John J Bauer, MD, FACS John J. Bauer, M.D.

Urology Services, Inc.
G-1121 West Hill Rd.
Flint, Michigan 48507
Tel: 810.232.8888
Fax: 810.232.9190

Radical Cystectomy, Continent Diversion
Surgery Details

General information
Pre-operative instructions
Risks and Complications
Detailed Surgery Description
Family waiting instructions
Post-operative instructions

Printing tip: If you want to print only one portion of this entire document, you should be able to do this depending on your software. To print a selection, highlight the section you want to print using your mouse, then click on print, and then in the print menu, choose "selection."

Terminology tip: If you come across words you don't understand, look them up in the On-Line Medical Dictionary?.

General Information

This procedure is commonly performed for aggressive or locally advanced Bladder cancer, for more background information about bladder cancer please see the link at Bladder Cancer Information.

Surgical Therapy


Bladder cancers that are no longer confined to the surface lining and have grown into surrounding tissue usually require surgical therapy. Specifically, Stage T2 to T3a tumors?that is, tumors that have invaded the muscle or fatty tissue around the bladder?need surgical management. In men, a standard surgical procedure is Cystoprostatectomy (removal of the bladder and prostate) with pelvic lymphadenectomy (removal of the lymph nodes within the hip cavity). Bladder surgery, which usually involves removal of the seminal vesicles (semen-conducting tubes), can be performed in a manner that preserves sexual function in some men. In addition, new surgical methods of urinary diversion (re-routing of urine through a surgical channel) may eliminate the need for an external urinary appliance.

Radical Cystectomy

In women with T2 to T3a tumors, a standard surgical procedure is Radical Cystectomy (cutting away of the entire bladder and associated tissues) with pelvic lymphadenectomy. Radical cystectomy in women includes removal of the uterus (womb), tubes, ovaries, anterior vaginal wall (front of the birth canal), and urethra (the tube that passes urine from the bladder out of the body). Preoperative radiation therapy may have some merit when combined with bladder surgery, although radiation therapy alone usually is unsuccessful.

Urinary Tract Diversion

Until recently, most bladder cancer patients who underwent cystectomy (bladder removal) needed an ostomy (surgical creation of an artificial opening) and an external bag to collect their urine. Now, reconstructive surgical methods have been developed to replace the cancerous bladder. The continent urinary reservoir is the newest form of urinary diversion. With this technique, a piece of colon (large intestine) is removed and used to form an internal pouch to store urine. The pouch is specially refashioned to prevent back-up of urine into the ureters (one of two tubes that pass urine out of the kidneys and into the bladder) and kidneys. The patient?whether male or female?can urinate as before, without the need for an external bag or collection device. The urinary reservoir procedure is associated with some complications, such as bowel (intestine) obstruction, blood clots, pneumonia (lung inflammation), ureteral reflux (back-flow), and ureteral blockage.

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Pre-Operative Instructions

Your pre-operative appointments

Before your surgery, you will be seen by the physician and the anesthesiologist, and when applicable, there is a pre-admission appointment with the hospital. Click here to read more details about these appointments, referred to as the Pre-Operative Work-Up.

Change In Health Status

Notify your surgeon if you experience any significant change in your health status: develop a cold, influenza, a bladder infection, diarrhea, or other infection, before your surgery.

Pre-Operative Medication Instructions

Unless specifically instructed otherwise by your surgeon or anesthesiologist, please observe the following guidelines for taking your medicines before surgery:

  1. One Week Prior to Surgery:
    - STOP all aspirin and all aspirin-containing medicines (e.g., Anacin, Excedrin, Pepto-Bismol). Check any cold or pain medication bottles to make certain aspirin is not contained. See additional list at Blood Thinners.

