Such serious surgical intervention as bladder removal is prescribed only in extreme cases - usually in severe oncological diseases of the organ, when chemotherapy and other auxiliary treatments do not lead to recovery of the patient.
The first operation to remove the bladder was carried out in the XIX century, and since then this method has been successfully used to eliminate cancerous tumors, papillomatosis, ectopia of the bladder. Such an operation is scheduled, except for urgent situations with bleeding.
Indications for the procedure
The operation of bladder removal is appointed when it is necessary to get rid of a pathological tumor - a tumor. Removal is a radical way to eliminate a malignant focus, but in recent years it is rarely used, because in the arsenal of modern medicine there are other, more gentle methods.
However, in some cases, the removal of the bladder in cancer is still carried out, and it is appropriate in such situations:
if the cancer is in the T4 stage, but there are no metastases;
with diffuse papillomatosis;
if there are several tumors in the T3 stage;
with the modification of the bladder against tuberculosis or interstitial cystitis.
Some clinics practice the removal of the bladder and in the early stages of development of oncology. Indeed, this approach allows you to get rid of the disease for sure and for a short period of time. However, such treatment is carried out only after a personal interview with the patient and with his consent.
Before proceeding to remove the bladder, the patient is examined to weigh the risk of complications and to ensure that there are no contraindications to the operation.
Preoperative preparation is carried out in stages:
The patient is taking blood for general and biochemical analysis to assess his overall health.
Blood is also taken to determine the level of glucose.
Assess the quality of blood coagulability.
Conduct an ultrasound examination of internal organs, chest X-ray.
A cystoscopy procedure is performed followed by a biopsy, in order to indicate the version of the anesthesia used and the technique of the operation.
6-7 days before the intervention, the patient is advised to switch to liquid, digestible food with a minimum of fiber.
For 36 hours before the intervention, eating is prohibited: the patient can drink only liquids in the form of tea, compote or juices (dairy products are banned).
24 hours before the intervention, the patient is cleared of the intestines, and also given diuretics.
On the day of surgery the patient does not take food.
Immediately before surgery remove (shave) the scalp from the inguinal zone and the abdominal region to exclude the possibility of infection in the wound.
Most often, laparotomy is used to remove the bladder - this is a kind of surgery, in which healing is faster, and tissue trauma is minimal. The technique of carrying out such an operation consists of the following stages:
The surgeon treats the patient's skin at the site of the alleged punctures (incisions).
A special catheter is inserted into the urethra by means of which the urinary fluid will be excreted during the operation.
Using the arcuate suprapubic access, the surgeon uncovers and fixes the bladder.
The doctor opens the cavity of the bladder and examines it.
Further, the walls of the bladder are fixed, while in men the prostate gland is fixed.
If the ureters are not discharged outside and do not move to the part of the intestine, they are cut off in the area of healthy tissue.
The doctor conducts a catheterization.
In men, the vas deferens are bandaged (this is done carefully so as not to disrupt intestinal integrity).
The bladder is pushed back and forth, bandaged, crossed by the pubic-vesicle and pre-tubercular ligament, and the urethra (in men this is done with caution, as one can touch the prostate located next to it).
The doctor removes the bladder, places the bleeding sites, sips the vessels, and establishes drainage.
Through an external opening in the abdominal wall, the surgeon inserts a catheter-reservoir into the urethra, forming a new bladder.
The surgeon sutures the wound (layer by layer), leaving a place for drainage, and impose a sterile bandage.
Methods for removing the bladder
Removal of the bladder, carried out with the help of laparoscopy, is more easily tolerated by patients, and the wound heals faster after such intervention.
As for the procedure for removing and replacing the bladder, then there are several ways:
If the organ is modeled from the site of the small intestine, then a length of approximately 600 mm is used: it forms a volume formation similar to the bladder, which is connected to the ureter and the urinary tract. This variant of the operation is considered to be the most acceptable, since later the patient will be able to empty the bladder in a natural way. But this operation is not shown to all patients. For example, if a patient has tumors of the urethra or intestine, or he suffers from acute enterocolitis, then the gut can not be used for transplantation.
If the outlet for outflow of urine is taken outward in the area of the anterior wall of the stomach, a new intestinal container is simultaneously created, which the patient will periodically have to release using a special catheter.
If the ureter is connected to the small intestine, the intestinal loop can be withdrawn, and urine will be collected in a suspended reservoir. The second variant of such a connection is the excretion of the ureteral mouth into the intestinal cavity: in patients in this case, urine will be excreted from the body through the rectum, simultaneously with the calves.
