procedure can take anything from two to six hours to perform, depending on how complex the procedure is and what approach (open or keyhole) is used
You should expect to be in hospital for seven to 14 days

Following radical cystectomy, some urology units have introduced Enhanced Recovery Pathways. These actually start before you are admitted to hospital. After your surgery, they are designed to speed your recovery, shorten your time in hospital and reduce your risk of re-admission.

We will encourage you to get up and about as soon as possible. This reduces the risk of blood clots in your legs and helps your bowel to start working again. You will sit out in a chair shortly after the procedure and be shown deep breathing/leg exercises. We will encourage you to start drinking and eating as soon as possible.

We normally remove your drains when they have stopped draining. The splints in your stoma will be removed 10 to 14 days after the procedure, sometimes after an X-ray along the splints shows that the ureters and bowel have been joined securely.

Are there any after-effects?

The possible after-effects and your risk of getting them are shown below. Some are self-limiting or reversible, but others are not. We have not listed very rare after-effects (occurring in less than 1 in 250 patients) individually. The impact of these after-effects can vary a lot from patient to patient; you should ask your surgeon’s advice about the risks and their impact on you as an individual:

After-effect	Risk
Inability to ejaculate (or father children) because your sperm-carrying mechanism has been removed	All patients
Inability to get an erection (impotence)	Almost all patients (unless the nerves can be preserved)
Your cancer may not be cured by the procedure (this possibility will have been discussed with you before the operation)	Between 1 in 2 & 1 in 10 patients
Blood transfusion	Between 1 in 2 & 1 in 10 patients
Paralytic ileus (failure of your bowel to work) for several days causing nausea, bloating & vomiting, and requiring an intravenous drip and stomach drainage tube through your nose until it recovers	Between 1 in 2 & 1 in 10 patients
Anaesthetic or cardiovascular problems possibly requiring intensive care (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death)	Between 1 in 10 & 1 in 50 patients (your anaesthetist can estimate your individual risk)
Infection in your wound or an abscess in your abdominal (tummy) cavity	Between 1 in 10 & 1 in 50 patients
Decrease in kidney function over time	Between 1 in 10 & 1 in 50 patients
Need to abandon a keyhole procedure and convert to open surgery because of operative difficulties	Between 1 in 10 & 1 in 50 patients
Need to remove your urethra (waterpipe) as part of the procedure	Between 1 in 10 & 1 in 50 patients
Scarring, narrowing or hernia formation around your urostomy requiring revision	Between 1 in 10 & 1 in 50 patients
Need for return to theatres for re-operation due to bleeding, bowel leakage, urine leakage or bowel obstruction	Between 1 in 50 & 1 in 250 patients
Hernia of the incision (or keyhole ports) requiring further surgical repair	Between 1 in 50 & 1 in 250 patients
Diarrhoea/vitamin deficiency due to shortened bowel requiring specific dietary supplements or other treatment	Between 1 in 50 & 1 in 250 patients
Late stricturing (scarring) of the bowel or ureters requiring further surgery	Between 1 in 50 & 1 in 250 patients
Rectal injury at the time of surgery requiring a temporary colostomy (bowel opening on your abdomen)	Between 1 in 50 & 1 in 250 patients

What is my risk of a hospital-acquired infection?

Your risk of getting an infection in hospital is between 4 & 6%; this includes getting MRSA or a Clostridium difficile bowel infection. This figure is higher if you are in a “high-risk” group of patients such as patients who have had:

Long-term drainage tubes (e.g. catheters)
Bladder removal
Long hospital stays; or
Multiple hospital admissions

What can I expect when I get home?

You will be given advice about your recovery at home
You will be given a copy of your discharge summary and a copy will also be sent to your GP
Any antibiotics or other tablets you may need will be arranged & dispensed from the hospital pharmacy
By the time you get home, you should be able to perform “daily living” activities such as making a cup of tea, preparing food and emptying your stoma bag
You will feel tired for several weeks and may need to take regular “cat naps” during the day
We will arrange for the stitches or clips in your wound to be removed after 10 to 12 days
If you get a fever or start vomiting, especially if associated with unexpected pain in your abdomen, you should contact your GP immediately
A follow-up appointment will be made for you six to 12 weeks after your surgery

General information about surgical procedures

Before your procedure

Please tell a member of the medical team if you have:

An implanted foreign body (stent, joint replacement, pacemaker, heart valve, blood vessel graft)
A regular prescription for a blood thinning agent (e.g. warfarin, aspirin, clopidogrel, rivaroxaban, dabigatran)
A present or previous MRSA infection; or
A high risk of variant-CJD (e.g. if you have had a corneal transplant, a neurosurgical dural transplant or human growth hormone treatment)

Questions you may wish to ask

If you wish to learn more about what will happen, you can find a list of suggested questions called “Having An Operation” on the website of the Royal College of Surgeons of England. You may also wish to ask your surgeon for his/her personal results and experience with this procedure.

For several years, BAUS has collected data from urologists undertaking this surgery. You can view these data, by unit and by Consultant, in the Surgical Outcomes Audit section of the BAUS website.

Before you go home

We will tell you how the procedure went and you should:

Make sure you understand what has been done
Ask the surgeon if everything went as planned
Let the staff know if you have any discomfort
Ask what you can (and cannot) do at home
Make sure you know what happens next; and
Ask when you can return to normal activities

We will give you advice about what to look out for when you get home. Your surgeon or nurse will also give you details of who to contact, and how to contact them, in the event of problems.

Smoking and surgery

Ideally, we would prefer you to stop smoking before any procedure. Smoking can cause bladder cancer, increase the risk of cancer recurrence and make complications more likely after surgery. We strongly advise anyone with bladder cancer to stop smoking. For advice on stopping, you can:

Contact your GP
Access your local NHS Smoking Help Online; or
Ring the free NHS Smoking Helpline on 0300 123 1044

Driving after surgery

It is your responsibility to make sure you are fit to drive after any surgical procedure. You only need to contact the DVLA if your ability to drive is likely to be affected for more than three months. If it is, you should check with your insurance company before driving again.