  2. Two Days Prior to Surgery:
    - STOP all nonsteroidal anti-inflammatory medications (e.g., etodolac [Lodine], fenoprofen [Nalfon], ibuprofen [Advil, Motrin, Nuprin], ketorolac [Toradol], maproxen [Aleve], meclofenarnate [Meclomen], mefenamic acid [Ponstel], naproxen [Anaprox, Naprosyn].

  3. Day Before Your Surgery:
    Start the pre-operative Bowel Prep (cleansing procedure) appropriate for this surgery, as described below:

    Your procedure involves the bowel and therefore needs the most thorough cleaning protocol. It will be ordered by your physician and it may require hospital admission the day before.

  4. On the Morning of your Surgery:

Pre-Operative Diet Instructions

Unless specifically instructed otherwise by your surgeon or anesthesiologist, patients of all ages must observe the following diet restrictions before surgery:

  1. Eight hours before the Scheduled Start of your Surgery:
    DO NOT EAT any solid foods, including juices with pulp (e.g., orange juice, nectars), lozenges, candy, chewing gum, and mints. DO NOT DRINK full liquid, such as milk, cream, and jello. You may continue to drink up to eight ounces of clear liquids until SIX hours before the scheduled start of your surgery. Clear liquids include Water, clear juices (e.g., apple, grape), black tea and black coffee.
  2. Six hours before the Scheduled Start of your Surgery:
    DO NOT TAKE anything by mouth except for your usual medicines; follow the Preoperative medication instructions above.
  3. Exceptions:
    DO NOT TAKE anything by mouth for eight hours, except for your usual medicines, if you are pregnant, morbidly obese, or are diagnosed with diabetes, renal failure, or stomach acid reflux with heartburn.

Patients undergoing operative or diagnostic procedures involving sedation are required to refrain from eating, drinking or taking anything by mouth for a stated period prior to their surgery or procedure. The reason for this is to prevent complications caused by nausea or vomiting while you are unconscious. Should you vomit while in the unconscious state, the risk exists that the vomit may enter into your lungs causing serious complications such as pneumonia. These complications may result in an extension of your hospitalization following your surgical procedure. It is for this reason patients are often instructed to have nothing by mouth after midnight the night prior to your operation unless otherwise instructed by an anesthetist.

Pre-Operative Cleaning Instructions (bathing and showering instructions)

Pre-operative showers are to be taken the night before and the morning of surgery just prior to your arrival. All adults are required to take a shower using either a Betadine or Hibiclens Surgical Scrub antibacterial soap. The reason is to remove as much bacteria from your skin as possible prior to your surgery. If you are allergic to these products please notify your physician or nurse. Perform your shower as follows:

  1. Generously lather your body, scrub well, and rinse. Give particular attention to the area were the incision will be made for your procedure.
  2. Following the morning shower, do not apply creams, body oils, lotions, perfumes, deodorants, makeup, lipstick, nail polish or any other cosmetic product to the skin or nails.
  3. Do not use Hibiclens on your face. You may use any other antibacterial soap for the face.
  4. Children under 5 years of age are to be given a bath using an over the counter antibacterial soap.

On The Day Of Surgery

The anesthesiologist will discuss with you the anesthetic most appropriate for your medical condition and procedure prior to surgery.

After your surgery you must be escorted/driven home by a responsible adult. You may take a taxi car or shuttle if accompanied by a responsible adult who can stay with you after the driver departs.

Time To Arrive For Your Surgery

During your Pre-Admission Interview, our Registered Nurse will provide you with the correct time to arrive for check-in prior to your surgery.


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Risks and Complications

The risks and complications for this surgery are described in the "Counseling and Pre-Op Note" that you will need to sign before the surgery. The main content of that note is listed below.


Patient presents with a high grade, invasive bladder cancer diagnosed by TURBT. Metastatic work-up of liver function tests, CT scan of the pelvis and CXR were negative.


Alternatives include watchful waiting, chemotherapy, radiation therapy or combination, bladder sparing procedures such as radical TURBT and chemo/rads, partial cystectomy with pelvic lymph node dissection. The options for the urinary diversion are bowel conduit, bowel continent reservoir with catheterizable stoma, bowel orthotopic neobladder.


