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Patient Care

Radical Cystectomy with an Orthotopic Neobladder


What does your urinary system look like?

The human urinary system normally has two kidneys, two ureters, one bladder and one urethra. The kidneys are bean shaped organs that filter your blood and remove water and waste through the urine. Connected to each kidney are narrow tubes called ureters. Ureters carry urine to the bladder. The bladder is the storage area for the urine until you are ready to urinate. The urine leaves the bladder through a narrow tube called the urethra. The female urethra passes through the vagina. The male urethra passes through the prostate gland and penis.

What happens to your urinary system when you have a Radical Cystectomy with an Orthotopic Neobladder?

A cystectomy is an operation to remove the bladder. In men, the bladder, prostate, seminal vesicles and lymph nodes are removed. In women, the bladder, urethra, part of the vagina and lymph nodes are removed. In addition, the uterus, fallopian tubes and ovaries may be removed.

After the bladder has been surgically removed, your doctor will create a new urinary resorvoir in place of the old bladder. Orthotopic means "in the same place". Neobladder means "new bladder". Your doctor will make a new bladder in the same place from a piece of the small intestine called an ileum. Once the piece is removed from your small intestine, it is reconnected.

The piece of the intestine that is removed to make the bladder is sewn together to form a pouch. The bottom portion of the pouch is connected to the urethra. This new pathway is made to act like your normal urinary system. Temporary tubes are used to drain your newly created bladder to help the healing process. They are ureteral stents, a suprapubic catheter and a urethral catheter. These drains will be described in more detail.

Since the neobladder has been created out of a piece of bowel, it will produce mucus. Mucus is a thick substance made by the lining of your intestine. This mucus can clog the tubes and build up on the lining of the neobladder, so you will learn to irrigate your catheter.

Your nurse will teach you how to irrigate your catheter. This will begin during your hospital stay and continue after discharge through your follow-up appointment. The catheter needs to be irrigated every six hours. Your doctor will tell you when you may stop.

The"new bladder" made out of small intestine may not work as well as a normal bladder, and may leak urine. This can happen especially at night. If the catheter does not drain well on its own, your doctor may have you use a catheter for a longer period of time. Your doctor will be following you closely to see how your new bladder is working and to answer any of your questions.

Before Surgery

  • You will be told what time to arrive at the hospital.
     

  • You will be given a prescription for a bowel cleaner called GoLytely.
     

  • You will be given a bowel preparation guide. Follow the instructions on that guide.
     

  • You will be given prescriptions for two antibiotics called Neomycin and Erythromycin.
     

  • An electrocardiogram (EKG), chest x-ray, blood work and other tests may need to be done prior to surgery. Your doctor and nurse will give you this information.
     

GoLytely Bowel Prep for Abdominal Surgery

A "bowel prep" is done to prepare the bowel for surgery or a procedure. Its purpose is to clear out the bowel of all solid matter. Begin the bowel prep one day before your scheduled surgery.

You will need these items from a pharmacy:

  • Prescriptions for two antibiotics
     

  • Prescription for GoLytely

On the Day Before Your Surgery

  1. Begin drinking only clear liquids 36 hours before surgery. You should not have any solid food or milk products.
     

  2. Drink plenty of clear liquids during the day to prevent dehydration. These clear liquids are allowed:
    Water
    Ice
    Clear broth or bouillon
    Coffee or tea (no milk or cream)
    Kool-aid
    Soft drinks
    Jell-O (no red or purple)
    Strained fruit juices (no pulp)
    Popsicles
    Gatorade
     

  3. You should also begin the bowel clean out with the GoLytely and antibiotics. Plan ahead so you will have a bathroom nearby. You may need to get to the toilet right away. You will have several bowel movements during the day. They will become very watery. The bowels are "clear" or clean when there is only pale yellow fluid without flecks of stool.
     

  4. Follow this schedule for the bowel prep:

     

    8:00am

    Start drinking the GoLytely. Follow directions for mixing. Drink 1 glass every 15 minutes. finish drinking the gallon as soon as possible (may take a few hours).

    1:00pm

    Take the first dose of antibiotics (Neomycin and Erythromycin). Follow the dose instructions on the prescription package or bottle.

    2:00pm

    Take the second dose of antibiotics (Neomycin and Erythromycin). Follow the dose instructions on the prescription package or bottle.

    11:00pm

    Take the last dose of antibiotics (Neomycin and Erythromycin). Follow the dose instructions on the prescription package or bottle.

    Midnight

    Do not eat or drink anything after 12 midnight. You may gargle but do not swallow any liquid. Do not smoke after midnight.


Day of Surgery

Take medicines the day of surgery, as prescribed by your doctor, with small sips of water.

Bring all your medicines with you (in the original containers) when you come to the hospital.

