Anatomy of urinary system

How do the kidneys and urinary system work?

The body takes nutrients from food and converts them to energy. After the body has
taken the food that it needs, waste products are left behind in the bowel and in the
blood.
The kidney and urinary systems keep chemicals, such as potassium and sodium, and
water in balance and remove a type of waste, called urea, from the blood. Urea is
produced when foods containing protein, such as meat, poultry, and certain vegetables,
are broken down in the body. Urea is carried in the bloodstream to the kidneys, where it
is removed.
Other important functions of the kidneys include blood pressure regulation and the
production of erythropoietin, which controls red blood cell production in the bone
marrow.

Kidney and urinary system parts and their functions:

Two kidneys are a pair of purplish-brown organs located below the ribs toward
the middle of the back. Their function is to remove liquid waste from the blood in the
form of urine, keep a stable balance of salts and other substances in the blood, and
produce erythropoietin, a hormone that aids the formation of red blood cells.
The kidneys remove urea from the blood through tiny filtering units called
nephrons. Each nephron consists of a ball formed of small blood capillaries, called a
glomerulus, and a small tube called a renal tubule. Urea, together with water and
other waste substances, forms the urine as it passes through the nephrons and down
the renal tubules of the kidney.
Two ureters are narrow tubes that carry urine from the kidneys to the bladder.
Muscles in the ureter walls continually tighten and relax forcing urine downward,
away from the kidneys. If urine backs up, or is allowed to stand still, a kidney
infection can develop. About every 10 to 15 seconds, small amounts of urine are
emptied into the bladder from the ureters.
Bladder is a triangle-shaped, hollow organ located in the lower abdomen. It is
held in place by ligaments that are attached to other organs and the pelvic bones.
The bladder's walls relax and expand to store urine, and contract and flatten to empty
urine through the urethra. The typical healthy adult bladder can store up to two cups
of urine for two to five hours .Two sphincter muscles are circular muscles that help
keep urine from leaking by closing tightly like a rubber band around the opening of
the bladder .The nerves in the bladder alert a person when it is time to urinate, or
empty the bladder.
Lastly, is urethra .It is a tube that allows urine to pass outside the body. The
brain signals the bladder muscles to tighten, which squeezes urine out of the bladder.
At the same time, the brain signals the sphincter muscles to relax to let urine exit the
bladder through the urethra. When all the signals occur in the correct order, normal
urination occurs.

The Urinary Bladder

The urinary bladder is a musculomembranous sac which acts as a reservoir for the
urine and as its size, position, and relations vary according to the amount of fluid it
contains, it is necessary to study it as it appears (a) when empty, and (b)
when distended.In both conditions the position of the bladder varies with the condition of
the rectum, being pushed upward and forward when the rectum is distended.
The Empty Bladder
When hardened in situ, the empty bladder has the form of a flattened tetrahedron,
with its vertex tilted forward. It presents a fundus, a vertex, a superior and an inferior
surface. The fundus is triangular in shape, and is directed downward and backward
toward the rectum, from which it is separated by the rectovesical fascia, the vesicul
seminales, and the terminal portions of the ductus deferentes. The vertex is directed
forward toward the upper part of the symphysis pubis, and from it the middle umbilical
ligament is continued upward on the back of the anterior abdominal wall to the
umbilicus. The peritoneum is carried by it from the vertex of the bladder on to the
abdominal wall to form the middle umbilical fold.
The superior surface is triangular, bounded on either side by a lateral border which
separates it from the inferior surface, and behind by a posterior border, represented by a
line joining the two ureters, which intervenes between it and the fundus. The lateral
borders extend from the ureters to the vertex, and from them the peritoneum is carried
to the walls of the pelvis. On either side of the bladder the peritoneum shows a
depression, named the paravesical fossa .The superior surface is directed upward, is
covered by peritoneum, and is in relation with the sigmoid colon and some of the coils of
the small intestine. When the bladder is empty and firmly contracted, this surface is
convex and the lateral and posterior borders are rounded whereas if the bladder be
relaxed it is concave, and the interior of the viscus, as seen in a median sagittal section,
presents the appearance of a V-shaped slit with a shorter posterior and a longer anterior
limbthe apex of the V corresponding with the internal orifice of the urethra.
The inferior surface is directed downward and is uncovered by peritoneum. It may be
divided into a posterior or prostatic area and two infero-lateral surfaces. The prostatic
area is somewhat triangular. It rests upon and is in direct continuity with the base of the
prostate and from it the urethra emerges. The infero-lateral portions of the inferior

surface are directed downward and lateralward: in front, they are separated from the
symphysis pubis by a mass of fatty tissue which is named the retropubic pad , they are
in contact with the fascia which covers the Levatores ani and Obturatores interni.

FIG. 1135 Median sagittal section of male pelvis.

