chirurgie reconstructrice après la cystectomie radicale

Reconstructive surgery after radical cystectomy

Reconstructive surgery after radical cystectomy
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Since the bladder has been removed, it is necessary to find a different way of evacuating the urine after this removal.

There are several possibilities for urine flow. They depend on age, patient condition and co-morbidities, tumour characteristics and patient preferences.


Incontinent derivations

The easiest way to terminate a cystectomy is to connect the ureters directly to the skin. This is a bilateral ureterostomy of the skin.

This option is simple and is suitable for very fragile patients for whom another of the solutions that we will expose cannot be realized. It is relatively uncomfortable because it requires two pockets and permanent catheters in each ureter that need to be changed regularly.

It is therefore rarely practiced because we want to avoid it as far as possible.

The usual option is to remove a short graft of small intestine. The two ureters are attached to one end of the graft and the other end to the skin.

So there is only one urinary bypass, so only one pouch, and no catheter.

This intervention is known as the ileal conduit, or Bricker’s operation, or Wallace’s operation. The urinary flow produced by the kidneys passes through the ureters and into the pocket.

This bypass is the one that best protects the kidneys from infectious complications.

The stoma needs to be fitted. The equipment today is much more comfortable and adapted than it has ever been.

It is an incontinent derivation because there is no control of the urinary flow by the patient: the flow of urine in the pouch is permanent and therefore needs to be emptied at regular intervals.


Continuous Diversions

This reconstructive surgery of the urinary tract after cystectomy also involves the use of small intestine.

In this approach, a long graft of small intestine is deflected and reconfigured to form a sphere-shaped cavity.

At one end, the ureters are re-implanted into this reservoir.

The other end is attached to the skin at the abdominal wall.

A valve is created at this cutaneous outlet to prevent urine from flowing freely and to allow it to fill the intestinal reservoir.

The patient must empty this intestinal reservoir several times a day by inserting a catheter into the skin ostomy through the valve.

The advantage of this technique is that there is no visible pocket on the abdominal wall. On the other hand, the assembly is complex and involves a number of complications, including valve malfunction.


Intestinal neovessia

This involves surgically creating a new bladder to replace the native tumour bladder that had to be removed.

This neovessia is again created using a small intestine graft that is decubulated and reconfigured to create a pouch. Here again the ureters are re-implanted at one end of this pouch but the difference is that the other end is connected to the urethra canal. Dissection during bladder removal helped preserve the sphincter.

This bladder reconstruction allows patients to urinate through the natural flow. After the operation, it takes a few months for the ileal reservoir to mature and acquire its definitive capacity. At this time, most patients urinate naturally without leakage during the day.

A number of patients, on the other hand, have nocturnal incontinence.

When the cancer has spread and cannot be removed surgically, urinary diversion may be necessary without removing the bladder.

The purpose of surgery is then to avoid or treat the obstruction of the upper urinary tract, but in these cases it is no longer about trying to cure bladder cancer.