When you arrive for your surgery, you and your family should report to the:
Hospital Admissions Office
Room 105, Rhodes Hall
450 W 10th Avenue, Columbus, OH 43210

Medicines You Must Stop Taking Before Surgery

These medicines must be stopped 7-10 days before surgery. Check with your surgeon:

  • Aggrenox
     

  • Plavix
     

  • Coumadin
     

  • Vitamin E

These medicinies must be stopped 5-14 days before surgery. Check with your surgeon:

  • Aspirin
     

  • Ibuprofen (Advil and Motrin)
     

  • Naproxen (Aleve)

After Surgery

Once your surgery is finished, you will be moved to the Post Anesthesia Care Unit (PACU) for 1 to 2 hours. Your doctor will decide if you need to transfer to the Surgical Intensive Care Unit (SICU) or a hospital room. You will be connected to monitors, drains and tubes. The following is a list of what to expect after surgery.

  • Oxygen (O2): You may remain on this for 1 to 2 days depending on your levels. Your nurse will check your O2 levels with your vital signs every 4 hours.
     

  • Nasogastric Tube (NG): This tube is placed during surgery through your nose ending in your stomach. It helps drain your stomach contents, which helps let the bowel heal. This tube will be in for 5 to 7 days. You may have a sore throat and dry mouth. Mouth swabs can be used to help with the discomfort. While this tube is in place, you will not have anything to eat or drink. Your doctors will decide when the tube can be removed, usually when your bowels regain function.
     

  • Central Venous Catheter (CVC): Since you will not be eating, you will have intravenous (IV) fluids. These fluids will enter into a large vein in your body, often in the neck/chest through a CVC. It is a thin, soft, plastic tube that is inserted during surgery and will be used for IV fluids, medicines, blood transfusions and withdrawing blood samples.
     

  • Patient Controlled Analgesia (PCA): A small pump with a supply of pain medicine ordered by your doctor will be attached to your IV line. The pump is set so that you can push the button when you have pain. This will give a small amunt of the pain medicine into your blood stream for quick relief. You are the only person allowed to push the button. Your nurse will give you further instructions about this pump.
     

  • Sequential Compression Devices (SCDs): A sleeve is placed around each leg. This sleeve is connected to a pump. This pump forces air into different parts of the sleeve in sequence, creating pressure around the calves. This pressure pushes the blood through the vessels in your legs to prevent blood clots. You will wear these during the night while resting, and throughout the day, except when you are out of bed and/or walking.
     

  • Incentive Spirometer: This is a device that will help keep your lungs healthy after surgery. Your nurse and respiratory therapist will teach you how to use your spirometer. By using the Incentive Spirometer, you will help reduce your risk of lung infection and/or breathing difficulties.
     

  • Incision: Your surgeon will make an incision on your abdomen from above the belly button to the pubic bone. Staples will be used to close the wound. A dressing will be placed over the incision for a few days. Your surgeon will remove the dressing and the incision will remain open to air while it is healing. 
     

  • Ureteral Stents: Ureteral stents are thin tubes which drain urine from the kidneys while your new bladder is healing. The stents allow the urine to flow freely. The ends are brought through a small opening in the abdominal wall. A small plastic pouch will be placed around the opening to collect the urine from the stents. This pouch is temporary. The stents will be removed prior to your discharge from the hospital. The opening will close on its own.
     

  • Suprapubic Catheter: This is a tube placed through your abdominal wall into the new bladder to keep it drained and to help healing. You will go home with this tube. Your nurse will teach you how to irrigate and care for your drain. This catheter is usually removed in 2 to 3 weeks at your first appointment after surgery. A cystogram (x-ray) is performed by your doctor to ensure all sites of your new bladder are healed before any tubes can be removed.
     

  • Urethral Catheter: This is a tube inserted through your urethra into the new bladder. It is to protect the healing of the sutures that join the urethra and the neobladder. Your will go home with this tube. Your nurse will teach you how to care for your drain. The catheter will be removed a few days after your suprapubic catheter is removed.
     

  • Hemovacs: Hemovacs are a type of drainage collection device that help promote healing by draining fluid from the wound. The drainage tube is placed during your operation, through the skin into the wound near the surgical incision. It is held in place by stitches. Usually, you will have two drains (one on each side of the abdomen) that will remain in place until you are discharged.
     

Patient Care Resource Manager

Before you go home from the hospital you will meet with a Patient Care Resource Manager (PCRM). This member of your health care team will work with you and your family to assist with any needs you may have when you are discharged. Once you are home, you or your family should contact the PCRM if you have any additional needs or questions regarding your care.

You may need a home health nurse, medical equipment or be moved to a Skilled Nursing Facility (SNF) when you are discharged. If this is the case, your PCRM will work with your doctor and other members of the team to arrange what you need.

