In some types of bladder cancer, the only treatment is the removal of the bladder. When the bladder is removed, it is taken out along with its appendages, such as the prostate and seminal vesicles in men, and the uterus, ovaries, and a portion of the vagina in women. As mentioned in other sections of this site, removing lymph nodes from the correct location and in sufficient numbers significantly benefits the patient. (See: Why is the Removal and Number of Lymph Nodes Important?)
As noted in the bladder cancer section of the site, if bladder cancer penetrates deeply into the muscle layer of the bladder, or if there are numerous large tumors close to the muscle layer, or if the patient does not respond to TUR Tm surgery and BCG treatment, the likelihood of metastasis to distant organs is very high. In this extremely negative situation for the patient’s life, the only solution is to perform a surgery called “Radical Cystectomy” in urology.
How Do Patients Urinate After the Bladder is Removed?
The bladder (urinary bladder) is an organ that stores urine. Once the bladder is removed, where will the urine be stored, and where will it flow?
Many methods have been found for this purpose in urology, but the most commonly used method is called the “ILEAL CONDUIT.” This involves connecting the two ureters (urinary ducts) to one end of a 12-15 cm piece of small intestine, and the other end of the intestine is connected to the abdominal skin. The reason for using the intestine is that the two ureters alone cannot reach the skin. Therefore, a 12-15 cm piece of intestine is inserted so that the urine from the ureters flows into a bag attached to the abdominal wall, which patients empty through a tap as the bag fills up. This is the traditional method, and the bag needs to be replaced every 3-4 days.
This method has some undesirable outcomes besides the bag attached to the abdominal wall:
– The most notable is that 40% of patients, especially women, develop a hernia at the site of the bag attachment.
An important alternative to this old method, which has been applied in developed countries for the past 20 years and successfully implemented by us for the last 20 years, is the “ORTHOTOPIC BLADDER,” which is referred to as the ORTHOTOPIC BLADDER = BLADDER FROM INTESTINE method in urology. This is not actually artificial; it is a term that has stuck because our patients prefer it. If oncological conditions (except in cases where cancer has not advanced to the end points) are suitable, which can only be determined by examining the junction of the prostate with the external urinary tract (urethra) during surgery using the frozen method in the pathology unit. If the tumor persists at this point (which occurs in 5-8% of cases), the external urinary tract and urethra will also need to be removed, leaving no other option but the ileal conduit.
If the frozen examination shows no tumor at this end point (which is true in 92-95% of cases), an orthotopic bladder (artificial bladder) can be created. In this surgical technique, a new bladder is constructed from small or large intestines, or both. A 50 cm piece of intestine is separated and shaped into a “sphere” to resemble and function like the bladder (urinary bladder) and to carry out its tasks. Thus, its capacity, or internal volume, is expanded to store urine. The two ureters (urinary ducts) are connected to one end of the sphere-shaped intestine (anastomosed), and the other end of the new sphere-shaped intestine is anastomosed to the external urinary tract (urethra).
After this surgery, whether the patient leaks urine during the day depends on whether the urinary retention valve (sphincter) is damaged during the bladder removal surgery. If the surgeon is very experienced, such a complication will not occur.
The capacity of a normal healthy person’s bladder (urinary bladder) is around 400 ml, meaning a normal healthy person can hold their urine up to this level. Patients who have undergone artificial bladder (bladder from the intestine) surgery reach this bladder capacity in about 6 months.
Major Advantages of the Intestinal Bladder (Orthotopic Bladder) Method
1. “Not reducing quality of life” and “Being socially acceptable.”
2. After being diagnosed with bladder cancer, it takes much longer for the patient to agree to a major surgery (ileal conduit with a bag) compared to the orthotopic bladder, leading to the progression of the disease and the loss of critical time. Patients who learn about the orthotopic bladder alternative make the decision for radical cystectomy surgery much earlier, thus preserving critical time. According to the results of multi-center studies, the time to decide on surgery for patients recommended the bag method can reach up to 15 months, while this period is found to be 3 months for patients who hear about the orthotopic bladder alternative.
