A radical cystectomy is standard treatment for muscle infiltrating urothelial cancer in the bladder. This operation is also relevant for certain high risk groups of superficial tumors.
Orthotopic bladder substitute
An orthotopic reconstruction using intestinal tissue connected to the urethra has been implemented mostly on male patients, but in later years, the operation has been increasingly used on female patients. The reconstruction is performed using a 50-60 cm long isolated intestinal segment. The intestinal reservoir is emptied using abdominal pressure, relaxation of the pelvic floor, or intermittent catheterization. The majority of patients will experience encumbant nighttime incontinence and lacking or incomplete emptying. In the long term, many develop difficulties emptying the bladder and require self catheterization.
Contraindications for an orthotopic bladder substitution are tumor involvement of the prosthatic urethra, extenstive Tis, high preoperative radiation dose to the pelvis, and longer urethral strictures. A bladder substitution is contraindicated if the patient is not willing to accept that self catheterization may be necessary as well as the risk of urinary incontinence.
The indications for a radical cystectomy are:
- T1 tumor with deep infiltration of lamina propria
- T1 tumors with accompanying carcinoma in situ
- Extensive T1 tumors
- Recurring T1 tumors
- Muscle-infiltrating urothelial cancer without detectable lymph node metastasis or distant metastasis