Discharge

Your nurse will give you the following information when you are discharged from the hospital.

  • An appointment to see your doctor
     

  • Important phone numbers
     

  • Home health care agency information
     

  • Signs/symptoms of infection
     

  • Instructions on wound and drain care
     

  • A list of current medicines and prescriptions
     

  • Activities you can or cannot do while healing from surgery

Herbal Use Before Surgery

It has been shown that taking some herbal remedies may cause complications for people having surgery. Use of a small amount of herbs to season food is not a problem. The American Society of Anesthesiologists lists the use of herbs and remedies that could cause problems. Some of these herbs are known by other names. Read the package labels carefully. Here is the list:

  • Echinacea
     

  • Ephedra
     

  • Feverfew
     

  • Garlic
     

  • GBL, BD and GHB (abbreviations used for remedies taken for body building, weight loss aid and sleep)
     

  • Ginger (high doses)
     

  • Ginkgo biloba
     

  • Ginseng
     

  • Goldenseal
     

  • Kava-kava
     

  • Licorice
     

  • Saw Palmetto
     

  • St John's Wort
     

  • Valerian
     

  • Vitamin E

What Should You Do Before Surgery?

To be safe, talk with your doctor, surgeon and nurse about all herbals and remedies you use. Tell them how often and how much you take when you have your exam before surgery.

Studies are being done to learn more about how herbs and other remedies affect bleeding and anesthesia. Much is not known. Some herbs may change or lengthen the effects of medicines used with anesthesia. Others may affect bleeding or clotting. Some can change blood pressure or interact with medicines used during surgery. In some cases the effects may be slight but still important for the anesthesiologist and doctor to know about.

In many cases it is best to stop taking herbal remedies at least 2 to 3 weeks before surgery. Anesthesiologists here at OSUMC support this advice. The anesthesiologist is the doctor who balances the medicines that keep you safely in a very deep sleep for surgery. If it happens that you do not have enough time to stop taking herbs or remedies in advance of your surgery, bring them with you to show the doctor. Bring the products in their original bottle or container. This way the anesthesiologist can read what they contain and see how much you take.

Talking openly with the doctor about all herbal remedies and health practices before you have surgery is very important. This helps keep you safe.

Bladder Cancer Websites

Cancer-Related Resources

Bladder Cancer Advocacy Network

www.bcan.org     888-901-BCAN

  • The Bladder Cancer Advocacy Nerwork (BCAN) is a nonprofit organization dedicated to advancing research, providing information and support to the bladder cancer community, and raising awareness of bladder cancer across the country.

American Bladder Cancer Society

www.bladdercancersupport.org

  • This website offers information, resources and support for people with bladder cancer.

Bladder Cancer WebCafe

www.blcwebcafe.org

  • The WebCafe presents information on current treatment options for bladder cancer in an unbiased way. This website also helps users find more resources available on the internet.

National Comprehensive Cancer Center Network

www.nccn.org     888-909-NCCN(6226)

  • NCCN is an organization of cancer centers, including The James. The site has treatment guidelines, links to treatment centers and more.

Arthur G James Cancer Hospital and Richard J Solove Research Institute

http://cancer.osu.edu/ (The James)     800-293-5066

  • This site has information and links about cancer, about The James, cancer prevention, detection, treatment, support programs, clinical trials and survivor news. You can link to patient education materials or be referred to a doctor. Note, this is our site, so we are biased.

American Cancer Society (ACS)

www.cancer.org     Ohio: 888-ACS-OHIO

  • ACS gives information about cancer, treatment, caregiving, and skills to survive. It is easy to use and has good links to local offices and more. Also has information about anemias.

Ostomy Resources

United Ostomy Associations of America Inc (UOAA)

www.uoaa.org     800-826-0826

  • The UOAA is a national organization that provides support and information to people with an ostomy and their caregivers.

The Phoenix Magazine

http://www.phoenixuoaa.org/   949-600-7296

  • This is the official publication of the UOAA. It's the leading source for ostomy product information, personal stories and practical management tips.

Medical Identification Bracelet

It is important for you to purchase a medical identification bracelet. In an emergency, this bracelet will let doctors and nurses know that your bladder has been surgically removed and a new one made. It should be worn at all times. The bracelet shoud have the following words printed on it.

"Neobladder - Continent Urinary Diversion. May catheterize urethra with #18Fr Catheter."

You can purchase a bracelet at any of the following locations:

American Medical ID
949 Wakefield, Suite 100
Houton, TX 77018
1-800-363-5985
Website: www.americanmedical-id.com

MedicAlert Foundation
2323 Colorado Ave
Turlock, CA 95382
1-888-633-4298
Website: www.medicalert.org

Medic ID International
PO Box 571687
Tarzana, CA 95382
1-800-926-3342
Website: www.medicid.com