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Radical cystectomy with construction of Bricker bladder


Medical editor Bjørn Brennhovd MD
Urologist

Oslo University Hospital

General

A radical cystectomy is standard treatment of muscle-infiltrating urothelial cancer of the bladder. This operation is also relevant for certain high risk groups of superficial cancer. 

Construction of Bricker bladder (cutaneous uretero-ileostomy ad modum Bricker) may be performed with open surgery or robot-assisted laparoscopy.

A segment of ileum about 25 cm long is used for bladder substitution. The ureters are anastomosized to the oral end of the ileum segment. The anal end is prepared as an abdominal stoma (incontinent), usually in the right iliac fossa. The urine will continually drain from the stoma and collect into a urostomy bag. An ideal stoma is about 2 cm high. This allows for easy attachment of the stoma bag and also keep urine from seeping out on the skin under the bag, causing skin problems. This can in turn also cause the bag to fall off.

Indications for radical cystectomy

  • T1 tumor with deep invasion of lamina propria
  • T1 tumor with accompanying carcinoma in situ
  • Extensive T1 tumors
  • Recurring T1 tumors
  • Muscle infiltrating urothelial cancer in the bladder without detectable nodal metastasis 

Goal

  • Curative treatment
  • Palliative treatment for local problems from the bladder and where there are bone or nodal metastases

Equipment

  • Laparotomy tray  
  • Bookwalter's retractor 
  • Pigtail catheters Ch. 7–9, x 2
  • Optionally robot

 


Preparation

Preoperative preparation of the patient

  • Marking for stoma before the operation
  • Antibiotic prophylaxis
  • Thrombosis prophylaxis
  • Preoperative hair removal for abdominal incision

Preoperative preparation in the operating theatre

  • Operating table appropriate for patient and type of surgery
    • Men: square drape, penis free
    • Women: back/leg supports
  • Diathermy
  • Suction
  • Insertion of Foley catheter

Implementation

  • The abdominal cavity is opened using a long midline incision, or the operation is performed with a robot with removal of the urinary bladder and lymph nodes before urinary diversion. 
  • The ureters are identified on both sides and clamped towards the bladder.
  • The peritoneum is opened around the bladder.
  • Proceed to the midline and identify the layer between the bladder and the rectum.
  • The side ligaments are defined, ligated, and divided with a stapling instrument.
  • Proceed to the front and open the endopelvic fascia

Removal of the primary specimen 

  • In men, the neurovascular bundle is cut on both sides of the prostate using a sharp scissors, and the nerves are spared as much as possible to preserve erectile function.  
  • In women, the length of the vagina is spared as much as possible.
  • Proceed back to the urinary bladder. Maintain a good margin until the specimen is removed. 

Cutaneous u reteroileostomy ad modum Bricker

  • Isolate a segment of small intestine about 30 cm long.
  • Construct a Wallace anastomosis between the ureters and oral end of the segment. 
  • Construct a regular eversion ileostomy.
  • Pigtail catheters are inserted to the renal pelvis bilaterally and out through the intestinal segment during the procedure. 
  • Resume the intestinal continuity as a side-to-side anastomosis with a stapling instrument and reinforce with sutures, if necessary.
  • Check that the anastomosis lies without tension and that the color of the intestinal sections are acceptable. 
  • Insert the vacuum drain down in the pelvis.
  • Close the abdominal cavity with monofilament continuous sutures.
  • Send the specimen for a histological examination. 

 

 


Follow-up

Postoperative observations

  • Circulation in the stoma
  • Sutures, bandage, and skin around the stoma
  • Urine drainage
  • The vaccum drain can be removed as indicated by the surgeon
  • The pigtail catheters can be removed on the 10th postoperative day.
  • Sutures in the incision can be removed 12-14 days postoperatively (with the primary care doctor) 

Training 

On the second postoperative day, the patient's training on stoma care will be initiated. The patient should be trained every day or every other day according to the needs of the patient. The patient should be able to take care of the stoma alone upon discharge. Anbefalt kontrollregime

Recommended follow-up

The patient should have follow-up by a specialist 3 and 6 months after the surgery. Thereafter, checks should be with 6 month intervals over a period of 5 years. After 5 years, follow-up can be taken over by the primary care doctor.

Evaluation should include

  • Clinical examination with palpation of the abdomen and transrectal exploration
  • Blood tests: Hb, creatinine, ALP, venous acid-base test (should be followed closely for tendency of increasing creatinine), vitamin B12 (followed from 2 years) 
  • Thoracic X-ray (after 2 years x 1 annually)
  • CT urography should be performed after 3 months and 1 year. If these are satisfactory, CT urography should be performed later upon indication (hematuria, clinical UVI, flank pain). Somewhat more liberal CT urography is performed for Tis. For monitoring of hydronephrosis, ultrasound of the kidneys is an alternative.
  • Urine for cytology

 


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