21st July 2020
Orthotopic / Neo-bladder / Bladder reconstruction
If you have to have your bladder removed or reconstructed this type of operation is an alternative to having a urostomy where you would have a stoma and wear a urine collecting pouch on your abdomen. Instead this operation allows you to pass urine naturally.
Your urologist may be able to replace or reconstruct your bladder if:-
- The bladder has to be removed completely due to cancer in the bladder or other pelvic organs
- The bladder or urethra does not function properly due to an abnormality. Sometimes this may have been present from birth.
- The bladder is very painful, causing severe urinary frequency, due to a condition known as interstitial cystitis/painful bladder syndrome.
- The bladder has reduced capacity due to chronic inflammation or radiotherapy treatment
- A kidney transplant is necessary and your own bladder is unsuitable to take the transplant
- You have a urinary stoma (urostomy), which is no longer working. The tubes from the kidney, which transport urine, are sewn back into the neo-bladder so that a stoma is no longer necessary. This is known as “undiversion”.
Before a decision is made to proceed with a bladder reconstruction, several investigations, including blood tests and scans, will be necessary to make sure it is the best option. If you have had previous radiotherapy to the pelvis or a history of bowel problems this procedure would not be possible. If an undiversion is being considered bladder pressure studies (Urodynamics) will give information about how the bladder is behaving and whether the sphincter muscles are strong enough to keep you dry without any urinary leakage.
How the new bladder is made
A piece of intestine (bowel) is used to reconstruct the new bladder. A length of intestine is isolated and the remaining part is rejoined back together so that it will continue to function as before. As the intestine is like a tube it is opened lengthways and then stitched together in the most suitable way to form a new bladder. It is then joined either to the existing bladder or to the urethra (the tube through which the urine passes to the outside). The ureters bringing urine from the kidneys are inserted into the bladder to complete the operation.
How the new bladder works
The muscles in the new bladder will not work in the same way as a normal bladder. Initially you may not have complete control of the new bladder but you will be shown how to perform pelvic floor exercises to strengthen the muscles. Sometimes the continence problem persists at night and you will be advised to set an alarm clock once or twice to empty your new bladder before it gets too full and may leak.
The capacity of the new bladder will increase over time and after 3-6 months it should hold about a pint of urine (similar to a normal bladder capacity). Initially you will be advised to empty your new bladder at 1-3 hour intervals and then gradually build up the time in between. As the nerve supply to the new bladder has been interrupted you will not have the same sensation when the bladder requires emptying. You will need to relax your pelvis and strain your abdominal muscles to squeeze urine out. Men may find it easier to sit on the toilet to empty the bladder.
Excessive straining is not recommended and if you are unable to expel all the urine you will have to use a fine tube (catheter) to drain your new bladder. This is known as Clean Intermittent Self Catheterisation (CISC).
Arrangements may be made for you to be shown this procedure before surgery, so that you understand the implications and are physically able to perform the technique. You may have to use a catheter each time to empty your bladder to drain any residual urine. It is important your bladder is emptied completely, as any urine remaining may irritate the bladder and be a source of urinary infection or stone formation which could cause problems with the kidneys.
The intestine used for the new bladder will secrete a thick, white, jelly-like substance called mucus. This will always be present in the urine and is quite normal. You may be advised to flush the bladder regularly to remove excess mucus.
Preparing for surgery
The Urologist and Specialist Nurse should provide you with information so that you understand the implication of the surgery and how it will affect you afterwards. There are permanent changes to the body by this surgery which affect urinary, sexual and reproductive function and sometimes bowel function. The bowel is shortened when a section is removed to make the new bladder. There are also risks with any major surgery and these should be explained to you.
The surgery is a major undertaking and a hospital stay of 2-3 weeks should be expected. The medical and nursing staff in the urology unit will explain the pre and post-operative care and any possible complication which may develop. You will be given fluids through an intravenous drip until you are able to drink enough. You will be given adequate pain relief which you may control yourself.
You will have a catheter in your new bladder, a drain in your abdomen which is usually removed after a few days and also two fine tubes will be draining the kidneys and these are usually removed after 7-10 days.
After the initial surgery you will be allowed to go home for a few weeks with a catheter inserted, to allow healing. You will be shown how to flush your new bladder to remove excess mucus. It is important that the catheter does not become blocked. On re-admission to hospital the catheter will be removed and you will be instructed how to empty the new bladder.
Note: Protocols vary in different urological centres and Urologists also have their own preferences.
Your Urologist and Specialist Nurse will give you any specific instructions and the following information should give you an idea of what to expect.
It will take several months before you regain your strength. A healthy, nutritious diet is recommended to promote recovery. Fresh fruit, vegetables and plenty of liquids will help to prevent constipation. After any surgery involving the bowel, the action of the bowel may be disturbed for a while. This can continue and may need treatment to help it settle.
Heavy lifting must be avoided for at least three months.
Driving should be avoided for at least 6-8 weeks, to give time for tissues inside the abdomen to heal properly. Your Consultant will advise you when you can start driving again.
Back to work
Depending on the nature of your work, an average of three months is usually required for convalescence after major abdominal surgery.
Some active sporting hobbies may be resumed after about three months, but it is always best to consult your Consultant or Specialist Nurse.
Travelling in either this country or abroad for business or pleasure should not be a problem. In hot weather extra fluids should be taken to reduce the risk or dehydration and urinary infection.
If travelling by air, catheters should be carried in your hand luggage. When applying for holiday insurance, pre-existing medical conditions must be declared including the neo-bladder. Details of suitable travel insurances are available from the Association’s National Secretary.
If your bladder has been removed completely you will have been warned about changes in sexual function.
Men – as the prostate gland lies close to the bladder it is also removed to eradicate any cancer cells. The nerves that are responsible for obtaining an erection touch the prostate gland and are also removed. In a few cases, nerve sparing surgery may be possible. If not treatment is available if you wish.
Women – if the surgery is for cancer, the uterus, fallopian tubes and ovaries are also removed. Some tissue is removed between the bladder and vagina as it has a shared blood supply. The vagina may be shortened causing some discomfort during intercourse. Trying a different position may help.
For further details see the following UA leaflets:
- Male Sexual Matters
- Female Sexual Matters and Pregnancy
If your own bladder has been reconstructed, resuming sexual activity should not be a problem, as soon as you feel strong enough.
After bladder reconstruction, advice should be sought from your Urology Consultant who understands your medical condition and will advise about the possibility of becoming pregnant. Obviously, if you have had your bladder and reproductive organs removed due to cancer pregnancy is not possible. For further details see the Urostomy Association leaflet “Female Sexual Matters and Pregnancy”.
It is essential to keep hospital appointments to ensure that the new bladder and your kidneys are working well. For guidelines of when to seek advice from your GP and which annual investigations are required see our leaflet “Expectations of care for people with a Neobladder in the Primary Care setting”.
Important points to remember
- Empty your new bladder at the recommended intervals
- Drink plenty of fluids – at least 2-3 litres daily
- A pendant or bracelet alerting healthcare professionals of your medical condition is advised, especially if you intend to travel abroad.
Note: This leaflet has been written only as a guide to what may happen when the bladder is replaced or reconstructed. Remember that procedures may not be the same in your Urology Department.