Cystectomy

8 min read Last updated April 8, 2026

Surgical approach

  • Indication usually muscle-invasive bladder cancer (also high-risk NMIBC, refractory symptoms, selected benign disease e.g. radiation cystitis)
  • Approach: open midline laparotomy or robot-assisted (often with open/extra-corporeal diversion)
  • Key steps (radical cystectomy)
    • Pelvic lymph node dissection (variable extent)
    • Bladder removal; in men often en bloc with prostate/seminal vesicles; in women may include uterus/anterior vaginal wall (depends on tumour/approach)
    • Ureteric division and reconstruction into urinary diversion
  • Urinary diversion options
    • Ileal conduit (Bricker): short ileal segment to skin stoma; ureters anastomosed to conduit
    • Orthotopic neobladder: bowel reservoir anastomosed to urethra (requires suitable urethra and patient factors)
    • Continent cutaneous diversion (e.g. Indiana pouch) less common
  • Typical intraoperative issues: major fluid shifts, blood loss, prolonged surgery; bowel handling → ileus; ureteric/vascular injury; stoma formation

Anaesthetic management (overview)

  • Type of anaesthesia: GA ± thoracic epidural (or spinal/epidural + GA); consider regional alternatives (TAP/QL catheters) if epidural unsuitable
  • Airway: ETT (almost always); SGA inappropriate due to duration, aspiration risk, positioning, need for muscle relaxation
  • Duration: typically 4–8 hours (robotic can be longer; depends on diversion and complexity)
  • Pain: severe (open) / moderate–severe (robotic + extraction incision); multimodal analgesia essential
  • Monitoring/lines: arterial line; 2 large-bore IVs; consider CVC if poor access/vasopressors/major comorbidity; temperature monitoring; urinary catheter (often urethral + stents/drains depending on diversion)
  • Key goals: haemodynamic stability, normothermia, blood conservation, goal-directed fluid therapy, lung-protective ventilation, ERAS principles, early mobilisation

Preoperative assessment

  • Patient profile: older, frail, high comorbidity burden; smoking/COPD common; cardiovascular disease common
  • Cancer/therapy-related issues
    • Obstructive uropathy → AKI/CKD, electrolyte disturbance
    • Haematuria → anaemia; iron deficiency
    • Neoadjuvant chemotherapy (e.g. cisplatin-based) → nephrotoxicity, neuropathy, ototoxicity; marrow suppression
    • Prior pelvic radiotherapy → difficult dissection, higher bleeding/adhesion risk; bowel complications
  • Investigations
    • FBC (anaemia), U&E/creatinine/eGFR, LFTs, coagulation, group & screen/crossmatch
    • ECG; consider echo/functional testing if indicated (major surgery, limited METs, symptoms)
    • ABG if significant respiratory disease; baseline lactate not routine but useful in high-risk
  • Optimisation
    • Treat anaemia (iron ± EPO per local pathways), manage anticoagulants/antiplatelets, optimise COPD/heart failure, smoking cessation
    • Discuss epidural suitability (anticoagulation, spine pathology, sepsis, patient preference)
    • Plan postoperative destination: HDU/ICU commonly (especially open, frail, major comorbidity, high blood loss risk)

Intraoperative anaesthetic technique

  • Induction/maintenance
    • Balanced GA with volatile or TIVA; ensure deep neuromuscular blockade if robotic; consider BIS if TIVA/elderly
    • Antibiotics as per local policy (bowel segment used → colorectal-type prophylaxis often used); redose for long cases/major bleeding
    • PONV prophylaxis (high risk: long duration, opioids, bowel surgery)
  • Analgesia strategy
    • Thoracic epidural (e.g. T8–T10): excellent dynamic analgesia, reduces ileus/opioid; watch hypotension/vasopressor requirement
    • If no epidural: intrathecal opioid (selected), TAP/QL blocks or catheters, wound infiltration, IV lidocaine infusion (if local policy), ketamine (opioid-sparing), paracetamol ± NSAID (if renal function permits)
    • Avoid excessive opioids to reduce ileus/respiratory depression; consider PCA if no neuraxial
  • Monitoring and access
    • Arterial line early; frequent ABGs (Hb, lactate, electrolytes), especially with major blood loss
    • Large-bore IV access; rapid infuser available; consider CVC if vasopressors anticipated or poor access
    • Temperature: active warming (forced air, fluid warmer) to prevent coagulopathy and wound infection
  • Fluid and haemodynamic management
    • Use goal-directed therapy (stroke volume optimisation) where available; avoid both hypovolaemia (AKI) and overload (ileus, pulmonary oedema)
    • Crystalloids: balanced solutions often preferred; monitor chloride/acid-base (large volumes of 0.9% saline → hyperchloraemic acidosis)
    • Vasopressors (e.g. noradrenaline) commonly needed, especially with epidural and during major fluid shifts; treat cause, not just numbers
    • Blood management: crossmatch; cell salvage often appropriate in cancer surgery per local policy; use tranexamic acid if indicated (balance VTE risk and local practice)
  • Ventilation/positioning considerations
    • Open: supine; robotic: steep Trendelenburg + pneumoperitoneum → reduced compliance, raised airway pressures, facial/airway oedema; careful fluid balance and cuff leak check before extubation
    • Lung-protective ventilation (TV 6–8 ml/kg PBW, PEEP, recruitment as tolerated); monitor CO2 with pneumoperitoneum
    • Pressure area/nerve protection; arms positioning; eye protection (robotic head-down)

