Bladder reconstruction (neo-bladder)

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1 Bladder reconstruction (neo-bladder) We have written this leaflet to help you understand about your operation. It is designed to help you answer any questions you may have. The leaflet contains the following information about your Bladder reconstruction operation. What is a neo-bladder? What exactly is done at the operation? How will this affect my body? How will I pass urine after the operation? How else will my body be affected? Risks associated with the operation Admission to hospital for your operation The recovery period Preparation for home Getting back to normal Follow up after a Cystectomy and bladder reconstruction. Contacting the hospital What is a neo- bladder? Your doctor has recommended a Cystectomy (removal of the bladder) as treatment for your condition. This leaflet is for people who may be suitable to have a new bladder constructed out of bowel tissue. The advantage of this operation is that, in the long term, you will not need to wear a bag on your abdomen to collect urine. Instead the neo (new) bladder is connected onto the urethra (water pipe) and urine is passed the usual way. Some people will need to use a small disposable catheter once or twice a day to empty the neo-bladder. This type of bladder reconstruction is sometimes called an orthotopic reconstruction. This operation is not suitable for everyone who has a Cystectomy, especially if you have had previous radiotherapy or previous bowel abnormalities. What exactly is done at the operation? The operation to remove the bladder includes removing the prostate gland in men, and the uterus (womb) and a small part of the vagina in women. If a woman having this operation has not been through the menopause, it may be possible to leave the ovaries for normal hormone balance.

2 The male pelvis The female pelvis Neo - bladder reconstruction operations can be carried out in several ways. The operation usually involves using a section of small bowel approximately cm long. This piece of bowel is used to make the new reservoir that replaces the existing bladder. The tubes from the kidneys are implanted into this new reservoir or pouch which is then attached to the urethra (water pipe). A catheter is placed into the new bladder through the urethra and left in place for about 4 weeks (The healing process usually takes about 3 to 4 weeks). Arrangements will be made for you have the catheter removed.

3 ( Diagram of orthotopic/neo bladder). How will this affect my body? Orthotopic or neo-bladder As we have already described in the section about the operation, there are permanent changes made to the body by having this surgery. These changes affect urinary, sexual and reproductive function. In some bowel function may be affected to some extent. How will I pass urine after the operation? After the operation the kidneys will produce urine in the normal way. The new bladder will store urine until you decide to empty it. The sensation of the bladder being full is different from the usual feeling. Some experience a full sensation in the abdomen; others say that it feels a bit like having wind. Another way of knowing when to empty your new bladder is by keeping an eye on the time and emptying the bladder at regular intervals. To pass urine, many people who have had this operation will need to relax their pelvis and use some abdominal pressure or straining to empty the new bladder. The capacity of the new bladder will increase in time. After about 3 to 6 months, it should hold around a pint of urine, which is similar to normal bladder capacity. At first you will need to empty your bladder every 1 to 3 hours until you are able to build up the time between as the bladder reaches its full capacity. At night we recommend that you get up at least once or twice at night to empty your new bladder before it is full. This is important, as controlling the flow of urine may be difficult when you are asleep if the bladder is full. About 10% of people who have undergone this surgery may have some leakage at night. As the new bladder stretches, and is able to hold more urine, you will not need to empty it as often.