When the bladder is empty it is placed entirely within the pelvis, below the level of the
obliterated hypogastric arteries, and below the level of those portions of the ductus
deferentes which are in contact with the lateral wall of the pelvis; after they cross the
ureters the ductus deferentes come into contact with the fundus of the bladder. As the
viscus fills, its fundus, being more or less fixed, is only slightly depressed; while its
superior surface gradually rises into the abdominal cavity, carrying with it its peritoneal
covering, and at the same time rounding off the posterior and lateral borders.
The Distended Bladder
When the bladder is moderately full it contains about 0.5 liter and assumes an oval
form, the long diameter of the oval measures about 12 cm and is directed upward and
forward. In this condition it presents a postero-superior, an antero-inferior, and two
lateral surfaces, a fundus and a summit. The postero-superior surface is directed
upward and backward, and is covered by peritoneum: behind, it is separated from the
rectum by the rectovesical excavation, while its anterior part is in contact with the coils
of the small intestine.
The antero-inferior surface is devoid of peritoneum, and rests, below, against the

pubic bones, above which it is in contact with the back of the anterior abdominal wall.
The lower parts of the lateral surfaces are destitute of peritoneum, and are in contact
with the lateral walls of the pelvis. The line of peritoneal reflection from the lateral
surface is raised to the level of the obliterated hypogastric artery. The fundus undergoes
little alteration in position, being only slightly lowered. It exhibits, however, a narrow
triangular area, which is separated from the rectum merely by the rectovesical fascia.
This area is bounded below by the prostate, above by the rectovesical fold of
peritoneum, and laterally by the ductus deferentes. The ductus deferentes frequently
come in contact with each other above the prostate, and under such circumstances the
lower part of the triangular area is obliterated. The line of reflection of the peritoneum
from the rectum to the bladder appears to undergo little or no change when the latter is
distended; it is situated about 10 cm. from the anus. The summit is directed upward and
forward above the point of attachment of the middle umbilical ligament, and hence the
peritoneum which follows the ligament, forms a pouch of varying depth between the
summit of the bladder, and the anterior abdominal wall.

FIG. 1136 Male pelvic organs seen from right side. Bladder and rectum distended;
relations of peritoneum to the bladder and rectum shown in blue. The arrow points to the
rectovesical pouch.

The Bladder in the Child

In the newborn child the internal urethral orifice is at the level of the upper border of
the symphysis pubis the bladder therefore lies relatively at a much higher level in the
infant than in the adult. Its anterior surface is in contact with about the lower two-thirds

of that part of the abdominal wall which lies between the symphysis pubis and the
umbilicus (Symington). Its fundus is clothed with peritoneum as far as the level of the
internal orifice of the urethra. Although the bladder of the infant is usually described as
an abdominal organ, Symington has pointed out that only about one-half of it lies above
the plane of the superior aperture of the pelvis. This maintains that the internal urethral
orifice sinks rapidly during the first years, and then more slowly until the ninth year, after
which it remains when it again slowly descends and reaches its adult position.

FIG. 1137 Sagittal section through the pelvis of a newly born male child.

FIG. 1138 Sagittal section through the pelvis of a newly born female child.

The Female Bladder

In the female, the bladder is in relation behind with the uterus and the upper part of
the vagina. It is separated from the anterior surface of the body of the uterus by the
vesicouterine excavation, but below the level of this excavation it is connected to the
front of the cervix uteri and the upper part of the anterior wall of the vagina by areolar
tissue. When the bladder is empty the uterus rests upon its superior surface. The female

bladder is said by some to be more capacious than that of the male, but probably the
opposite is the case.

FIG. 1139 Median sagittal section of female pelvis.

Ligaments
The bladder is connected to the pelvic wall by the fascia endopelvina. In front this
fascial attachment is strengthened by a few muscular fibers, the pubovesicales, which
extend from the back of the pubic bones to the front of the bladder; behind, other
muscular fibers run from the fundus of the bladder to the sides of the rectum, in the
sacrogenital folds, and constitute the rectovesicales.
The vertex of the bladder is joined to the umbilicus by the remains of the urachus
which forms the middle umbilical ligament,a fibromuscular cord, broad at its attachment
to the bladder but narrowing as it ascends.
From the superior surface of the bladder the peritoneum is carried off in a series of
folds which are sometimes termed the false ligaments of the bladder. Anteriorly there
are three folds which is the middle umbilical fold on the middle umbilical ligament, and
two lateral umbilical folds on the obliterated hypogastric arteries. The reflections of the
peritoneum on to the side walls of the pelvis form the lateral false ligaments, while the
sacrogenital folds constitute posterior false ligaments.
Interior of the Bladder
The mucous membrane lining the bladder is, over the greater part of the viscus,

loosely attached to the muscular coat, and appears wrinkled or folded when the bladder
is contracted in the distended condition of the bladder the folds are effaced. Over a
small triangular area, termed the trigonum vesic, immediately above and behind the
internal orifice of the urethra, the mucous membrane is firmly bound to the muscular
coat, and is always smooth. The anterior angle of the trigonum vesic is formed by the
internal orifice of the urethra and its postero-lateral angles by the orifices of the ureters.
Stretching behind the openings is a slightly curved ridge, the torus uretericus, forming
the base of the trigone and produced by an underlying bundle of non-striped muscular
fibers. The lateral parts of this ridge extend beyond the openings of the ureters, and are
named the plic ureteric. They are produced by the terminal portions of the ureters as
they traverse obliquely the bladder wall. When the bladder is illuminated the torus
uretericus appears as a pale band and forms an important guide during the operation of
introducing a catheter into the ureter.

