Cystectomy

Cystectomy

Anesthesia type	General / Neuraxial
Airway	ETT
Lines and access	Partial: PIV x 1 (20) Radical: PIV x 2 (18 or 16)
Monitors	Partial: Standard Radical: Std + art line
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative	hemorrhage, wound infection, DVT, UTI, ureterointestinal leakage, ileus
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A cystectomy is the removal of all or part of the urinary bladder. Most commonly, this procedure is performed to address cancer. May be combined with prostatectomy, ileal conduit, or neobladder reconstruction.

Preoperative management

Patient evaluation

System	Considerations
Neurologic
Cardiovascular
Pulmonary
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Regional and neuraxial techniques

• If spinal used, ensure T4 sensory level
  • Consider using epi in spinal to prolong block
• Can consider placing epidural if significant post-op pain anticipated

Intraoperative management

Monitoring and access

• 2 PIVs for open, radical, or robotic cystectomy (18g+)

Induction and airway management

• GETA

Positioning

• Supine
• Sometimes females placed in lithotomy

Maintenance and surgical considerations

• If robotic, patient will be in steep Trendelenburg for a large portion of the case
• If radical cystectomy, have T&S and consider T&C 2 units
• Some centers use indocyanine 25mg to visualize blood flow to the ureters
• If construction of ileal conduit or neobladder, surgeons generally like to keep the patient dry to prevent diuresis and high UOP during the case; liberalize fluid goals after completion of anastamoses

Postoperative management

Disposition

• PACU

Potential complications

• Bleeding

Procedure variants

	Radical cystectomy	Partial Cystectomy	Open cystectomy	Minimally invasive cystectomy	Robotic cystectomy
Unique considerations	Involves removal of entire bladder, nearby lymph nodes, part of the urethra, and nearby organs that may contain cancer cells	Possible when the cancerous lesion is located in the dome of the bladder. Does not require urinary diversion	Simple, open cystectomy involves removal of the entire bladder without removal of any adjacent structures or organs. Urinary diversion is then created.
Position	Supine, sometimes lithotomy for females	Supine	Supine, one or both arms out		Steep Trendelenburg
Surgical time	4-6 hours	~ 2 hours (urinary diversion not required)			~ 4-6 hrs
EBL	300-1500	Minimal	1000mL		100-200mL
Postoperative disposition					PACU
Pain management					2
Potential complications