Radical cystectomy

What is Anterior Exenteration or Radical Cystectomy?

Anterior exenteration or radical cystectomy is a major surgical procedure employed for the treatment of cancers of the anterior pelvic organs such as the reproductive organs and urinary bladder present in the front part of the pelvis. The procedure involves removal of the reproductive organs and urinary bladder along with the lymph nodes for treatment of cancer that has spread to the nearby tissues, and creation of a new opening for urine to exit called a urostomy.

Indications for Anterior Exenteration or Radical Cystectomy?

Anterior exenteration or radical cystectomy is usually indicated to treat cancers of the pelvis in individuals who:

Have already received treatments for cancer
Have recurrence of cancer following previous treatment
Have had no cure from initial cancer treatment
Have cancer confined to anterior pelvis and has not spread elsewhere
Want permanent relief from some of the symptoms associated with the cancer

Preparation for Anterior Exenteration or Radical Cystectomy

Pre-procedure preparation for anterior exenteration or radical cystectomy will involve the following steps:

A thorough examination is performed by your doctor to check for any medical issues that need to be addressed prior to surgery.
Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could threaten the safety of the procedure.
You will be asked if you have allergies to medications, anaesthesia, or latex.
You should inform your doctor of any medications, vitamins, or supplements that you are taking.
You should refrain from medications or supplements such as blood thinners, aspirin, or anti-inflammatory medicines for 1 to 2 weeks prior to surgery.
You should not consume any solids or liquids at least 8 hours prior to surgery.
You will be placed on a special diet prior to surgery and laxatives may be used to clean out your bowel.
You may be instructed to shower with an antibacterial soap on the day of your surgery to help lower your risk of infection after surgery.
You should arrange for someone to drive you home after surgery.
A written consent will be obtained from you after the surgical procedure has been explained in detail.

Procedure for Anterior Exenteration or Radical Cystectomy

The surgery is performed under general anaesthesia with open surgery. Your surgeon will make a long vertical incision starting at the top of the pubic hairline and going up to the belly button or umbilicus and sometimes above the umbilicus. The inside of the abdomen is carefully examined to ascertain the spread of cancer. Depending on the extent of cancer spread, the affected pelvic organs including the bladder and lymph nodes, urethra, and reproductive organs such as the uterus, ovaries, fallopian tubes, and part of the vagina in women and prostate and seminal vesicles in men are removed accordingly.

When the urethra and bladder are removed, a urinary diversion, also known as a urostomy, becomes a necessity for urine to exit the body. During the urinary diversion procedure, your ureters and kidneys are attached to the urinary diversion that exits through an opening in the abdominal wall. Two types of urinary diversions with stomas (artificial opening) can be made: a urinary pouch and an ileal conduit. In a urinary pouch, a drainage catheter tube is placed in the stoma to drain the urine. In an ileal conduit, a collection bag is attached around the stoma to drain the urine. Vaginal reconstruction using skin graft and/or muscle flap from other parts of the body may also be performed. At the end of the procedure, the incision is closed with absorbable sutures and sterile dressings are applied.

Postoperative Care and Recovery

In general, postoperative care instructions and recovery after anterior exenteration or radical cystectomy will involve the following steps:

You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anaesthetic reactions and monitor your vital signs as you recover.
As it is a major surgery, you will likely require 7 to 10 days of hospital stay before discharge to home.
You may experience pain, inflammation, and discomfort in the operated area. Pain and anti-inflammatory medications are provided as needed.
Antibiotics are also prescribed as needed to address the risk of surgery-related infection.
Walking and moving around in bed is strongly encouraged as it lowers the risk of blood clots and pneumonia. It also helps to stimulate your bowels and assist with passing gas.
Your diet is slowly advanced post surgery. You will start with clear liquids, then progress to having normal solid foods, as tolerated.
It is important to keep the surgical site clean and dry. Instructions on surgical site care, stoma care, urine collecting bag/pouch, and bathing will be provided.
Refrain from smoking for a specific period of time as it can hinder the healing process.
Refrain from strenuous activities and lifting anything heavier than 10 pounds for the first couple of months. Gradual increase in activities over a period of time is recommended.
Eating a healthy diet rich in low fat and high-fibre is strongly recommended to promote healing and faster recovery, as well as drinking 8 to 10 glasses of water daily to prevent constipation. Laxatives or stool softeners may also be recommended as needed.
You may need to take off from work for at least a couple of months to rest and promote healing.
Walking is a good exercise and is strongly recommended to improve your endurance.
Refrain from driving until you are fully fit and receive your doctor’s consent.
You will be able to resume your normal activities within a couple of weeks but may have certain activity restrictions.
A periodic follow-up appointment will be scheduled to monitor your progress.

Risks and Complications

Anterior exenteration or radical cystectomy is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as:

Infection
Bleeding
Hematoma (accumulation of blood in the wound)
Seroma (accumulation of clear fluid in the wound)
Damage to surrounding soft tissue structures, such as nerves, vessels, and organs
Post-procedure pain, requiring narcotics for relief
Blood clots or deep vein thrombosis (DVT)
Pneumonia
Bladder problems
Anaesthetic/allergic reactions
Kidney problems