FIG. 1140 The interior of bladder

The orifices of the ureters are placed at the postero-lateral angles of the trigonum
vesic, and are usually slit-like in form. In the contracted bladder they are about 2.5 cm.
apart and about the same distance from the internal urethral orifice in the distended
viscus these measurements may be increased to about 5 cm.
The internal urethral orifice is placed at the apex of the trigonum vesic, in the most
dependent part of the bladder, and is usually somewhat crescentic in form; the mucous
membrane immediately behind it presents a slight elevation, the uvula vesic, caused
by the middle lobe of the prostate.
Structure (Fig. 1141).The bladder is composed of the four coats: serous, muscular,
submucous, and mucous coats.

The serous coat (tunica serosa) is a partial one, and is derived from the peritoneum.
It invests the superior surface and the upper parts of the lateral surfaces, and is
reflected from these on to the abdominal and pelvic walls.
The muscular coat (tunica muscularis) consists of three layers of unstriped muscular
fibers: an external layer, composed of fibers having for the most part a longitudinal
arrangement; a middle layer, in which the fibers are arranged, more or less, in a circular
manner; and an internal layer, in which the fibers have a general longitudinal
arrangement.
The fibers of the external layer arise from the posterior surface of the body of the pubis
in both sexes (musculi pubovesicales), and in the male from the adjacent part of the
prostate and its capsule. They pass, in a more or less longitudinal manner, up the
inferior surface of the bladder, over its vertex, and then descend along its fundus to
become attached to the prostate in the male, and to the front of the vagina in the female.
At the sides of the bladder the fibers are arranged obliquely and intersect one another.
This layer has been named the Detrusor urin muscle.
The fibers of the middle circular layer are very thinly and irregularly scattered on the
body of the organ, and, although to some extent placed transversely to the long axis of
the bladder, are for the most part arranged obliquely. Toward the lower part of the
bladder, around the internal urethral orifice, they are disposed in a thick circular layer,
forming the Sphincter vesic, which is continuous with the muscular fibers of the
prostate.
The internal longitudinal layer is thin, and its fasciculi have a reticular arrangement, but
with a tendency to assume for the most part a longitudinal direction. Two bands of
oblique fibers, originating behind the orifices of the ureters, converge to the back part of
the prostate, and are inserted by means of a fibrous process, into the middle lobe of that
organ. They are the muscles of the ureters, described by Sir C. Bell, who supposed that
during the contraction of the bladder they serve to retain the oblique direction of the
ureters, and so prevent the reflux of the urine into them.
The submucous coat (tela submucosa) consists of a layer of areolar tissue, connecting
together the muscular and mucous coats, and intimately united to the latter.

FIG. 1141 Vertical section of bladder wall

The mucous coat (tunica mucosa) is thin, smooth, and of a pale rose color. It is
continuous above through the ureters with the lining membrane of the renal tubules, and
below with that of the urethra. The loose texture of the submucous layer allows the
mucous coat to be thrown into folds or rug when the bladder is empty. Over the
trigonum vesic the mucous membrane is closely attached to the muscular coat, and is
not thrown into folds, but is smooth and flat. The epithelium covering it is of the
transitional variety, consisting of a superficial layer of polyhedral flattened cells, each
with one, two, or three nuclei; beneath these is a stratum of large club-shaped cells, with
their narrow extremities directed downward and wedged in between smaller spindleshaped cells, containing oval nuclei (Fig. 1141). The epithelium varies according as the
bladder is distended or contracted. In the former condition the superficial cells are
flattened and those of the other layers are shortened; in the latter they present the
appearance described above. There are no true glands in the mucous membrane of the
bladder, though certain mucous follicles which exist, especially near the neck of the
bladder, have been regarded as such.
Vessels and Nerves
The arteries supplying the bladder are the superior, middle, and inferior vesical,
derived from the anterior trunk of the hypogastric. The obturator and inferior gluteal
arteries also supply small visceral branches to the bladder, and in the female additional
branches are derived from the uterine and vaginal arteries.
The veins form a complicated plexus on the inferior surface, and fundus near the
prostate, and end in the hypogastric veins.

