Total cystectomy with ileal conduit formation

Background

Ileal conduit (IC) is the standard urinary diversion procedure for patients undergoing cystectomy. It has been replaced more recently by bladder substitution procedures in suitable cases. However, IC is still the preferred procedure for patients with comorbidities and those less able to self-catheterize after neo-bladder formation.

A short segment of the small bowel is dissected, into which the ureters are anastomosed and a stoma is formed. This allows urine to traverse the abdominal wall and empty into a bag fixed to the skin.

Learning outcomes

1 Outline a perioperative plan for a patient having a radical cystectomy

2 Discuss potential complications, including major haemorrhage

3 Plan appropriate post-operative analgesia and fluid balance monitoring.

CPD matrix matches

2A03, 2A07

Case history

A 69-year-old man, recently diagnosed with invasive bladder cancer, is on your operating list for an open radical cystectomy and IC formation.

Past medical history includes a left MCA infarct 4 years previously, with a mild residual right-sided weakness. He is able to mobilize well with a stick, walking up to half a mile twice per week. He is hypertensive, with no history of ischaemic heart disease, but is a previous heavy smoker with COPD. His medications include tamsulosin, aspirin, Seretide®, salbutamol, lisinopril, and amlodipine. At pre-admission clinic, he is advised to omit his lisinopril on the day of surgery.

Which preoperative investigations are required?

◆ FBC: Hb 145 g/L, WCC 5.2 × 10⁹/L, Plt 254 × 10⁹/L

◆ U&E: urea 4.2 mmol/L, Cr 87 micromoles/L, Na⁺ 146 mmol/L, K⁺ 4.5 mmol/L

◆ Normal LFTs

◆ Coagulation studies: APTT ratio 1.1, PT ratio 1.0

◆ Group and save: group A rhesus-positive, no antibodies detected

◆ ECG shows a sinus rhythm, rate of 74 bpm, with occasional ventricular ectopics

◆ Pulmonary function tests carried out at pre-admission clinic show FEV₁ of 2.95 L and FVC of 4.2 L, with a ratio of 70%.

What are the issues to discuss with the patient preoperatively?

◆ Anaesthetic technique: ideally combined general anaesthetic and regional technique.

Post-operative analgesia

This gentleman would benefit from the insertion of an epidural. He has a degree of impaired respiratory function, and therefore there is an indication to recommend this procedure.

The potential risks and benefits of a perioperative epidural are discussed with the patient, in order for him to make an informed decision as to accepting this analgesic technique.

Invasive vascular access and monitoring

He has good venous access, and two large-bore cannulae should be inserted. An arterial line and CVC are indicated, as significant blood loss is expected, and they will be helpful for monitoring the BP and delivering vasopressor support in the peri- and post-operative period, if required.

Cardiac output monitoring

Oesophageal Doppler monitoring will be useful to guide fluid replacement in theatre. The perioperative administration of fluids and/or vasoactive drugs, targeted to increase the global blood flow defined by explicit measured goals, reduces mortality following surgery. The use of oesophageal Doppler perioperatively is recommended in the NICE guidelines.

Possible blood transfusion

The possibility of a blood transfusion should be discussed with the patient and documented that he agrees to receive blood products, if necessary.

Post-operative high dependency care environment

Inform the patient and his relatives that he will be nursed in the surgical HDU post-operatively.

What other alternative analgesic techniques could be discussed?

Alternative techniques are bilateral TAP blocks, morphine or fentanyl PCA, and subcutaneous ketamine infusion. Wound catheters, with regular post-operative top-ups of 0.25% bupivacaine, could also be considered.

What is the sequence of events in the anaesthetic room?

◆ Routine monitoring set-up for the patient (ECG, NIBP, oxygen saturation probe)

◆ Insert a large-bore IV cannula, and run IV fluids

◆ Insert a low thoracic epidural awake, with an aseptic technique: the patient either sitting or lying on his side. A test dose of local anaesthetic should be administered

◆ Once the epidural has been inserted, anaesthesia is induced. After the patient has been intubated and ventilated, put in the arterial and central lines.