The risks and complications of the procedure where extensively discussed with the patient. The general risks of this procedure include, but are not limited to bleeding, transfusion, infection, wound infection/dehiscence, pain, scaring of tissues, failure of the procedure, potential injury to other surrounding structures, deep venous thrombosis, pulmonary embolus, myocardial infarction, heart failure, stroke, death or a long-term stay in the Intensive Care Unit (ICU). Additionally, mentioned were the possible serious complications of the anesthesia to include cracked teeth, airway damage, aspiration, pneumonia, spinal headache, nerve damage, spinal canal bleeding and malignant hyperthermia. Your anesthesiologist will discuss the risks and complications in more depth separately. Additional procedures may be necessary.

The specific risks of this procedure include, but are not limited to: injury to obturator nerve with resultant adductor palsy and gait disturbance, lymphoceole, lower extremity edema, ureteral obstruction (5-8%), stoma problems (5-10%, stricture, peristomal hernia, prolapse, retraction, renal insufficiency), metabolic and electrolyte abnormalities potentially requiring chronic medication, ileus, bowel obstruction, impotence, impression of penile shortening, recurrent tumor formation, failure of the procedure to cure unidentified metastatic disease, urinary tract infection, pyelonephritis (10%), reservoir stone disease, increased GU stone disease (5%), fistula of ureter/bowel/reservoir (3%),wound scarring, need for chronic life-time external urinary appliance, positive margins or lymph nodes potentially requiring adjuvant radiation or chemo therapy, daytime incontinence more than once a week (2-18%), nighttime incontinence (16-28%), and need for possible reoperation (3%).

You understand the procedure, general and specific risks as discussed and agree to proceed with the procedure. You also understand that not every possible complication can be listed in this counseling note and additional risks are possible, although unlikely.

To view the actual printable form for this surgery, click here: Counseling Note for Radical Cystectomy, Continent Diversion. To print the document, simply select print after you have opened the page. You can use that copy to sign before your surgery.

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Detailed Surgery Description

Terminology tip: If you come across words you don't understand, look them up in the On-Line Medical Dictionary?.

Indications: Patient with invasive bladder cancer

Sample Procedure Dictation:

Patient was given a continuous epidural anesthetic with supplemental general anesthesia. He was placed in the supine position and then was prepped and draped in the usual standard sterile fashion. A 24 French Foley catheter was placed per urethra with good return of urine; balloon was inflated to 30 cc with sterile saline. A midline incision was made from the above the umbilicus to the symphysis pubis coagulating all bleeders as they where encountered. The rectus fascia was divided the length of the incision, the pre-peritoneal space was identified, and the peritoneum was entered taking care to avoid any injury to the bowel. The umbilicus and the median umbilical ligament were isolated and dissected to the dome of the bladder leaving the posterior peritoneum wrapped over the bladder. We then placed a Buckwalter self-retaining retractor to expose the abdominal cavity. The small bowel was then retracted from the field with moist sponges and the White Line of Tolt was identified and incised along the lateral colonic gutters. This was carried superiorly to allow adequate expose of the bifurcation of the Aorta. The small bowel and the sigmoid colon were reflected from the field with moist sponges. These were inspected periodically to assure normal bowel integrity. The ureters were noted bilaterally and were isolated beyond the iliac arteries to just shy of the entrance into the posterior bladder. The common iliac and iliac lymph nodes were harvested without damage to the vasculature bilaterally and sent for permanent section analysis.


These lymph nodes were not felt to be clinically involved and were not sent for frozen section.


