PERIOP BRIEFING
PROCEDURE AT A GLANCE
Radical cystectomy
IND ICATIONS FOR PROCEDU R E
During a radical cystectomy, the surgeon removes
the entire bladder.1 The prostate gland and seminal
vesicles are also typically removed in men, and the
uterus, the ovaries, and part of the vagina are also
removed in women.2 It is indicated for people with
muscle-invasive or recurrent noninvasive bladder
cancer, other tumors of the pelvis (e.g., advanced
colon cancer), or some benign conditions (e.g.,
interstitial cystitis).1,2
P RE PAR ING FOR PROCEDURE
• In addition to instruments typically used for
major abdominal surgeries, the perioperative
RN should also assemble instruments for
a prostatectomy if the patient is male and
instruments for vaginal and abdominal
hysterectomy and plastic surgery if the patient is
female.1
• Skin antisepsis extends from the nipples to
midthigh.3
• A 20 French Foley catheter is placed in the
bladder.1
• In female patients, the vagina is fully prepped.3
PATIE N T POS ITIONING
The perioperative RN typically places the patient
in a hyperextended supine position to facilitate
exposure of the pelvis. The superior iliac crest is
lined up with the fulcrum of the OR bed and
the legs are slightly abducted so that the heels are
near the corners of the OR bed.1,3 Female patients
having orthotopic neobladder reconstruction (i.e.,
a urinary reservoir created with the intestine and
attached to the urethra) are placed in the lithotomy
or modified frog-leg position.3
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BASIC WORKFLOW FOR PROCEDURE
To perform a radical cystectomy in a male patient,
the surgeon will
1. make an incision from the pubic symphysis
to the epigastrium;
2. incise the rectus fascia;
3. retract the rectus muscles;
4. enter the peritoneal cavity;
5. clamp, divide, and ligate the urachal remnant
to be removed with the bladder;
6. lift the bladder dome and dissect it laterally
on either side;
7. ligate the vesical arteries;
8. divide the vas deferens;
9. cut the urethra at the level of the pelvic
diaphragm;
10. trace the ureters to the bladder;
11. perform intra-abdominal exploration to
determine the extent of disease;
12. perform pelvic lymphadenectomy, if needed,
which may vary depending on patient and
surgeon preference;
13. retract the bladder;
14. dissect the dorsal venous complex, prostate,
and seminal vesicles to be removed;
15. ligate the urethra with absorbable sutures;
16. perform urethrectomy, if needed;
17. place radiopaque soft goods in the pelvis;
18. apply pressure; and
19. create a urinary diversion.1,3
 PERIOP BRIEFING
RADICAL CYSTECTOMY

POSTOPERATIVE RECOVERY COURSE

Kidneys • The patient may remain hospitalized for five to six
days.2
Ureters
• Early mobilization after surgery should be
encouraged.7
• A normal diet should be reestablished four hours
after surgery.7
Stroma • The transurethral catheter can be removed the first
Ileal postoperative day if there is a low risk of urinary
conduit retention.7
Bladder • To prevent ileus, gut function should be optimized
(removed) using gum and oral magnesium.7
• There will likely be pain and discomfort around
the incision for a few weeks.8
• Most patients will be prescribed pain medication
P RO CE DURAL VARIATIONS
and antibiotics.8
• Cystectomy can also be performed via a
• It typically takes approximately six weeks to
minimally invasive technique or robotic-assisted
completely heal.8
laparoscopy.2,4
• If urinary conduit surgery was performed, there
• Salvage or partial cystectomy combined with
may be drainage from the urethra, starting out
radiation intraoperatively is an alternative option
red and eventually turning yellow, for six to eight
to radical cystectomy.4
weeks after surgery.2
• A gastrocystoplasty may be needed after partial
• With neobladder reconstruction, there may be
cystectomy, especially if there is impaired renal
bloody urine after surgery, which should resolve in
function.4
several weeks.2
• After removing the bladder, a urinary diversion
• With both urinary conduit surgery and
needs to be created. Some options include a
neobladder reconstruction, there will be mucus
cutaneous urinary diversion (e.g., ileal conduit) or
in the urine, which will decrease but not go away
a continent urinary diversion (e.g., Indiana pouch,
entirely.2
orthotopic neobladder reconstruction).1,2,5,6
• Depending on the type of reconstruction
• When performing radical cystectomy in
performed, the patient may need instructions on
women, after abdominal exploration and
how to empty a urostomy bag or place a catheter.9
lymphadenectomy, the surgeon incises the broad
• The patient may experience sexual changes, which
ligament, the endopelvic fascia at the bladder
should be discussed.
neck, along the lateral walls of the vagina, and
o For men, nerve damage could affect the ability
the anterior vaginal wall. The vagina is then
to have erections, which can resolve with time.2
reconstructed.1
o For women, alterations to the vagina could
make sex uncomfortable and nerve damage
could affect the ability to generate or maintain
POSSIBLE COMPLICATIONS arousal or to orgasm.2
Complications associated with cystectomy include
• bleeding,
• blood clots,
• infection,
• pneumonia,
• dehydration,
• electrolyte abnormalities,
• urinary tract infection,
• bowel obstruction, and
• ureter blockage.2

© AORN, Inc, 2018 April 2018 Vol 107 No 4 • Periop Briefing | P11
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RADICAL CYSTECTOMY

RE FE RENCES
1. Marley HK. Genitourinary surgery. In: Rothrock, JC, McEwen DR, eds. Alexander’s Care of the Patient in Surgery.
15th ed. St. Louis, MO: Elsevier Mosby; 2015:461-557.
2. Bladder removal surgery (cystectomy). Mayo Clinic. https://www.mayoclinic.org/home/ovc-20322413. Accessed
February 19, 2018.
3. Stein JP, Skinner DG. Surgical atlas. Radical cystectomy. BJU Int. 2004;94(1):197-221.
4. Phillips N. Urologic surgery. In: Berry & Kohn’s Operating Room Technique. 13th ed. St. Louis, MO: Elsevier Mosby;
2017:701-729.
5. Chang DTS, Lawrentschuk N. Orthotopic neobladder reconstruction. Urol Ann. 2015;7(1):1-7.
6. Meyer J, Fawcett D, Gillatt D, Persad R. Orthotopic neobladder reconstruction—what are the options? BJU Int.
2005;96(4):493-497.
7. Cerantola Y, Valerio M, Persson B, et al. Guidelines for perioperative care after radical cystectomy for bladder cancer:
Enhanced Recovery After Surgery (ERAS) Society recommendations. Clin Nutr. 2013;32(5):879-887.
8. Radical cystectomy. UCLA Health. http://urology.ucla.edu/radical-cystectomy. Accessed February 19, 2018.
9. Bladder cancer surgery. American Cancer Society. https://www.cancer.org/cancer/bladder-cancer/treating/surgery.
html. Revised May 23, 2016. Accessed February 19, 2018.

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