Actos Bladder Cancer : While still awake, you will be transferred onto the operating room table and secured on it. If an epidural has not already been placed, one may be inserted. You may have an additional intravenous line placed. Next, your anesthesiologist will have you breathe through a mask placed over your nose and mouth. You will be given a mixture of agents which will allow you to become relaxed. Further anesthetics will result in an unconscious state. At this time, an endotracheal tube will be passed down your windpipe to provide oxygen, which is delivered automatically by a respirator, controlled by the anesthesiologist. The anesthesiologist will continuously monitor your heart rate, blood pressure, electrocardiogram, and tissue oxygenation throughout your operation.
Fluid balance may also be measured via an intravenous line passed close to your heart. Urine output will be followed. Antibiotics will be infused intravenously. Usually, compression stockings will be secured around your legs. These stockings periodically squeeze the legs to prevent blood from becoming stagnant, lowering the risk of blood clots forming in your legs, which can occur when you lie completely motionless for extended periods of time. A nasogastric tube will be passed through your nostril down your esophagus into the stomach, draining the stomach secretions during and after the surgery. A grounding pad will be placed on your side to allow for the safe use of electric current which is used to sometimes cut tissue and often in the cauterization of small bleeding vessels to stop bleeding.
Your abdomen will be prepared for surgery by shaving any hair and prepping the skin with an antiseptic solution. Female patients will have the vagina prepped with antiseptics as well. The surgical field will then be draped with sterile towels and sheets to prevent contamination from surrounding non-sterilized areas. Your upper body may be kept warm with a warming blanket. Your surgical nurse, surgeon, and assistant will all have thoroughly cleaned their hands and arms (scrubbed) and will then don a sterile gown and gloves. Their hair will be covered with a surgical cap, and they will be wearing masks over their mouths to prevent any contamination of the sterilized surgical field.
The standard operation is called Radical Cystectomy. This operation is accomplished through an incision which extends down the middle of the abdomen beginning at the level of the umbilicus and extending down to the pubic bone. The peritoneum (the sac around your intestines) is opened. The surgeon will examine the abdomen to make sure there is no evidence of cancer spread. Removal of the lymph nodes from the pelvis around the bladder is accomplished. The bladder is removed in its entirety along with the prostate and seminal vesicles in the male. In the female, the uterus and vagina are adjacent to the bladder and may be involved with local spread of cancer beyond the bladder. Consequently, the uterus and part of the vagina are removed. Since most females having a cystectomy are well past menopause, the ovaries are also removed, thus avoiding the possibility of future diseases including ovarian cancer.
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Once the bladder and surrounding organs are removed, the urinary tract must be reconstructed. This is most often accomplished by sewing the ends of the ureters into a piece of ileum (a section of small intestine) which is brought out through the skin as an ostomy. This form of reconstruction is called an ileal loop diversion. Since this reconstruction involves the urinary tract, the ostomy is referred to as a urostomy. Prior to sewing the ureters into the ileum, a biopsy of the ends of both ureters is examined by a pathologist to make sure there is no carcinoma in situ present. If cancer is found at the end of the ureter, this section is removed and the next higher level is examined by the pathologist to assure the ureter is free of cancer at the implantation site. If a neobladder is being planned, the prostatic urethra is examined by the pathologist to assure no cancer is present prior to proceeding further.
Transitional cell cancer extending into the urethra of a female patient or the prostatic urethra of a male patient would generally require urethrectomy at the time of cystectomy. Urethrectomy requires more dissection, potential for bleeding and infection, and possibly increased post operative drainage. It should therefore be performed only when necessary. Cancer located close to the bladder neck may raise the odds of cancer developing in a urethra which is left behind. The status of the urethra can be followed post cystectomy with washings sent for cytology. If cancer subsequently develops, a urethrectomy can be accomplished as a separate operation long after cystectomy has been done.
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At the conclusion of surgery, generally while still in the operating room, the endotracheal tube is removed when the patient is awake enough to breathe on his own. The patient will then be brought to the recovery room where he will be carefully observed by trained nurses in conjunction with the anesthesiologist and urologist. The individual is kept in the recovery room until conscious, breathing on his own and stable. Recovery room stays may be short, on the order of 30 minutes, or may extend to several hours, depending on how the individual is doing. If doing well, the patient will then be transferred to a floor in the hospital. If the individual’s surgery was particularly complicated, extended, or if the individual is unstable (irregular heart beat, low blood pressure, inability to be taken off the respirator), or if the individual has significant medical problems or has experienced a complication from surgery, transfer to an ICU (intensive care unit) may be warranted. In the ICU, there exists a much higher ratio of nurses to patients than on a standard postoperative floor, allowing for constant surveillance and care for critical patients. Also, if a respirator is required postoperatively, initial treatment in an ICU is usually necessary.
After transfer to the floor from the recovery room, the patient is often kept on bed rest for the rest of the day. The nasogastric tube is left in and placed to gentle suction to remove excess stomach fluids. Initially, nothing is allowed by mouth other than ice chips or sips of water. Adequate fluids and some nutrition are given via an intravenous catheter. By the following day, patients are often out of bed and sometimes walking with assistance. Sequential stockings on the lower legs are removed while ambulating, and discontinued once the individual is able to move about well. Traditionally, nasogastric tubes have been left in until the bowel activity returns (generally 3-4 days). This is generally heralded by the passing of flatus (gas) or the presence of active bowel sounds, which will be checked by your urologist with a stethoscope. Recent studies have indicated nasogastric drainage for this length of time may not be necessary and may impede normal breathing, leading to other problems. Some urologists are therefore removing the tubes earlier. Feeding is gradually introduced however, once bowel activity has returned.
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