Cystectomy and neobladder: how to prepare and what recovery is like

General and important instructions before surgery

Before surgery:

- When you are admitted to hospital, bring all the tests done for the surgery.
- You must fast for at least 8 hours before surgery, including water.
- There is no need to shave the hair on the abdomen and pubic area (trichotomy) at home. If indicated, this will be done at the hospital shortly before surgery.
- Bowel cleansing of the rectum (Fleet enema) is not done routinely. Exceptionally, in specific situations, this procedure may be necessary.
- Allergies to medications, latex, foods and other substances must be reported to the medical and nursing team on admission.
- Antihypertensive medications (blood pressure pills) should be taken even on the day of surgery, with the smallest amount of water needed to swallow them.

​

- Some medications must be stopped before surgery:
- Oral hypoglycemic agents (diabetes pills) should be stopped the day before surgery.
- Antiplatelet agents such as acetylsalicylic acid (AAS®, Somalgin®, etc.) and clopidogrel (Plavix®, etc.) should be stopped at least 7 days before surgery if the patient takes only one of these medications. If both are used, they should be stopped 10 days before the surgical procedure.
- Patients taking anticoagulants such as warfarin (Marevan®) or rivaroxaban (Xarelto®) must stop the medication 5 and 3 days beforehand, respectively. During this period, some patients will need to use enoxaparin sodium or unfractionated heparin until the day before surgery.

After surgery:

- Because this is a major operation, the immediate postoperative period usually takes place in the ICU, where the patient will stay for about 48 hours, or until the medical team considers it appropriate, before moving to a ward room.
- Because the bowel is handled during surgery, all patients remain fasting after the procedure for about 24 to 48 hours; the diet is then reintroduced gradually, starting with liquids and progressing according to the patient's tolerance, the return of normal bowel function and the medical team's assessment. Longer periods of fasting may be needed in some cases.
- Usually, on the morning after surgery, whenever possible, the patient should already be helped out of bed to begin careful early walking, always with the assistance of the nursing team or a family member.
- After the surgical procedure, all patients have a urinary catheter (Foley) placed in the neobladder and an abdominal drain. During the hospital stay, the medical and nursing teams will care for these devices and teach patients and family members how to handle them at home.
- Because the bowel segment used to build the ileal reservoir (neobladder) produces mucus, the reservoir may need to be flushed with saline to prevent the urinary catheter from becoming blocked.

After hospital discharge:

Diet:

- There are no specific dietary restrictions; the patient should eat a healthy diet. In the first weeks, it is advisable to avoid foods that are harder to digest, such as fried foods, foods high in fat or heavily seasoned, and sweets, as they cause intestinal gas to build up.
- Fluids (water, tea and natural juices) can be consumed freely.

Incision care:

- Dressings protecting the incision should be changed daily, preferably after showering. If discharge from the wound soaks the dressing, it can be changed more than once a day. The dressing can get wet; after showering, it should be carefully removed and the wound cleaned with saline, dried and covered with gauze or directly with Micropore tape.
- Usually there is no need to remove stitches, as we use absorbable sutures.
- If the skin around the incision is very irritated by the adhesive tape, hypoallergenic tape can be used, or the incision can even be left uncovered.

Care of the urinary catheter, urine collection bag and abdominal drain:

- All patients who undergo radical cystectomy with creation of a neobladder are discharged with a Foley catheter placed in the neobladder. This catheter requires no special care and should preferably remain secured to the thigh or abdomen. Soap and water can be used freely on the area when showering.

- Under no circumstances should the collection bag be disconnected from the urinary catheter.
- The collection bag must always remain below the level of the bladder, that is, below the waist, to help urine drain. When the patient is seated, the bag can be placed on the floor.

- The urine collection bag should be emptied 4 to 5 times a day or whenever it is full.
- The urinary catheter is usually removed after 14 days. Longer periods (14 and up to 21 days) may be needed depending on each case. Until the catheter is removed, small amounts of blood may appear in the urine (collection bag) or around the catheter through the urethra, usually with movement or minor exertion. Occasionally, a large amount of urine may also leak around the catheter. This usually has no significance and generally happens when the catheter is kinked and urine cannot drain. When this occurs, check the position of the catheter to make sure it is not kinked and that the clamp is not closed.

- Urine drains continuously through the catheter into the collection bag. If you notice a growing sensation of a full bladder and urge to urinate and see that no urine is draining through the catheter, check that it is not kinked and that the clamp is not closed. If the catheter still does not drain, it may be blocked by a clot or mucus, for example, and you should contact the medical team and go directly to the emergency department of the hospital where you had surgery.

- After the catheter is removed, it is advisable for the patient to wear a protective disposable diaper until he or she is sure of having full urinary control.

- After the urinary catheter is removed, many patients have full control and complete continence. Others experience urine leakage, sometimes in large amounts in the first weeks, requiring the use of disposable diapers or pads. This leakage usually improves within 3 months, although in some cases it persists longer. Nighttime urinary catheterization may be needed after the catheter is removed, and the medical and nursing teams will provide guidance.

- The abdominal drain (Blake drain) is a closed system for vacuum drainage of secretions from the surgical site. Its reservoir should be emptied 3 times a day or whenever it is full and has lost its vacuum. The amount discarded, the date and the time should be recorded for later review by the medical team. The drain is usually removed when output is below 100 ml over a 24-hour period.

- Physical activity:

- In the first 4 weeks after surgery, the patient should take relative rest, avoiding strenuous work, carrying weights (including small children and pets) and any kind of intense physical exercise. During this period, however, it is important for the patient to move around carefully, and careful daily walks are allowed.

- After 4 weeks, the patient may do gentle activities such as somewhat longer walks. Work that does not require physical effort may be resumed if the patient wishes. More strenuous activities, such as driving, running, sit-ups, tennis and soccer, horseback riding, cycling or workouts involving greater muscular effort, will be cleared on a case-by-case basis after assessment by the medical team.

- After discharge, the patient may go up and down stairs, as long as this is done carefully.

- Sexual activity can be resumed about 6 weeks after surgery. For men, the presence of erections should be assessed, bearing in mind that the first experiences may be accompanied by some discomfort in the genital area.

- Erectile dysfunction may occur after surgery. At the appropriate time, and if there is no contraindication, the medical team will prescribe medications to help erections recover (tadalafil, sildenafil, among others).

Medications:

- At discharge, you will receive instructions about the medications you will take at home. In general, pain relievers for mild pain are prescribed and, when needed, anti-gas medications and laxatives. Antibiotics are used only prophylactically before surgery and are not prescribed for home use, except in selected cases where the medical team deems it necessary.
- Venous thromboembolism will be prevented by encouraging early walking, using intermittent pneumatic compression devices, compression stockings and, when indicated, medications such as enoxaparin sodium or unfractionated heparin given by subcutaneous injection, according to your risk of developing VTE.

Important:

In case of severe pain that does not improve with the prescribed painkillers, significant bleeding through the catheter or drain, fever, thick yellowish discharge (pus), shortness of breath with pain when breathing, feeling unwell with a drop in blood pressure, or any other complication or question, go directly to the emergency department of the hospital where you had surgery.
- Note: This information is intended as general guidance for patients. It does not replace the personal guidance given by your attending physician, which must be individualized according to the characteristics of the patient, the disease and the planned operation.