Postoperative care

  • Location: HDU/ICU commonly for open cases, significant comorbidity, major blood loss, vasopressors, respiratory risk
  • Analgesia: continue epidural (monitor block, hypotension, motor block); if no epidural use PCA + regional catheters; regular paracetamol; cautious NSAIDs if CKD/AKI risk
  • Fluids/renal: strict fluid balance, daily weights, U&E; avoid overload; early recognition of AKI/obstruction; consider stoma output and drains
  • Respiratory: incentive spirometry, early mobilisation, physiotherapy; watch for atelectasis/pneumonia
  • GI: ileus common—minimise opioids, early enteral intake per ERAS, chewing gum where used, correct electrolytes (K/Mg)
  • VTE prevention: mechanical + pharmacological prophylaxis; extended prophylaxis often used after pelvic cancer surgery (follow local policy)
  • Complications to anticipate: bleeding, sepsis, anastomotic leak, bowel obstruction, urinary leak, metabolic derangements from bowel diversion, delirium

Physiology and metabolic consequences of urinary diversion (high-yield)

  • Bowel segments absorb/secrete electrolytes when exposed to urine → hyperchloraemic metabolic acidosis (especially ileal/colonic segments)
    • Mechanism: chloride absorption and bicarbonate loss; ammonium absorption contributes
    • Risk increased with renal impairment, dehydration, high urine contact time (continent reservoirs)
  • Electrolytes: may see hypokalaemia (or hyperkalaemia if renal failure), hypocalcaemia; monitor U&E and acid-base post-op
  • Vitamin B12 deficiency can occur long-term with terminal ileum resection (more relevant to longer segments); not an acute anaesthetic issue but viva point
You are asked to anaesthetise a 72-year-old man for open radical cystectomy and ileal conduit. Talk through your anaesthetic plan.

Structure: pre-op assessment/optimisation → intra-op technique/monitoring → analgesia → fluids/blood → post-op disposition.

  • Pre-op: assess cardiorespiratory reserve, frailty, anaemia, renal function/obstruction; review chemo/radiotherapy; plan HDU/ICU; consent for epidural and blood products
  • Monitoring/access: A-line, 2 large-bore IVs, consider CVC; active warming; ABGs for Hb/lactate/electrolytes
  • Anaesthesia: GA with ETT; muscle relaxation; antibiotic prophylaxis and redosing; PONV prophylaxis
  • Analgesia: thoracic epidural (T8–10) + multimodal; if contraindicated use TAP/QL + PCA ± ketamine
  • Haemodynamics/fluids: goal-directed therapy; avoid saline overload; vasopressors often required (especially with epidural); crossmatch, cell salvage if available; consider TXA per policy
  • Post-op: HDU, epidural care, VTE prophylaxis, early mobilisation/ERAS, monitor for AKI, ileus, sepsis, acid-base disturbance
What are the advantages and disadvantages of an epidural for cystectomy?
  • Advantages
    • Superior analgesia (rest and movement), improved coughing/mobilisation
    • Opioid-sparing → less ileus, less PONV, less respiratory depression
    • May reduce stress response and improve gut function within ERAS pathways
  • Disadvantages/risks
    • Hypotension → vasopressors/fluids; risk of fluid overload if hypotension treated with excess crystalloid
    • Failure/migration; motor block limiting mobilisation; urinary retention (less relevant as catheterised)
    • Contraindications: anticoagulation, sepsis, coagulopathy; rare complications (epidural haematoma/abscess)
How would you manage major haemorrhage during cystectomy?