The nerves of the bladder are fine medullated fibers from the third and fourth sacral
nerves, and non-medullated fibers from the hypogastric plexus. They are connected with
ganglia in the outer and submucous coats and are finally distributed, all as nonmedullated fibers, to the muscular layer and epithelial lining of the viscus.
What is cystectomy ?

Cystectomy is the surgical removal of all or part of the bladder. It is used to treat
bladder cancer that has spread into the bladder wall or to treat cancer that has come
back (recurred) following initial treatment. There are two types of cystectomy which is
radical and partial surgery.
RADICAL CYSTECTOMY
Radical cystectomy is defined as removal of the bladder without removal of
adjacent structures or organs and is infrequently performed today. In the man, this
would mean leaving behind the prostate, urethra, and seminal vesicles with the
advantage that potency is conserved. However, in the impotent male in whom the
urinary diversion is not expected to be reversed, removal of these structures adds little
morbidity to the operation. In the woman, this means leaving behind the urethra, uterus,
and anterior wall of the vagina. Simple cystectomy also implies that there is no
dissection of the pelvic lymph nodes.

Indications for Surgery

Upper tract diversion has been a popular treatment alternative for a range of benign
lower tract pathology and upper tract obstruction since the development of ureteroilieal
cutaneous diversion in the 1950s. The indications for supravesical diversion are varied
and include radiation cystitis after treatment of pelvic malignancies, interstitial cystitis,
cyclosphosphamide cystitis, severe incontinence, neurogenic bladder, severe urethral
trauma, and obstruction of the upper tracts. Infection (in this case, infection of the
intestine is especially dangerous as it can lead to peritonitis (inflammation of the
membrane lining the abdomen). Interstitial cystitis (chronic inflammation of the
bladder),endometriosis

that

has

spread

to

the

bladder,severe

urinary

dysfunction,damage to the bladder from radiation or other treatments,excessive

bleeding from the bladder.Initially, radical cystectomy was not routinely included during
supravesical diversion because of the increased morbidity involved in radical
cystectomy.
However, complications from the retained bladder occur in up to 80% of patients
undergoing supravesical diversion without simple cystectomy and include pyocystis,
hemorrhage, sepsis, pain, vesicocutaneous fistula, colovesical fistula, feelings of
incomplete emptying, and development of cancer in the retained bladder. Indeed, the
rate of secondary cystectomy approaches 20% in some series. Because of the high
complication and reoperation rate, we recommend simple cystectomy as a part of upper
tract diversion in any patient whose urinary diversion is not expected to be reversed,
and especially in patients who have some component of bladder outflow obstruction.
Alternative Therapy
Other alternatives to radical cystectomy include conservative management, total
cystoprostatectomy, radical cystectomy, and partial cystectomy. With the recent
advances

in

laparoscopic

technology

and

laparoscopic

surgical

techniques,

laparoscopic simple cystectomy has become a potential treatment alternative, with

several centers reporting success with the procedure as well as shortened postoperative
convalescence times.

Surgical Technique
A male patient is prepped and draped in the standard position as for radical
cystectomy, in a supine position with the legs apart with gentle hyperextension. A female
patient is placed in a lithotomy position for access to the perineum. This operation can
be performed entirely extraperitoneally if prior upper tract urinary diversion has already
taken place. This is preferred because it obviates the need for lysis of adhesions, which
can be numerous in a patient who has had prior intra-abdominal surgery and/or
radiation therapy. Obviously, if urinary diversion is to take place at the same time, an
intraperitoneal approach is used.

In the extraperitoneal approach, we use a lower midline incision extending from the
pubis to immediately lateral to the umbilicus. The space of Retzius is entered by dividing
the rectus abdominis in the midline. The retropubic space is developed down to the
bladder, using a combination of blunt and sharp dissection to separate the parietal
peritoneum from the dome and posterior wall of the bladder. It is important to repair with
3-0 or 4-0 chromic any tears made in the parietal peritoneum, as the parietal peritoneum
provides an important boundary between the peritoneal contents and the raw surface of
the pelvis after simple cystectomy. During dissection of the parietal peritoneum in the
man, the vas deferens are encountered. If we are going to leave the seminal vesicles
and prostate, we do not sacrifice the vas but instead dissect it posteriorly. If the seminal
vesicles and prostate are to be sacrificed, we divide the vas. During the dissection of the
parietal peritoneum posteriorly, the superior vesical pedicle is encountered. At this point
it is clamped and divided between 2-0 silk ties.
After control of the superior vesical pedicles bilaterally, the ureters are identified
where they enter the bladder. In patients who have had prior upper tract diversion, the
ureters are dissected proximally to the point where they were divided previously in order
to ensure complete excision of the distal ureters. In patients who are to undergo urinary
diversion at the same time, we use an intraperitoneal approach and divide the ureters
close to the bladder wall.
The bladder is then divided from the prostate at the prostatovesical junction using
electrocautery starting anteriorly at the bladder neck and working laterally on both sides
until the posterior bladder neck is reached. If the patient has significant prostatic
hypertrophy, which will impede adequate closure of the bladder neck, then a suprapubic
prostatectomy is performed with rigorous attention to hemostasis afterward because a
Foley catheter can not be used to help control hemorrhage. The posterior bladder wall is
then divided from within using electrocautery until the ampulla of the vasa are seen. The
base of the bladder is then bluntly dissected off the seminal vesicles and ampulla of the
vas. During this dissection, the lateral vascular pedicles are identified and divided
between 2-0 silk ties. The bladder is now removed from the operative field. The prostate
is then oversewn with a double layer of 0 chromic catgut.
In women, after development of the retropubic space, the parietal peritoneum is
dissected off the dome and posterior wall of the bladder until the anterior vaginal fornix
is reached. The superior vesical pedicles are divided as in a man. The ureters are

