Enlargement of the bladder using a segment of bowel

What is the evidence base for this information?

This leaflet includes advice from consensus panels, the British Association of Urological Surgeons, the Department of Health and evidence based sources; it is, therefore, a reflection of best practice in the UK. It is intended to supplement any advice you may already have been given by your urologist or nurse specialist as well as the surgical team at Addenbrooke’s. Alternative treatments are outlined below and can be discussed in more detail with your urologist or specialist nurse.

What does the procedure involve?

This involves enlargement of the bladder through a lower abdominal incision by taking an isolated segment of bowel, and forming this into a patch that is sewn into an opening made in the bladder. It is also known as ileocystoplasty or clam cystoplasty.

What are the alternatives to this procedure?

Observation, bladder training, pelvic floor exercises, drugs, injections into the bladder, urinary diversion, sacral nerve stimulation.

What should I expect before the procedure?

A pre-assessment appointment will also be sent to you to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations.

You will usually be admitted on the same day as your surgery. After admission, you will be seen by members of the medical team which may include the consultant, specialist registrar, junior doctors, your named nurse and possibly a urology nurse specialist. You will also be seen by the anaesthetist before the operation.

You will be given intravenous antibiotics at the time the anaesthetic is given, and possibly after surgery too.

Immediately before the operation, you may be given a pre-medication by the anaesthetist, which will make you dry-mouthed and pleasantly sleepy.

You will be given an injection under the skin of a drug (dalteparin) that, along with the help of elasticated stockings provided by the ward, will help prevent thrombosis (clots) in the veins.

Please be sure to inform your urologist in advance of your surgery if you have any of the following:

• an artificial heart valve
• a coronary artery stent
• a heart pacemaker or defibrillator
• an artificial joint
• an artificial blood vessel graft
• a neurosurgical shunt
• any other implanted foreign body
• a prescription for warfarin, aspirin, rivaroxaban, dabigatran, apixaban, edoxaban or clopidogrel , ticagrelor or blood thinning medication
• a previous or current MRSA infection
• high risk of variant CJD (if you have received a corneal transplant, a neurosurgical dural transplant or previous injections of human derived growth hormone)

What happens during the procedure?

Normally, a full general anaesthetic will be used and you will be asleep throughout the procedure. In some patients, the anaesthetist may also use an epidural anaesthetic which produces freedom from pain post operatively.

Through an incision in your lower abdomen, the bladder will be opened and spilt almost in two. The two halves will then be joined together using a patch fashioned from an isolated segment of bowel and the ends of the bowel from where the segment has been taken will be re-joined.

What happens immediately after the procedure?

The average stay in hospital will last approximately seven to 10 days.

Two catheters will be placed in the bladder for about two to three weeks, one via the urethra and one (suprapubic catheter) via a small incision in the skin over the bladder. There will be a drainage tube close to the wound, to drain fluid away from the internal area where the operation has been done. A tube may be placed through the nose to drain the stomach.

After your operation, you may be in the intensive care unit or the special recovery area of the operating theatre before returning to the ward; visiting times in these areas are flexible and will depend on when you return from the operating theatre. You will have a drip in your arm and you may have a further drip into a vein in your neck.

You will be encouraged to mobilise as soon as possible after the operation because this encourages the bowel to begin working. We will start you on fluid drinks and food as soon as possible.

Normally, we use elastic stockings to minimise the risk of a blood clot (deep vein thrombosis) in your legs.

A physiotherapist will come and show you some deep breathing and leg exercises, and you will sit out in a chair for a short time soon after your operation. It will, however, take at least six months for you to recover fully from this surgery, although much of the recovery comes a good deal sooner than this.

Are there any side effects?

Most procedures have a potential for side effects. You should be reassured that, although all these complications are well recognised, the majority of patients do not suffer any problems after a urological procedure.