4 Occasionally you may need to pass a catheter into the new bladder after you have emptied it to ensure that there is no urine left behind. If a significant amount of urine is left behind in the bladder this could cause problems with infection and difficultly controlling leakage of urine from the new bladder. To prevent this, we recommend that you use a special catheter twice a day to make sure that the bladder is completely emptied. About 30% of patients having this type of operation will need to insert a catheter once or twice a day in the long term. Learning to pass a catheter into your new bladder is not as difficult as it sounds and it doesn t take long to become an expert. It is a safe procedure, done in clean conditions and can be carried out at home, work or wherever with a minimum of fuss. There are specially trained nurses to help you make these changes to your new lifestyle. They are there to teach you how to pass the catheters and support you as you regain your independence. Pelvic floor exercises are helpful to restore tone to the muscles in the pelvis; these muscles help you to control leakage. You will be taught these exercises before your surgery. How else will my body be affected? In Men the prostate gland, which sits directly below the bladder, is removed. The nerves that are responsible for obtaining an erection touch the prostate gland and are removed at the time of the operation. This will mean that the ability to obtain an erection is lost. This effect is usually permanent in most men. In some cases it may be possible to preserve the nerves on one side of the prostate; this may increase the chances of restoring the ability to get an erection. Treatment to restore erections using tablets or injections is helpful for some men, but not all. If you would like further information, it would be advisable to discuss this specifically with your doctor or nurse looking after you before you are admitted to hospital. The surgeon will discuss exactly what is going to happen during your operation. In women, there is a small amount of tissue between the bladder and vagina which has a shared blood supply. The surgeon removes a small part of the vagina in the operation and this can lead to some shortening of the vagina. In some cases, the remaining length of the vagina is adequate which may mean that penetrative sexual intercourse may be possible. The ovaries are usually removed with the uterus. The ovaries may be left in place in women who have not gone through the menopause. It is important to discuss with the surgeon exactly what is going to happen during your operation.

5 Bowel function After this operation some people notice a change in bowel habit. You may go to the toilet more frequently or notice that you are more loose than you were before. This is due to the effect of shortening the bowel when a section is removed to make the new bladder. Admission to hospital for your operation You will come to hospital 2 days before your operation for a stay of about 14 days. On your admission day, you will usually be admitted to ward F3 where you will meet the nursing and medical staff who will be looking after you. There will also be an opportunity to meet the anaesthetist and maybe the physiotherapist who will take part in your care. After admission, we will ask you not to have anything more to eat the day before the operation until after the operation. However, we will encourage you to maintain a high fluid intake. This is part of the bowel preparation. The nursing staff will give you some medicine that causes diarrhoea; this clears the bowel in preparation for your surgery. Sometimes during the operation, it is not possible for the surgeon to make a new bladder and you may need to have a procedure called a urinary diversion. Your doctor will discuss this with you before the day of your operation. The tubes that connect the kidneys to the bladder are disconnected from the bladder. The ureters are then joined to one end of a segment of bowel that is isolated from the rest of the intestine. This is then brought to the skin surface, usually on the right hand side of the abdomen. The end of the bowel that opens onto the skin is known as a stoma or urostomy. To prepare you for this possibility, a stoma nurse will visit you and discuss this with you. The stoma nurse will also put a mark on your abdomen where your stoma could be sited. It is important to do this with you whilst you are awake to ensure that it goes in the most suitable place. This will be away from any skin creases when you sit up, away from any previous operation scars and somewhere that you can see easily.

6 The day of the operation Before you go to theatre you will have nothing to drink for 2 hours before the operation. However you can take prescription medicines. The anaesthetist will discuss exactly which tablets you will be able to take. We will also give you some tablets as part of the preparation for your anaesthetic: the "pre med. After your operation When you come out of theatre, you will be transferred to the recovery area for an hour or two, in some cases it maybe necessary for you to be transferred to the high dependency unit (HDU). Your stay in the HDU will probably last for 48 hours until you are ready to return to the main ward. The purpose of your stay in HDU is to enable close monitoring of your condition. To reduce the pain in your abdomen after the operation the staff will give you pain killers. The anaesthetist will discuss your options before your operation. Either: 1. A pain killer device that you control, that releases pain relief into your blood stream via a drip (patient controlled analgesia), or 2. An epidural by which pain relief and local anaesthetic are given directly into the spinal nerve system through a fine plastic tube in your back. After about two days the need for these types of pain killers are greatly reduced, and you will be able to have these systems removed. The ward staff will then give you pain relief injections or tablets instead. Please tell your nurse if you are still in pain or discomfort. You will have a drip running into a vein in your neck to give you fluid until you are able to drink normally about 3 to 4 days after the operation. When you are able to drink you will then be allowed to start to eat again from about 4 to 6 days after surgery. You will have a fine plastic tube inserted through your nose into the stomach to stop you from being sick. This tube is usually removed a day or two after your operation. As well as a dressing over your wound on your abdomen, there will also be a small plastic drain tube from your abdomen that will stay in place for about 5 7 days. You will also have a catheter in your new bladder; this is put there to drain urine, so that the new bladder does not fill until it has had time to heal.