The Space of Retsius was developed bluntly to expose the bladder and obturator fossa. The obturator lymph nodes were palpated. All nodes were normal in character and not sent for frozen section. We proceeded with obturator LN dissection, taking all nodes in the obturator fossa for permanent section analysis. This was accomplished without injury to the obturator nerve and vascular pedicle or the iliac artery and vein. All bleeders and lymphatics were bovied or clipped as they were encountered. We proceeded with incising the posterior peritoneal reflection into the Pouch of Douglas to gain access to the rectum and posterior bladder. This space was carefully developed to isolate the bladder with its attached vascular pedicles. The vascular pedicles were then clipped and bovied to avoid the posterior branch of the internal iliac artery. This division proceeded down to the inferior pedicle supplying the seminal vesicles and the prostate. The ureters were then clipped and cut with scissors just above the entrance into the bladder. The distal tips of the ureters were removed and sent for frozen section. The frozen section examination showed normal transitional mucosa bilaterally.

The pre-prostatic fat was removed from the anterior prostate with bovie coagulation; a 0-chromic figure eight suture was placed around the superficial dorsal veins at the level of the bladder neck to control back bleeding. The endopelvic fascia was then entered bilaterally to expose the puboprostatic ligaments. The dorsal vein complex was then isolated with the mixter clamp and #2-vicryl was used to tie the deep dorsal vein complex without division of the puboprostatic ligaments. The complex was then bovied and divided over the mixter clamp. Bleeding was controlled with a 0-chromic figure eight suture just above the urethra and below the pubis.

A tonsil clamp was then used to isolate the neurovascular bundles unilaterally/ bilaterally.

A generous urethral stump was left after sharp division of the urethra over a mixter clamp. The rectourethralis muscles were then divided and dissection of the prostate off the rectum proceeded without difficulty, the pedicles were clipped and divided exposing the posterior bladder neck and Denonvillier's fascia.

A nerve sparing technique was accomplished unilaterally/bilaterally as this dissection of the prostate proceeded.

The fascia was divided and the ampulla of the vas was isolated, clipped and divided. The seminal vesicles were then isolated, clipped at the apex and divided. The remaining portions of the pedicles were then clipped and divided exposing the posterior bladder neck. The remaining attachments of the bladder to the rectum were taken down and the specimen removed for permanent section analysis.

Continent Reservoir

Approximately 15 cm of Ileum proximal to the ileocecal valve was measured and tagged with 3-0 GI silk sutures. A similar section of the ascending (right) colon proximal to the hepatic flexture was tagged in a similar manner. The mesentery was then delicately dissected from the ileum and colon near the sutures to allow a GIA stapler to be placed. The mesentery was then incised in a sequential manner using Kelly clamps and 3-0 silk free ties. Large feeding vessels were avoided during this process to avoid vascular compromise. The wound was then draped off with sterile towels and the bowel segment was then divided using the GIA stapler. This segment was then wrapped in moist gauze while the re-anastomosis the ileum and remaining colon occurred. The two remaining ends of the ileum and ascending colon were then re-anastomosed using the GIA/TIA stapler in a standard side-to-side manner. The staple line was then reinforced and everted with 3-0 silk sutures. The anastomosis was inspected with bowel contents milked through without leakage. The mesentery was closed with 3-0 vicryl sutures to prevent internal herniation. The distal stapled end of the ileal segment was then excised using heavy scissors and opened to allow copious irrigation of the bowel lumen with saline until clear. The anti-messenteric border of the ascending colons and cecum were then opened using the bovie to detubularize this segment. The ileocecal valve and the distal ileum were left intact as the efferent limb to attach to the reconstructed umbilical stoma. The detubularized colon was then closed in a clamshell fashion connecting the ascending colon end to the cecal remnant. This was accomplished using 2-0 vicryl running suture with every third being an interlocking type throw. Before final closure, using a tonsil clamp, two openings in the pouch were made to anastomose the ureters. The anastomosis was accomplished using 4-0 vicryl-interrupted sutures in a refluxing technique. Two single-J 90cm stents were placed into the renal pelvis and brought out through the pouch and out the ileal efferent limb to drain into a urostomy bag placed at the end of the case. These stents were secured with single 4-0 chromic suture through the ureter and the sent. Additionally, before final closure, a 24-French Mallecot SP Tube was placed through a separate stab wound in the bladder and brought out through the anterior abdominal wall. It was secured with a purse-sting 0-chromic suture at the level of the bladder and 3-0 Nylon suture at the abdominal level and then drained into a collection bag. The remaining pouch was closed as previously described with running 2-0 vicryl sutures. After closure of the remaining mesentery, the closed detubularized pouch and its mesentery were in a position below the previously described anastomosis.