Features of bladder removal
Removal of the bladder in men has some features. So, given the specific nature of the anatomical structure of the genitourinary system in the male body, catheterization should be done very carefully and carefully. The fact is that in the absence of experience, the medical specialist may have problems with the introduction of the catheter, because the male urethra is relatively long (23-25 cm), narrow and has two natural constrictions. As a result, the catheter does not pass freely.
Especially, one should be careful when introducing a metallized catheter: manipulation with such a tool is difficult, and with inaccurate use, it is easy to damage the mucosa of the urinary tract. This can lead to bleeding and even to perforation of the walls of the urinary canal. Given this, it is preferable to use a soft disposable catheter.
In addition, with radical removal of the bladder, the men also remove the nearest lymph nodes, the prostate and seminal vesicles.
Removal of the bladder in women is combined with resection of the urethra, ovaries, uterus and anterior vaginal wall. The surgeon has to eliminate other organs because in most cases the cancer cells germinate in the nearby organs: the prostate gland in men, the uterus and the appendages of a woman.
Removal of the uterus and bladder is a forced measure that allows to give a relative guarantee that the malignant process will not reoccur - that is, does not recur. Unfortunately, often the cancer spreads and germinates quickly enough, and malignancy arises even in those organs that, when diagnosed, appear to be healthy.
But the removal of the kidney and bladder is also considered a fairly rare operation, although with the kidney disease the whole urinary tract can suffer. If the tumor process (more often - transitional cell carcinoma) affects the pelvis of the kidney and ureter, it is not necessarily that it will spread to the bladder. According to statistics, this happens only in 1% of all cases of malignant lesions of the kidneys and upper urinary tract.
Many patients ask the following question: if the tumor is small and does not grow into neighboring organs, can you remove the part of the bladder rather than remove it entirely? Indeed, such operations are conducted, and they are called simple, or non-radical. However, they are rarely done, only to some patients with superficial bladder cancer. Partial removal of the bladder often leads to relapses - repeated development of the cancer process, and the operation itself is classified as difficult and can be accompanied by various unforeseen circumstances.
One of the options for partial resection is the removal of the neck of the bladder - an endoscopic procedure that is performed transurethral - through the urethra. Such an operation is performed with inflammation of the neck of the organ, in the presence of cicatricial changes in the tissues. For the procedure, a special loop is used, heated by an electric current to a high temperature. With the help of a loop, the surgeon cuts the affected tissue and simultaneously cauterizes the damaged vessels, stopping the bleeding.
If the neck of the bladder is affected by a cancerous tumor, then in the vast majority of cases the doctor will not consider the possibility of partial organ removal. Radical resection is considered more acceptable in terms of complete cure for cancer pathology.
Contraindications to the procedure
You can not remove the bladder. This operation is prohibited:
if the patient is in serious condition;
if the patient has serious cardiovascular diseases, in which general anesthesia becomes impossible;
if the patient suffers from a disease that can subsequently lead to complications - during or after surgery;
with violations of blood coagulability, which can lead to the development of bleeding or thrombosis;
at infectious diseases in an acute stage.
Consequences after the procedure
The main consequence of the removal of the bladder is the emerging problem of excretion of the urinary fluid. Doctors are forced to create in the body detours for urinary outflow, as well as think through the possibility of installing containers for its collection.
The ways of urine output can be different, depending on the characteristics of the disease and the type of surgery, as well as many other reasons.
Similar problems are deprived only those patients who have been transplanted the site of the small intestine to the place of the bladder. The element of the bowel, playing the role of a urea, completely returns a person the ability to excrete urine from the body in a natural way.
However, it is not always possible to use part of the intestine: often the urine collection container is led out, limiting the free flow of fluid to a special valve. The patient periodically should independently catheterize the outlet and release the reservoir.
In some cases, the ureters themselves can be withdrawn outward: after such an operation, the patient is forced to use special receivers for urine, which are fixed to the skin immediately near the outlet.
Complications after the procedure
Most of the above ways to remove urine from the body are not perfect, but they still help the patient to solve the problem with urination. Among the possible postoperative complications are hemorrhages, attachment of infection - however, in a hospital environment such difficulties are rare.