handled the same way as in a man, with care taken not to injure the uterine artery
during their dissection. A sponge on a stick placed in the vagina is used for cephalad
traction, and the plane between the bladder and anterior vaginal wall is developed.
During dissection of this plane, the lateral bladder pedicles are divided between 2-0 silk
ties as they are encountered. Once the urethra is reached, the Foley catheter is
removed, and the urethra is divided and oversewn with 0 chromic catgut suture. If
simple cystectomy is being performed for interstitial cystitis, it is important to remove the
entire urethra and external rethral meatus because failure to do so may result in
persistent symptoms.
If an upper tract urinary diversion is to be performed at the same time, an
intraperitoneal approach is used with an incision from the symphysis pubis to a point
midway between the xyphoid process and the umbilicus. Our approach for simple
cystectomy in this case is the same, with the parietal peritoneum carefully preserved as
a boundary between the peritoneal contents and the raw pelvic surfaces.
Postoperatively, a drain is left in the pelvic space if the operation was performed in the
presence of pyocystis. We rarely find it necessary to leave this drain more than 48
hours. Otherwise, we do not routinely leave a pelvic drain unless the patient will have
placement of an orthotopic bladder.

PARTIAL CYSTECTOMY
Partial cystectomy has had a role in the management of bladder cancer for many
years, though its exact role today is not well defined. The advent of improved means of
transurethral resection of bladder tumors plus an improved understanding of the natural
biology of bladder tumors has ensured that partial cystectomy today is a much less
practiced procedure than in the past. There are certain advantages to partial
cystectomy, such as sparing potency in men, retaining a functioning urinary reservoir,
and the ability to achieve full thickness resection of bladder tumors and sample
perivesical nodal tissue. This makes partial cystectomy an attractive procedure in
selected patients. The major drawback in the use of partial cystectomy in the treatment
of bladder cancer lies in the high tumor recurrence rates, which range from 40% to 80%
in the reported series. Though this ensures that partial cystectomy is an uncommonly
performed procedure, we believe it is an important part of the urologic surgeons
repetoire.
Indications for Surgery

Certain criteria must be met before a patient can be considered for partial cystectomy.
The tumor must be a solitary, primary lesion located in a part of the bladder that allows
for complete excision with adequate margins. We feel that margins of at least 3 cm are
necessary for adequate resection.
Other indications for partial cystectomy include patients who are not candidates for a
complete transurethral resection of a bladder tumor because of a combination of patient
body habitus, hypomobility of the hips secondary to osteoarthritis, or a fixed prostatic
urethra. In this case, partial cystectomy may be required for complete diagnosis. It has
also been recommended that tumors located in bladder diverticuli be managed with
partial cystectomy. This is because bladder diverticuli have attenuated walls that may
easily be perforated with transurethral resection, allowing for tumor spillage into the
perivesical space. Other indications for partial cystectomy are in the management of
genitourinary sarcomas in adults and children, the management of urachal carcinomas
involving the dome of the bladder, involvement of the bladder by tumors in adjacent
organs, and in the palliation of severe local symptoms. Nonmalignant indications for
partial cystectomy include the management of colovesical or vesicovaginal fistulas and
the management of localized endometriosis of the bladder. Few other indications for
partial cystectomy exist.
At one time, partial cystectomy was offered to patients who were considered to be
poor cardiopulmonary risks. However, improvements in surgical technique, perioperative
care, and postoperative care have markedly reduced the operative mortality so that this
is no longer considered an indication for partial cystectomy.

