Cystectomy

8 min read Last updated April 9, 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&amp,E/creatinine/eGFR, LFTs, coagulation, group &amp, 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&amp,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&amp,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

Test yourself…

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&amp,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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