Catheterizable Stoma Construction

The efferent ileal limb was then tapered using a GIA stapler to fit an 18 French Foley catheter. The distal portion was then brought through the previous position of the umbilicus after an adequate stellate opening was provided through the rectus fascia. The ileal segment with a 2 cm nipple was secured to the rectus fascia with 3-0 vicryl sutures that were placed at the 3, 6, 9, and 12 o'clock positions. The stoma was then matured to produce a final 1 cm nipple by suturing the mucosa to the skin with multiple interrupted 4-0 vicryl sutures. A 12 French Red Robbin catheter was placed into the stoma to the pouch without difficulty and was able to drain the urine. An 18 French catheter was placed through the catheterizable stoma to the pouch and 10cc of saline was placed in the balloon. The pouch was filled through the Foley catheter to identify areas of leakage. These were closed with figure eight 2-0 vicryl sutures until no leakage was noted with 500 cc of saline instilled in the bladder. The bladder was drained. The end of the catheter was capped with a catheter plug.

The bowel anastomosis was re-inspected without vascular compromise or leakage. The ileal segment was also re-inspected and noted to be devoid of vascular comprise. A 20 French Foley pelvic drain was placed through urethra with the balloon filled with 10 cc of saline. It was left to gravity drainage. The operative site was inspected for possible bleeders, which were clipped if found. The abdominal cavity was then irrigated with 2 liters of Ancef antibiotic and normal saline solution. The fascia was then closed in a running fashion with #2-vicryl suture. The subcutaneous tissue was irrigated with saline and the skin was closed with staples. Xerofoam gauze was placed over the incision and bandaged. The JP drain and Mallecot SP tube were secured with 3-0 nylon sutures to the abdominal wall. These and the Foley were securely tapped. A urostomy bag was placed over the stoma and ureteral catheters for drainage. The SP tube was placed to gravity drainage. The patient was then awaken from anesthesia without complications and transferred to the Recovery Room (RR) with the epidural used for pain control. The patient arrived to the RR in stable condition and without complications.

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Family Waiting Instructions

To the family and friends of patients undergoing surgery.



You should plan to check in at the waiting area information desk as soon as your family member or friend has left for the Operating Room. This is the only way we can talk to you afterwards, or on occasion; reach you to give you updates on the operation's progress. If the surgery is scheduled for many hours, you can leave to eat or do other things, but you should let the information desk know that you are going to leave the area, where you are going, and how long you might be gone so that we might reach you if need be. You should be in the area before the elected time of the end of the operation.

The information deck will overhead page you or the "family of" when they receive the recovery call to let you know that the surgery has been completed. The overhead page system works ONLY on the Surgical Waiting Area and not throughout the hospital or the cafeteria.

We will plan to see you in the surgical waiting area after we have safely completed the early phases of the post-anesthesia recovery in the "Recovery Room" or PAR (Post Anesthesia Recovery). This may take up to an hour after the initial call. Sometimes, especially if another case is ready to start, we will call and talk to you. If for some reason, we have not come or called within 30 minutes, please ask the information desk to page us.

Your family member will be in the Recovery Room for 1-2 hours. This is standard recovery time, although the times vary with each individual. For example, spinal anesthetics take longer to "wear off," local anesthetics are much shorter acting. Under no circumstances are family members or friends allowed in the recovery room. The information deck will inform you of the patient's return to the room as soon as they receive the information that the patient has left recovery. At that time, they will give you the room number and direct you to the correct wing and floor.