3. In every person (male/female), the tissue from where urine is born in the kidney to where it is expelled from the body is the same. Therefore, even after bladder removal (radical cystectomy), there is a possibility of tumor formation again in the 3-4 cm long urinary tract (urethra) after the bladder, whereas in those who have an orthotopic bladder (artificial bladder), the secretion from the intestines significantly reduces this risk compared to those with an ileal conduit (bag). According to studies conducted in urology centers in the USA and Europe, the occurrence rate is 11.2% in the bag method, while it is 3% in the artificial bladder method. This lost time severely affects the patient.
An operation performed by an experienced surgical team with the right technique should provide the following for the patients:
– Patients should not leak urine while awake during the day
– They should be able to urinate comfortably
– Their artificial bladder should be completely empty, with no residual urine
Expectations from Your Surgeon When Deciding on Orthotopic Bladder Surgery
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Who is Not Suitable for Orthotopic Bladder?
1. Patients who have previously received high-dose radiotherapy for testicular cancer, bladder cancer, cervical cancer in women, or for other reasons
2. Patients with liver failure or cirrhosis
3. Patients with chronic kidney failure or those in advanced stages of dialysis
4. Patients with spinal cord injuries and bladder cancer
5. Patients with dementia or Alzheimer’s disease
6. If the pathological examination (frozen) during surgery shows tumor persistence at the starting point of the external urinary tract in men or women, which occurs in 5-8% of cases
Lifespan of the Orthotopic Bladder
Another common question from our patients is whether the newly constructed bladder from intestines has a lifespan. There is no concept of the lifespan of an artificial bladder. As long as the patient lives, they will not experience any problems with their newly constructed orthotopic bladder. The oldest surgical operation we performed was 20 years ago. Therefore, we are still in contact with this patient, and they have no problems.
In the third year after surgery, a cystoscopic (endoscopic) examination of the artificial bladder of a patient we performed intestinal bladder surgery on showed that the bladder capacity was 500 ml and it was not easy to distinguish it from a normal healthy human bladder.
Post-Operative Process
Initially, they may not be able to hold urine for a reasonable time, but this lasts at most 2-3 weeks. Initially, we ask patients to empty their artificial bladder every 2 hours even if it is not completely full. As the capacity of their artificial bladder approaches normal, this is no longer necessary.
Patients wake up every 1.5-2 hours at night to urinate. If they do not, they may leak urine at night or wear a condom catheter or patient pad at night. Over time, the intervals between waking up at night gradually increase.
Urinating with an Orthotopic Bladder (Bladder from the Intestine)
Unfortunately, due to misinformation from other colleagues who are not familiar with this surgery, our patients develop a concern that they will not be able to urinate and will have to walk around with a catheter and insert it themselves. However, this is not the case for our male patients; none of our male patients who underwent this surgery have had to insert a catheter themselves to empty their urine!
For women, the situation is different; even in the most developed country in the world in medicine, the USA, 25% of patients have to perform what we call “TAK” (Clean Intermittent Catheterization), which means inserting a catheter themselves 3-4 times a day. However, since women do not have a penis like men, and the external urinary canal (urethra) is only 3-4 cm long in women, the process of inserting a catheter is very easy and painless.
To demonstrate this and alleviate their concerns, we have video recordings of our patients who underwent this surgery urinating, which we have shared both on this page and on youtube.com.
Among these patients, we have included recordings of various patients who underwent surgery 20 years ago and 1 month ago urinating, to show that their concerns about “how will I urinate, will I have to insert a catheter” can be put to rest.
Below is a link to watch interviews with all our patients who underwent the Orthotopic Bladder (Bladder from the Intestine) Surgery. You can visit our Urology Istanbul channel on YouTube.