RADICAL CYSTECTOMY PARTIAL CYSTECTOMY

Partial cystectomy - Indications :
Primary, solitary bladder tumours at a site that allows 2cm of normal tissue around it to be removed in a bladder that will have adequate capacity and compliance after operation. There should be:
- no prior history of bladder cancer
- no carcinoma in situ
- a solitary muscle-invasive tumour located well away from the ureteral orfices which includes 2cm of normal surrounding bladder

High-grade tumours should not be excluded if these criteria are met. The lesions most commonly amenable to partial cystectomy are G2 or G3 TCCs or adenocarcinomas located on the posterior wall or dome.

Contraindications : Associated carcinoma in situ; deeply invasive tumours; tumours at the bladder base (i.e. near the ureteric orifices).

Radical cystectomy - Indications :
- Muscle-invasive bladder cancer
- Adenocarcinoma of bladder (radioresistant)
- Squamous carcinoma of bladder (relatively radioresistant)
- Non-muscle-invasive TCC bladder which has failed to respond to intravesical chemotherapy or immunotherapy
- Recurrent TCC bladder post radiotherapy

Combined with urethrectomy if:
- multiple bladder tumours
- involvement of bladder neck or prostatic urethra

Anaesthesia :
General

Post-operative care and common post-operative complications and their management :
Monitor cardiovascular status, urine output, and respiratory status carefully in the first 48h. Routine chest physiotherapy is started early in the post-operative period to reduce the chance of chest infection. Mobilize the patient as early as possible to minimize the risk of DVT and PE. Drains are removed when they stop draining. Some surgeons prefer to leave them for a week or so, so that late leaks (urine, intestinal contents) will drain via the drain track and not cause peritonitis. Try to remove the nasogastric tube, if used, as soon as possible to assist respiration and reduce the risks of chest infection. The patient usually starts to resume their diet within a week or so. If the ileus is prolonged, start parenteral nutrition.

Haemorrhage
Persistent bleeding which fails to respond to transfusion should be managed by re-exploration.

Wound dehiscence
Requires resuturing under general anaesthetic.

Ileus
Common. Usually resolves spontaneously within a few days.

Small bowel obstruction
From herniation of small bowel through the mesenteric defect created at the junction between the two bowel ends. Continue nasogastric aspiration. The obstruction will usually resolve spontaneously. Re-operation is occasionally required where the obstruction persists or where there are signs of bowel ischaemia.

Leakage from the intestinal anastomosis
Leading to:
- Peritonitis requiring re-operation and repair or refashioning of the anastomosis
- An enterocutaneous fistula bowel contents leak from the intestine and through a fistulous track onto the skin. If low-volume leak (<500ml/24h), will usually heal spontaneously. Normal (enteral) nutrition may be maintained until the fistula closes (which usually occurs within a matter of days or a few weeks). If high-volume, spontaneous closure is less likely and re-operation to close the fistula may be required.