7 The recovery period The nursing staff will help you to get out of bed on the first or second day after your operation and help you to start walking soon after this. Normally you are up and about independently about 4 5 days after surgery. Your nurse will use the catheter to wash out your new bladder twice a day following your operation. The washout is done to help clear the bladder of mucus that is produced by the bowel tissue that the new bladder is made from. When you are feeling well enough your nurse will teach you how to do this. This is essential, as you will go home with the catheter in and it is important that the catheter does not become blocked. Potential risks associated with your operation DVT/pulmonary embolism (Blood clot in the leg or lung).this is a rare occurrence, moving your legs and feet will help prevent this. You may be given injections to thin your blood for a few days. You may be given special stockings to wear before theatre. Wound infection Bruising in and around the wound Bleeding and the need for a blood transfusion Injury to nearby tissue Poor wound healing or weakness in the wound site All the above are not common and are treatable. Preparing for home When you are eating and drinking and various tubes and drains have been removed you will, by then, be taking part in caring for your new bladder. We will arrange a date for your discharge home when you feel that you are able to look after yourself. If at the time of your operation you needed a stoma, the stoma nurse will ensure that you have everything that you need for your urostomy when you get home, and will explain how to obtain further supplies. The ward nurses will arrange for a district nurse to visit you at home whilst you are recovering. We will give you a letter for your GP and you should have a week s supply of any medications that you have been prescribed. An out patients appointment will normally be made for you to be seen 6 weeks after your discharge home.

8 We will give you a date for readmission for a cystogram (special x-ray of the bladder) and removal of your catheter. The cystogram Your new bladder takes around 4 weeks to heal, during this time you will have a catheter in your bladder to drain the urine. Four weeks after your operation, your catheter will be removed, before this you will have a test called a cystogram. The test involves putting some dye into the catheter to ensure that there are no leaks from your neo bladder. Once this test has been done you will return to the ward and have your catheter removed by the nurses. You will normally be in hospital for about 24 hours after removal of the catheter until you get used to emptying your new bladder. When the catheter is removed you may find you need to empty your bladder very frequently, but in the following days and weeks as the bladder stretches, you should be able to manage 2 to 3 hours in between emptying your bladder. At this time it is important to be doing the pelvic floor exercises as taught to you before your operation. Getting back to normal Recovery time after abdominal surgery varies but generally you should feel improvements from between 6 12 weeks. During the first 6 weeks you should not drive During this time you should not attempt to lift heavy objects, start digging the garden or doing housework. Getting back to work will depend on the type of job that you do. Please ask your surgeon if you are unsure. The ward clerk can give you a sick note for the time that you are in hospital. Your GP can then supply you with any further sick notes. Follow up after a bladder reconstruction We will see you six weeks after surgery in the out patients clinic. About 3 months afterwards, you will be asked to attend hospital for some routine tests on your kidneys and urinary system. This will involve blood tests, X-rays and scans. Some of these tests will be repeated each year after your operation.

9 Contacting the hospital If you have any worries or you would like advice, you can contact the urology specialist nursing team: Karen Robb/Fiona Murtagh Macmillan Urology Specialist Nurses Withington Community Hospital M20 2LR Janet Smith or Julie Bramley Specialist Urology Nurse Tarnya Hulme Nurse Consultant Ward F Wythenshawe Hospital. KR/FM/Urology October 2007.