Contraindications to partial cystectomy include patients with multiple lesions,

recurrences, or tumors located on the trigone, where adequate excision is not possible
because of the proximity of the ureteral orifices and bladder neck. In addition, patients
must have biopsy-proven absence of cellular atypia or CIS in the remainder of the
bladder and prostatic urethra. If there is evidence of fixation of the tumor to adjacent
pelvic structures, or if segmental resection of the tumor would require removal of so
much of the bladder as to necessitate augmentation cystoplasty, then a partial
cystectomy should not be performed.
These criteria, therefore, limit the number of patients who are candidates for partial

cystectomy to 6% to 19% of patients who present with bladder cancer. The ideal
candidate for partial cystectomy is a patient with a solitary primary lesion located on the
dome of the bladder with no evidence of diffuse involvement of the urothelium.
Alternative Therapy
Other potential therapies include transurethral resection of bladder tumors, laser
ablation of bladder tumors, intravesical chemotherapy, and radical cystectomy. There
are several problems associated with the performance of partial cystectomy in the
treatment of bladder cancer. After this operation, it can be difficult to treat tumor
recurrence, and the operation cannot be repeated. There is also the real risk of tumor
implantation in the wound, which is both difficult to treat and implies a poor prognosis for
the patient. Several authors have advocated the use of perioperative radiotherapy to the
incision to minimize the chance of tumor seeding. Perhaps the greatest contraindication
to partial cystectomy lies in its questionable efficacy in the treatment of bladder cancer.
Though randomized trials comparing partial cystectomy with other surgical therapies
stage for stage in the treatment of bladder cancer are lacking, recurrence rates ranging
from 40% to 80% have been reported.
Surgical Technique
The patient is placed on the operating room table in the supine position and is
sterilely prepped and draped. The sterile field includes the penis in men and vulva and
vagina in women. This allows for sterile insertion of a Foley catheter into the bladder
after resection of the tumor and before closure of the incision.
We prefer a lower midline incision to a transverse suprapubic incision because it allows
for easier access to the peritoneal cavity if needed. We position the patient on the table
such that the break in the table is at the anterior superior iliac spine, which allows for
adequate flexion of the patient and elevation of the bladder into the wound. The
standard incision extends from the pubic symphysis to the level of the umbilicus. The
rectus abdominis is divided in the midline, and the space of Retzius is entered. The
patient is then placed in the Trendelenburg position to elevate the abdominal contents
out of the pelvis.
Depending on the location of the tumor in the bladder, we proceed with either an
extraperitoneal or an intraperitoneal approach. For tumors located on the dome or

anterior part of the bladder, we prefer an extraperitoneal approach. For tumors located
on the posterior aspect of the bladder, an intraperitoneal approach is preferred.
Extraperitoneal Partial Cystectomy
For our extraperitoneal approach, we expose the anterior surface of the bladder
through the space of Retzius, mobilizing the peritoneum where it is readily separable
from the bladder. A bilateral pelvic lymph node dissection with the boundaries from the
bifurcation of the common iliac artery superiorly to Coopers ligament inferiorly and from
the external iliac artery laterally to the internal iliac artery medially. The bladder is freed
laterally and posteriorly well beyond the site of the tumor. The fat over the site of the
tumor is left attached to the bladder, and the superior vesicle pedicle can be divided if
necessary.
Several stay sutures are then placed in the bladder at a site known from cystoscopy
to be distant from the tumor. The wound edges are packed away from the bladder with
laparotomy pads or plastic drapes, and the bladder is entered between the stay sutures
using electrocautery, taking care to minimize the amount of spillage of urine in order to
minimize the risk of tumor implantation. The incision is extended for several centimeters
anteriorly and posteriorly to allow for adequate visualization of the tumor and its
relationship to the ureteric orifices and bladder neck. The tumor is then excised, with
care taken to leave a 3-cm margin of normal-appearing bladder surrounding the tumor.
The tumor should be removed en bloc with the overlying perivesical fat and peritoneum
using electrocautery or sharp dissection. If the tumor lies less than 3 cm from the
ureteric orifice, sacrifice the ureteric orifice and perform a ureteral reimplantation. If
enough ureter remains, a LeadbetterPolitano reimplantation is preferred, though a
nonrefluxing ureteroneocystostomy or simple nipple reimplantation is acceptable. If
excision of the tumor involves the bladder neck, it is possible to excise the bladder neck
and the surrounding prostatic capsule after enucleation of the prostate gland. We do not
recommend excising any portion of the bladder neck in women in order to avoid
incontinence.
After removal of the tumor, the bladder should be closed in two layers using a 3-0
Vicryl suture to close the urothelium and a 2-0 Vicryl to close the muscular layer. A
suprapubic cystostomy catheter is contraindicated in these patients because of the risk
of tumor spillage, so it is essential that a wide-bore Foley catheter be used. We drain the
perivesical space only if there is concern about the adequacy of bladder closure or a
lymphadenectomy has been performed. The abdominal wall is then closed in the

standard fashion.
Postoperatively the urethral catheter should be left in place for 7 to 10 days. If there
is any doubt as to the integrity of the repair, a gentle gravity cystogram may be
performed. If perivesical drains are placed, they may be removed when drainage is
minimal, usually on the third or fourth postoperative day.
Intraperitoneal Partial Cystectomy
For posteriorly located tumors, we take an intraperitoneal approach. After dividing the
rectus abdominis muscles in the midline, we open the peritoneum in the midline. We
then put the patient in the Trendelenburg position and pack the abdominal contents out
of the pelvis with laparotomy pads. The peritoneum over the iliac vessels is incised, and
we proceed with our bilateral pelvic lymph node dissection as described previously. We
follow the obliterated hypogastric artery to the takeoff of the superior vesical artery,
which we clamp and divide.
The bladder is then freed posteriorly as needed, and stay sutures are then placed in
the bladder, and the bladder is opened as described previously. Removal of the bladder
tumor including the perivesical fat and peritoneum, reimplantation of the ureters, closure
of the bladder, management of urethral catheters and perivesical drains, and wound
closure are all handled as described previously.