What drugs do you want to use in your epidural?

It is best not to use the epidural during the procedure if major blood loss is expected, as it may compound hypovolaemic hypotension. An infusion of remifentanil can be used for analgesia, and then the epidural is loaded once haemostasis is achieved.

A combined opiate/local anaesthetic technique is used. A bolus of 3 mg of diamorphine is injected, followed by an infusion of 0.1% of bupivacaine with 2 micrograms/mL of fentanyl.

In the initial stages of loading the epidural, be vigilant for hypotension, continuing with IV fluids and vasopressor support, if required.

How will the patient be positioned? What else is to be done before the operation starts?

◆ The patient will be in a lithotomy position, with padded supports for the legs

◆ A urinary catheter is inserted, and a volumeter attached

◆ The patient should be wearing antithrombosis stockings, and calf mechanical compression applied to be used perioperatvely

◆ Insert an oesophageal temperature probe, and apply a warming blanket to the patient

◆ Remember to check all pressure areas, and check the IV/arterial lines are unkinked, before the patient’s arms are wrapped by his sides and the surgical drapes are applied

◆ IV fluids should be delivered through a warming device

◆ Prophylactic antibiotics should be given before the first incision, as per local microbiology guidelines.

The surgical procedure involves an initial dissection and excision of the bladder and lymph nodes. There may be considerable blood loss during this stage. The theatre team should monitor suction and swabs for lost volumes. There will be a collection of urine in the pelvis, and the use of saline wash will confuse the amount of blood loss.

The use of bedside oesophageal Doppler monitoring of the cardiac output and regular ABG analysis are recommended to guide the perioperative fluid administration and use.

Once the bladder and prostate are removed, the pelvis will be packed with swabs, and the IC part of the procedure will begin.

A 12–15 cm segment of the ileum is dissected with its blood supply: one end opens as a stoma onto the abdominal wall, and the other end is attached to the ureters. The two ends of the small bowel from which it is dissected are anastomosed.

Case update

During theatre, despite adequate fluids and a Hb of 111 g/L, he required more regular vasopressor boluses, and therefore a noradrenaline infusion (80 micrograms/mL) was started at 3 mL/hour. This maintained his MAP at 70–80 mmHg.

The procedure finished after 7 hours, and the blood loss was estimated at 1700 mL.

The noradrenaline infusion was stopped soon after entering the recovery area, as his BP began to increase.

An FBC, U&E, coagulation, and an ABG were sent to the laboratory. The patient had a further 2 mg of diamorphine and a bag of solution top-up to the epidural, leaving him comfortable and stable cardiovascularly. There was urine output from the new stoma.

In the post-operative period, the patient was cared for in the surgical HDU where enhanced recovery protocols are used for the early introduction of an oral diet and mobilization. An effectively working epidural is very helpful in this process. VTE prophylaxis was administered 6 hours post-operatively, as per local guidelines.

The patient managed well post-operatively, as the epidural was effective and was kept in use for 3 days. For step-down analgesia, a fentanyl patch was applied, and the epidural stopped 12 hours later. Breakthrough pain was treated with short-acting oral oxycodone, as required.

He stayed in the HDU for 4 days and was then transferred to the urology ward. He continued to make a good recovery and was discharged home on the 10th post-operative day.

What post-operative complications may be expected?

Post-operative complications related to IC surgery have been reported in up to 56% of cases and relate mainly to anastomotic leaks, paralytic ileus, and fistula formation.

Later post-operative metabolic derangements are less common with IC, compared to previous ureterosigmoidostomy procedures. Hyperchloraemic acidosis, due to the absorption of Cl^– in exchange for HCO₃^– across the bowel mucosa, is less likely, as there is continual external drainage. This leads to shorter time of urine being in the bowel segment, limiting the time for anion exchange.

Summary

In general, the group of patients undergoing this procedure have a high incidence of existing comorbidity and therefore are higher-risk surgical candidates. In terms of reducing risk, standardized perioperative plans of care, in terms of enhanced recovery (ERAS) protocols, have led to improvement in post-operative morbidity. Patients undergoing IC should be included in the ERAS pathway.