Please use the check boxes to tick off individual items when you are happy that they have been discussed to your satisfaction:

Common (greater than one in 10)

• Infection or hernia of the incision requiring further treatment
• Diarrhoea/ vitamin deficiency/ constipation due to shortened bowel, requiring treatment
• Bowel and urine leakage from the anastomosis requiring re-operation
• Scarring of the bowel or ureters requiring further surgery
• Recurrent urinary infections, requiring long-term antibiotic treatment
• Temporary or long-term tendency for the blood to be more acidic than normal, requiring temporary or long-term medication
• Need to self-catheterise because the enlarged bladder will be unlikely to empty fully after the procedure
• Decreased kidney function with time
• Passing mucus in the urine which can cause intermittent blockage of the urinary stream

Occasional (between one in 10 and one in 50)

• Blood loss requiring repeat surgery
• Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death)

Rare (less than one in 50)

• Tumour formation at the site of the join between the bowel patch and the bladder
• Follow-up telescopic examinations of the bladder under local anaesthetic will begin at between 5 and 10 years after surgery to check for this possibility.

What should I expect when I get home?

When you leave hospital, you will be given a discharge summary of your admission. This holds important information about your inpatient stay and your operation. If, in the first few weeks after your discharge, you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge.

You will require painkillers at home for two or three weeks and it may take two or three weeks at home to become comfortably mobile.

You may go home with one or both catheters still in place, and have a planned return to hospital for these to be removed. If so, you or your carers will be taught how to look after the catheters and the drainage systems for them.

You will need a second visit to hospital for an x-ray test on the bladder at around three weeks (cystogram). If this is normal and shows no bladder leak, your catheters will be removed in hospital.

You should avoid driving for at least six weeks, and it may be longer before this is possible.

If you work, you will need a minimum of six weeks off, and it may be significantly longer if your work involves physical activity.

Heavy lifting should be avoided for six weeks.

Sexual intercourse should be avoided for at least a month.

You may see blood in the urine or vaginal discharge for up to a month after surgery.

What else should I look out for?

If you go home with catheters, you or your carers should check regularly to ensure that urine is draining via the catheters, which confirms that the catheters have not blocked. If the catheters are both blocked this could put pressure on the suture line in the bladder, and so the catheters would need to be flushed and unblocked very promptly.

Are there any other important points?

The urology specialist nurses will keep in contact by phone and by clinic visits in the first couple of months after surgery, and be available for long term follow up.

A follow up outpatient appointment will be arranged at about six to eight weeks after surgery.

Driving after surgery

It is your responsibility to ensure that you are fit to drive following your surgery.

You do not normally need to notify the DVLA unless you have a medical condition that will last for longer than three months after your surgery and may affect your ability to drive. You should, however, check with your insurance company before returning to driving. Your doctors will be happy to provide you with advice on request.

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high tech equipment and/or specialist one to one care is required.

Hair removal before an operation

For most operations, you do not need to have the hair around the site of the operation removed. However, sometimes the healthcare team need to see or reach your skin and if this is necessary they will use an electric hair clipper with a single-use disposable head, on the day of the surgery. Please do not shave the hair yourself or use a razor to remove hair, as this can increase the risk of infection. Your healthcare team will be happy to discuss this with you.

References

NICE clinical guideline No 74: Surgical site infection (October 2008); Department of Health: High Impact Intervention No 4: Care bundle to preventing surgical site infection (August 2007)

Is there any research being carried out in this field at CUH?

There is no specific research in this area at the moment but all operative procedures performed in the department are subject to rigorous audit at a monthly audit and clinical governance meeting.

Who can I contact for more help or information?

Oncology nurses

Uro-oncology nurse specialist
01223 586748

Bladder cancer nurse practitioner (haematuria, chemotherapy and BCG)
01223 274608

Prostate cancer nurse practitioner
01223 274608 or 01223 216897

Surgical care practitioner
01223 348590 or 01223 256157

Non-oncology nurses

Urology nurse practitioner (incontinence, urodynamics, catheter patients)
01223 274608

Urology nurse practitioner (stoma care)
01223 349800

Urology nurse practitioner (stone disease)
07860 781828

Patient advice and liaison service (PALS)

Telephone: 01223 216756
PatientLine: *801 (from patient bedside telephones only)
Email PALS

Mail: PALS, Box No 53
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

Chaplaincy and multi faith community

Telephone: 01223 217769
Email the chaplaincy

Mail: The Chaplaincy, Box No 105
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

MINICOM System ("type" system for the hard of hearing)

Telephone: 01223 217589

Access office (travel, parking and security information)

Telephone: 01223 596060

What should I do with this leaflet?

Thank you for taking the trouble to read this patient information leaflet. If you wish to sign it and retain a copy for your own records, please print this page.