Complications
The perioperative and early post operative complications of partial cystectomy and
radical cystectomy include hemorrhage and infection. Infection (in this case, infection of
the intestine is especially dangerous as it can lead to peritonitis (inflammation of the
membrane lining the abdomen).In the case of partial cystectomy, there is a risk of urine
leakage from the bladder incision site ,injury to nearby organs ,complications associated
with general anaesthesia (such as respiratory distress),excessive blood loss ,sexual
dysfunction ,urinary incontinence .Cystectomy can also lead to erection problems for
men if nerves are damaged during surgery.In patients undergoing partial cystectomy,
urinary extravasation is also a possible complication.Long-term complications of partial
cystectomy include reduced bladder capacity and recurrence of the tumor in the pelvis

or in the incision.
Results
When utilized for interstitial cystitis with a substitution of bowel for reconstruction,
partial (subtotal) cystectomy results in relief of pain and return of voiding ability in
approximately two-thirds of patients. When utilized for superficial transitional cell
carcinoma, the results are comparable to transurethral resection of superficial bladder
tumors, but in invasive tumors, the results are inferior to those of radical cystectomy.
Pathologic examination of the specimen will reveal the grade and stage of the tumor. If
perivesical fat or pelvic lymph nodes are involved, it is recommended that the patient
receive three courses of MVAC. Follow-up includes an IVP 3 months after surgery.
Cystoscopies should be performed with bladder washings every 3 months for 2 years,
then every 6 months for 2 years, and every year thereafter. With careful selection of the
case, the reduction in bladder volume should not be so great as to cause urinary
frequency. It is surprising how much of the bladder may be removed without causing
urinary frequency. Even if postoperative frequency does occur, in the majority of cases it
resolves spontaneously within 6 months.

Procedure
Make sure that you talk to your healthcare provider about the procedure, its effects
on you, and the likely outcome. Find someone to drive you home after the surgery. Plan
for your care and recovery after the operation. Allow for time to rest and try to find
people to help you with your day-to-day duties.
Follow your provider's instructions about not smoking before and after the
procedure. Smokers heal more slowly after surgery. They are also more likely to have
breathing problems during surgery. For these reasons, if you are a smoker, you should
quit at least 2 weeks before the procedure. It is best to quit 6 to 8 weeks before surgery.
If you need a minor pain reliever in the week before surgery, choose acetaminophen
rather than aspirin, ibuprofen, or naproxen. This helps avoid extra bleeding during

surgery. If you are taking daily aspirin for a medical condition, ask your provider if you
need to stop taking it before your surgery.
Your provider will give you laxatives and antibiotic pills to cleanse your bowels. Do not
eat anything the night before the procedure, and drink only clear liquids. After midnight
and the morning before the procedure, do not eat or drink anything. Do not even drink
coffee, tea, or water.
Follow any other instructions your provider gives you.
What happens during the procedure?
You will be given a general anaesthetic before the procedure. A general anaesthetic will
relax your muscles and put you to sleep. It will keep you from feeling pain during the
operation.
The surgeon will make a cut (incision) in your abdomen to expose the bladder and tie off
the blood supply to it. Then he or she will remove the bladder (a simple cystectomy).
If you are having a radical cystectomy, the surgeon will also remove the lymph nodes in
the area. In most cases the uterus, ovaries, fallopian tubes, and part of the vagina will
also be removed.
The surgeon will make a new passageway for urine through an opening in your belly.
The new passageway with the opening in the belly is called a urostomy. The surgeon
makes the urostomy by cutting the ureters at the place where they enter the bladder.
(The ureters are the tubes that normally drain urine from the kidneys into the bladder.)
The surgeon cuts out a piece of the small bowel. The ureters are connected to the piece
of bowel. One end of the piece of bowel is brought to an opening made in the skin of
your belly. Urine can drain from the kidneys and out of your body through this new
passageway. An ostomy bag attached to the opening in your skin will collect the urine.
This is called a standard urostomy.
In some cases, the surgeon may be able to make a new bladder inside your body out of
a piece of your bowel. This new bladder can collect urine. It may be connected to the
urethra so that a urostomy and bag will not be needed to drain urine. Or the new bladder
may be connected to a hole in your belly and urine will be drained from it with a small
flexible tube called a catheter. This is a type of urostomy called a continent urostomy.
Passing water:
Ileal conduit