Expect pelvic venous bleeding; be proactive and use a structured major haemorrhage approach.

  • Call for help; activate major haemorrhage protocol; inform surgeon and theatre coordinator
  • Resuscitation: secure large-bore access; rapid infuser; warmed fluids; maintain oxygenation/ventilation; correct hypocalcaemia
  • Transfusion: RBC/FFP/platelets guided by protocol and labs; use fibrinogen replacement if low; consider TXA early if appropriate
  • Monitoring: frequent ABG (Hb, lactate, base deficit), coagulation (TEG/ROTEM if available), temperature
  • Prevent triad of death: hypothermia, acidosis, coagulopathy
  • Consider cell salvage per local policy; document blood loss and products; plan postoperative critical care
A patient becomes hypotensive after epidural dosing during cystectomy. How do you manage this?
  • Immediate checks: confirm BP reading, ECG rhythm, depth of anaesthesia, surgical bleeding, anaphylaxis, pneumothorax (if CVC), high neuraxial block
  • Treat sympathectomy: vasopressor bolus (e.g. metaraminol/phenylephrine) and start noradrenaline infusion if persistent; titrate to perfusion targets
  • Assess volume status with dynamic indices/echo if available; give fluid bolus if responsive but avoid indiscriminate loading
  • Adjust epidural: reduce rate/stop temporarily; consider lower concentration local anaesthetic; add opioid adjunct if needed
What acid–base disturbance can occur after ileal conduit or neobladder formation, and why?
  • Typically normal anion gap (hyperchloraemic) metabolic acidosis
  • Mechanism: bowel mucosa in contact with urine absorbs chloride and ammonium and secretes bicarbonate; renal impairment and dehydration worsen it
  • Clinical relevance: monitor U&E/ABG post-op; treat dehydration, optimise renal perfusion; bicarbonate therapy occasionally required
How does robotic cystectomy change your anaesthetic management compared with open surgery?
  • Positioning: steep Trendelenburg → facial/airway oedema, raised IOP/ICP risk; secure airway/lines; eye protection; pressure area care
  • Pneumoperitoneum: reduced compliance, increased airway pressures and PaCO2; adjust ventilation; consider recruitment/PEEP; monitor ETCO2/ABG
  • Access constraints: patient may be inaccessible once docked; ensure reliable IV access, vasopressors running, emergency plan for undocking
  • Fluid strategy: avoid excess fluids to reduce airway oedema; rely more on vasopressors and goal-directed therapy
What are the key postoperative complications after cystectomy that the anaesthetist should anticipate?
  • Cardiorespiratory: myocardial injury, arrhythmias, pneumonia/atelectasis, respiratory failure (especially frail/COPD)
  • Renal: AKI, obstruction, dehydration; electrolyte/acid–base issues (hyperchloraemic acidosis)
  • GI: ileus, bowel obstruction, anastomotic leak; nausea/vomiting
  • Sepsis: urinary leak, intra-abdominal collections, wound infection
  • Thrombosis: high VTE risk after pelvic cancer surgery
  • Delirium and functional decline in older patients
How would you plan perioperative anticoagulation and neuraxial analgesia for cystectomy?

Answer should reference safe neuraxial practice and local/national guidance (e.g. ASRA/ESAIC/AoA) without quoting exact timings unless confident.

  • Assess indication for anticoagulation/antiplatelets (AF, VTE, stent) and thrombotic risk vs neuraxial bleeding risk
  • If epidural planned: ensure appropriate cessation of anticoagulants pre-op; check platelet count/coagulation; document neurological baseline
  • Post-op LMWH: coordinate dosing with epidural catheter management; avoid dosing close to insertion/removal; monitor for neurological symptoms
  • If anticoagulation cannot be interrupted: avoid neuraxial; use peripheral blocks + multimodal + PCA
What is your extubation strategy after a long robotic cystectomy in steep Trendelenburg?
  • Assess airway oedema: cuff leak test, direct laryngoscopy only if needed; consider delaying extubation if significant oedema/large fluid balance/OSA
  • Ensure full reversal of neuromuscular blockade (quantitative monitoring), normothermia, adequate analgesia, stable haemodynamics
  • Plan for postoperative respiratory support (HFNO/CPAP) and HDU monitoring in high-risk patients

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