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Post-Operative Instructions


  1. No heavy lifting (more than 15 lbs.) for 4 weeks (1 week for an implant).
  2. No driving for 3 weeks (1 week for an implant). We also discourage riding in a car since the vibrations and movement may cause bleeding.
  3. Use the stairs infrequently. Take one step at a time, and have assistance available.
  4. No long trips for 3 weeks.
  5. No cutting the lawn, shoveling snow, raking leaves, etc., for 4 weeks.
  6. No sexual activity for 6 weeks after surgery.
  7. No manipulation of the prosthesis
  8. Showers after the bandages are removed (48 hrs) are okay. It is okay to wash the wound, do not rub the wound just pat dry it. Avoid tub baths or swimming in a pool for 1 week.
  9. Regular light activity is encouraged several times daily. We encourage walking. Do not be a couch potato.
  10. If discomfort returns then reduce activity, take it easy, and more gradually resume activities.


  1. Drink plenty of fluids. We recommend 24-32 oz over your usual daily fluid intake. Limit fluids after 6 PM. Avoid tea, coffee (including decaf) and pop.
  2. Resume a regular diet at home. Take high calorie supplements if appetite is poor.
  3. If you have a special diet secondary to Diabetes, Renal Disease, Liver Disease, etc. you may resume eating when tolerated.


  1. Please take the medications as prescribed by your doctor. Start them on day of discharge, and please complete the entire prescription. Take pain medication only as needed. Try Tylenol or Motrin for milder pain. You will typically be discharged with your old medications and new pain medication, antibiotics and stool softeners
  2. Resume all medications you normally took before surgery, unless instructed otherwise. Do not take blood thinners or aspirin products for 1-2 weeks or as directed.
  3. If there is a problem taking or getting the medication, call us.

Catheter and Wound Care

  1. Do not remove the dressing from the wound unless instructed. If you are home with a bandage, it is usually removed after 48 hrs.
  2. Your sutures will dissolve over time and do not need to be removed. Your steri-strips will fall off over a two-week period; please let them fall off on their own rather than removing them. You can trim the edges of the steri-strips that have rolled up onto themselves if they bother you.
  3. You may cover the wound with gauze if there is mild drainage.
  4. If the wound becomes red, inflamed, or has excessive drainage, please contact your doctor immediately.
  5. If you notice pus coming from any wound, please call your physician.
  6. Expect some spotting or bleeding from your incision for the next 1-week, if it progressively worsens then please call your physician.
  7. If you have a catheter in place, wash around it gently with soap and water. Keep the catheter taped to your thigh or abdomen to avoid inadvertent jerking or pulling. Do not disconnect the catheter from the drainage bag unless directed by your doctor. You may apply Bacitracin ointment at the point the catheter enters your body.

Bowel Movements

  1. Do not strain when having a bowel movement. Expect irregular bowel habits after surgery until fully recovered. Increase fiber in your diet.
  2. You may need to use a stool softener or laxative. Try Colace (Docusate Sodium), Metamucil or Milk of Magnesia at your local pharmacy.

When to Contact your Doctor

  1. Excessive bleeding or passage of large clots. Also if you feel your bladder is not draining or if you are unable to urinate.
  2. Fevers greater than 101º F, excessive chills.
  3. Nausea and vomiting or inability to keep down fluids.
  4. If you have any questions or concerns that are not covered by this handout.
  5. Significant tenderness or swelling in the legs, chest pain, shortness of breath.
  6. If it is a serious emergency, go the Emergency Room or call 911.
  7. Please call the office to arrange your follow-up appointment.

Contacting Your Physician

Dr. Bauer can be contacted by calling the number listed at the top of the page. You may also call the hospital to have them contact us. Please do not hesitate to call with any questions or concerns.

Frequently Asked Questions after surgery

This section is under construction.

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