An ileal conduit (also called a noncontinent diversion) uses a segment of your

intestine to create a channel that connects your ureters (tube that goes from the
kidney to the bladder) to a surgically created opening (stoma) on your abdomen.
This procedure is called a urostomy. After a urostomy, the urine passes from the
ureters through the conduit and out the opening into a plastic bag that is
attached to your skin on your abdomen. You will need to empty the bag 3 or 4
times a day, and a larger bag that allows for longer storage can be worn
overnight. Throughout your hospital stay, the nurse specialists in stoma therapy
will visit you regularly to demonstrate how to care for stoma and monitor your
progress and discuss the best products for you. You will also be encouraged to
practice stoma care with the ward nurses on a daily basis once you are alert and
mobile.

Neo bladder (new bladder)

1

A continent reservoir (continent diversion) uses a segment of your intestine to

create a storage pouch that is attached inside your abdomen. The pouch is
effectively treated as a new bladder. If your urethra (tube that goes from your
bladder to the genitals) was not removed as part of the cystectomy, you may be
able to have this type of procedure. In an orthotopic diversion (neo bladder) the
pouch is attached to your ureters at one end and your urethra at the other. This
allows you to pass urine through the same opening as you did before surgery.
Because your new bladder does not know how to fill, contract and release urine
as your original bladder did, you will have to undergo bladder training. This
involves coming back into hospital about two weeks after discharge for 2-3 days.
We will remove the urethral catheter you have been using to void though and ask
you to void urine naturally every hour. By attempting to hold on to your urine for
one hour and then void you are training your bladder to contract and empty. At
night time we will fit a sheath for four hours at a time and wake you at 2am to
void urine. This keeps your bladder alert to emptying and stops the muscles
getting lazy.

2
3

ileal conduit

What happens after the procedure?

You may be in the hospital for 4 to 12 days, depending on your condition. You may be
in an intensive care unit for the first 2 or 3 days. Then , you may have a tube that passes
through your nose into the stomach. The cut in your abdomen may drain for a few days.
If you have a urostomy, you will have a bag on your side to collect urine as it flows out of
the new passage. If you have a new bladder, you will have a catheter for 2 to 3 weeks.
You will need to learn how to drain or dispose of your urine. You should avoid strenuous
activity for the next 6 to 8 weeks.

Pre operative surgery physiotherapy management

Assessment

Physiotherapist should look for any signs or complains by the patient , take
spirometry reading ( to compare before and after surgery , as aimed score )
Treatment
Before surgery, physiotherapist will give patient education. They will talk about the
effect of surgery ,effect of general anaesthesia , effect around incisional site, teach
breathing exercise to prevent further complication in lung, relaxation position, instruction
in scar massage and wound care. Therapist will give Instruction in proper lifting and
movement too. Lastly, therapist will teach the patient to do kegel exercise for bladder
control or training regarding urinary incontinence because patient might has possibility
to get urinary incontinence after surgery.
Post operative surgery physiotherapy management
Assessment
After surgery ,therapist can see that the patient look fatigue ,feel pain at lower
abdomen at incisional sites and slightly difficulty in breathing ,look pale ,has incisional
scar ,check for breathing pattern or chest expansion ,check the pouch or stoma (should
not have skin irritation and leakage ).
Physical examination
After the surgery, patient will reduced abdominal and thigh ROM and reduced
abdominal and thigh muscle power because the surgery involve lower abdomen of the
patient.

Treatment
Leg exercises

Leg exercises help keep muscle tone and promote the return of blood in your leg
veins to your heart. These include pedalling the feet, bending the knees and pressing
the knees down into the mattress.Do not cross your legs - this squashes your veins
causing
obstruction to the blood circulation
Anti-embolus stockings
These are special stockings that help prevent clotting of the blood in your veins while
you are less mobile. The stockings are used in combination with leg exercises and are
fitted by your nurse before your surgery. If you currently have leg ulcers, please let
your nurse know as the stockings may not be suitable for you. Along with anti-embolus
stockings, you may be prescribed a blood thinning medication.
Besides,therapist also can do huffing or supporting cough to the patient. It is
important to reduce pain during cough. Therapist can do breathing exercises or TEE
(thoracic expansion exercise ),Incentive spirometry ,relaxation position by place pillow
below knee or crook lying ,mobility exercise ,strengthening exercise such as abdominal
isometric contraction, bridging ,lumbar stabilization for post- operative treatment.Lastly
therapist should give patient education to the patient such as do kegel exercises a home
for urinary incontinence,posture during sitting and lying, instruction in scar massage and
wound care .Lastly, therapist will give Instruction in proper lifting and movement.

HJS 1053
CARDIORESPIRATORY
CYSTECTOMY
SEM IV

Lecturer s name : Ms. Hanisah

Azahari
Name: Nurulizzati Binti Husin
Matrix No :029040