Much more often the patient faces other complications, already being at home:
ureters can be hammered;
there may be incontinence due to a blockage or a defect in the valve;
can occur inflammation of the output pathways;
ways can be blocked by purulent discharge or mucus;
tubes and catheters can slip out and even leak.
How to solve such problems, the doctor will tell. Close people who live with an operated person should have a lot of patience and optimism to support the patient and help him when necessary.
Care after the procedure
The doctor in charge will inform you about the peculiarities of the patient's postoperative care. Immediately after the operation, the patient is placed in the intensive care unit, and after stabilization of the condition - in the department of urology. Approximately for 3 weeks, antibiotic therapy will be performed against the background of taking analgesics.
Drainage, established during the operation, is removed during the first few days. The patient can be discharged home after 10 days.
At home, the patient must independently monitor his state of health. It is necessary to inform the doctor immediately:
if the temperature has increased;
if postoperative pain intensified, reddening or bleeding from the wound appeared;
if vomiting occurs periodically;
If after taking pain medication does not become easier;
if the smell of urine has changed, pus appeared from the catheter;
if there were pains behind the sternum, a cough with difficulty breathing.
If you call a doctor in time, you can avoid many complications.
Life after removal of the bladder
After the patient is removed from the bladder and discharged from the hospital, his life almost returns to its original course. The only thing that changes is the urination process. From time to time, the patient will have to replace the urine collection, empty the receptacle with urine, process the place of excretion of the intestinal loop or container.
If the patient was shaped like a bladder from the intestinal wall during surgery, then the life of the operated person will be much more comfortable. During the first 12-15 days urine will be taken to a special urine receiver, as long as the "new" bladder with the urinary system is healing. Next, the doctor will wash the bladder with a disinfectant solution, remove the drainage tubes, catheters and seams. From that moment the patient can actually return to his habitual way of life.
Diet after removal of the bladder
Nutrition after removal of the bladder changes not too drastically. To eat the patient is allowed already on the second-third day after the intervention - it depends on the degree of damage to the intestine during the operation.
Doctors advise to remove from the diet fried, sharp and fatty foods. Dishes should contain a protein component, as well as enough vitamins and microelements, for the speedy recovery of the body. Under the ban fall alcoholic beverages, smoking, a large amount of salt and spices.
What you can eat after removing the bladder?
During the first 2-3 days after resection, as a rule, the patient is allowed to take only easily assimilated rubbed food: broths, light soups, liquid porridges - in small amounts. From drinks are allowed: weak tea, compote, jelly.
Then the menu is gradually expanded. To adjust the function of the intestine, the diet is gradually introducing fiber and sour-milk products. We welcome the use of vegetable side dishes, baked fruit, cereals (you can with dried fruits), low-fat meat and fish. For dessert, you can prepare cottage cheese, fruit, yogurt, jelly.
The amount of fluid consumed per day should be discussed with your doctor.
Sex after bladder removal
Doctors recommend during the first 1-1,5 months after the operation to refuse sexual contacts. But with all the recommendations of the doctor in the future, sexual life can be resumed.
It is important to pay attention to such moments:
sometimes during the operation, nerve endings may be affected, which can lead to loss of erectile function in men;
in some patients, after bladder removal, dry ejaculation is observed, which does not indicate a loss of orgasm;
in women after surgery, the vagina may be narrowed, which will create certain difficulties in sexual intercourse, and also affect the possibility of sensation of orgasm.
Each case of removal of the bladder is unique, so the opportunity to have sex should be considered in each patient individually. Without consulting a doctor in a similar situation can not do.
Disability after removal of the bladder
Disability to a person after removal of the bladder can be prescribed:
with a moderately limited ability to live or a significantly limited job opportunity;
with a pronounced and sharply expressed limitation of vital activity.
When submitting documents for disability registration, the patient should submit the results of general blood and urine tests, as well as information on histological and cystoscopic research, which allows to determine the prevalence of malignant process.
The third group of disability is assigned to persons with moderate limitation of vital activity with a low incontience of urine.
The second group is assigned in the presence of a postoperative urinary fistula in the anterior abdominal wall, as well as inefficient radical treatment with tumor recurrence.
The prognosis for a person who has had an operation to remove the bladder depends on whether the intervention was timely and to what extent. In most patients, such a prognosis is considered favorable. Life expectancy in operated patients can be dozens of years, provided all the recommendations of the doctor are observed.
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Medical expert editor
Portnov Alexey Alexandrovich
Education: Kiev National Medical University. A.A. Bogomolets, Specialty - "General Medicine"