Transcript: What to Expect with a Radical Cystectomy, Part 2

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Voice over:

This is Bladder Cancer Matters, the podcast for bladder cancer patients, caregivers, advocates, and medical and research professionals. It’s brought to you by the Bladder Cancer Advocacy Network, otherwise known as BCAN. BCAN works to increase public awareness about bladder cancer, advances bladder cancer research, and provides educational and support services for bladder cancer patients and their loved ones. To learn more, please visit bcan.org.

Rick Bangs:

Hi, I’m Rick Bangs, the host of Bladder Cancer Matters, a podcast for, by and about the bladder cancer community. I’m also a survivor of muscle invasive bladder cancer, the proud owner of a 2006 model neobladder and a patient advocate supporting cancer research at the Bladder Cancer Advocacy Network, or as many call it BCAN, producers of this podcast. I’m pleased to bring you part two of my conversation with Dr. Sia Daneshmand about radical cystectomy. If you missed it, please tune into part one of our conversation. Dr. Daneshmand is currently Professor of Urology with Clinical Scholar designation and serves as Director of Clinical Research as well as the Urologic Oncology Fellowship Director at the University of Southern California, USC, in Los Angeles.

All right, so we’re going to move to phase two. I’ve shown up at the hospital, it’s the day of my surgery, so how long is my surgery typically going to last? And I’m pretty sure the length of surgery might depend on my choice of diversion or whether there’s open or robotics. So what’s kind of the standards here?

Dr. Sia Daneshmand:

Wow, you hit upon a couple of things that will take me an hour to answer in a lecture, but I’ll summarize for you in lay language. So you hit upon the type of diversion and also the approach to surgery, robotic versus open, and I’ll try to be unbiased and give you an overview. So let’s talk about diversions first. Depending on what type of diversion you use, honestly, the recovery and the time in the hospital is not different at our center. Whether you have a neobladder, an ileal conduit, or an Indiana pouch, you are on exactly the same pathway. The only difference being the management of those things by the nurses and the teaching and whatever goes on and home health. So that’s the only difference. But as far as your diet, the way we manage it, the antibiotics we use, all that stuff is very, very similar with a slight difference in the Indiana pouches or the continent [inaudible 00:02:42] we use a different set of antibiotics because we’re using the colon, so that part’s easy.

And then the follow-up for the patients is also very similar. Now we see patients at our center 10 days after surgery and again, 21 days after surgery. And depending on the diversion you have, you’re just different sort of nursing care and needs depending on whether you need to learn how to change the bag or you need to learn how to irrigate your neobladder or we’re teaching you Kegel exercises at the three-week mark and self catheterization if you have a Indiana pouch or something. So more or less the same.

Now the other is a much more controversial issue and we are constantly having debates at our meetings whether there’s a difference between open surgery and robotic surgery. We all love robotic surgery because it seems like it’s much more technologically advanced and it’s certainly made a huge, huge difference in recovery for certain types of cancers like kidney cancer for instance, doing partial nephrectomies. We’ve gone from a complicated surgery to one that’s much more routine and patients going home the next day, radical nephrectomies, prostatectomy and so on and so forth.

In bladder surgery because of the reconstruction and the lymph node dissection and the time required to do all this stuff, it tends to be a longer operation with robotic surgery. So instead of the four or five hour surgery, it’s more like six to seven hours with a robot. So it’s consistently longer and it’s because there’s only so much we can speed up the operation with robotic hands. The question is, is it worth it? You have longer surgery is six, seven hours if you’re doing a neobladder, is it worth the recovery? Is it shorter? And there’s been a number of clinical trials trying to answer this question and each of them have their own specific sort of little nuances.

The bottom line, bottom line is that robotic surgery leads to a longer surgery, lower blood loss, in general, it’s less wound infections, but the hospital length of stay is more or less the same. There was a recent trial showing 2 less hospital days in the hospital over a 90-day period with robotic surgery versus open surgery in England. So each of them have their biases and 2 days over a 90-day period is really not that significant a change.

Bottom line, I think both approaches are acceptable. At our center, there’s no difference in the recovery between open or robotic surgery. We’re talking about a very small incision below the belly button with open surgery, and six or seven small incisions across the abdomen for robotic surgery. So we talk to patients about H1, but in general, I think patients are more concerned about the cancer control and sort of the urinary diversion option than the approach you take. Whatever the surgeon’s comfortable with, I think that’s what they should do. Fortunately, both are equivalent in cancer control, so there’s no difference there. So really surgeon preference and I would say no difference in outcomes.

Rick Bangs:

Okay, good. Now how long am I going to be in the hospital? And while I’m there, what kind of milestones are you looking for as my doctor?

Dr. Sia Daneshmand:

Yeah, so great question. Everybody wants to know that and it’s highly regional and highly dependent on the center you’re at. The typical hospital stay in the US, the average hospital stay is about seven to eight days. Now with enhanced recovery after surgery where we’re feeding you earlier, I’m sure that back in 2006 you must have stayed in the hospital at least a week because that was routine. But nowadays, our average hospital stay at USC is four days. So that means average, many patients are going home day three after surgery, which is really quick and that’s part of the enhanced recovery. If we’re feeding you on day one and you’re having … You said milestones and one of the big milestones is having a bowel movement. That’s when we know the bowels are moving. If the patient’s not distended, they’re eating, walking, having bowel movements and their labs are normal, you’ve met your discharge criteria. There’s no magic to it. It’s sort of obvious that the patient’s pain is under control and all those things I just mentioned.

Now in places like Europe where they keep patients, they don’t send anyone home with catheters and drains and things, we’ve got a problem because these catheters are staying in for weeks. So in parts of Europe you are seeing 2 week hospital stays, 14 to 17 days I’ve seen, which is really remarkable because I’m not sure, by then half our patients were halfway recovered. So yeah, highly dependent on the center. But in the US the typical hospital stays are about five to six stay, probably six days on average, six to seven with highly specialized centers sending home patients home at day three and four.

Rick Bangs:

Okay, so I would want the American version.

Dr. Sia Daneshmand:

Yeah, exactly. You don’t want to be hanging out in the hospital for that long.

Rick Bangs:

No. No. Just getting sleep in the hospital is not that easy.

Dr. Sia Daneshmand:

Exactly. Yeah.

Rick Bangs:

Okay. So you mentioned pain, and I know for me and for other people I’ve talked to, pain is something we are all apprehensive about. But I think even in 2006 it was better managed than I expected. So what’s the state of the art now? How well is my pain going to be controlled?

Dr. Sia Daneshmand:

Yeah, good question. And you’re right. We did manage pain pretty well there then, but it’s all about, again, the ERAS pathways and we want to … Back then we relied heavily on opioid medication, which does control pain quite well, but it also leads to constipation, leads to patients not feeling that great. So the buzzword nowadays is multimodal pain management and multimodal just means different pathways. So we use a little bit of Tylenol, we use NSAIDs or the nonsteroidal anti-inflammatories like Advil, Motrin, and we have different versions of those that are given intramuscularly or intravenously. And then at our center we use these little pain catheters. They look like an opposite of an epidural. We use it in the front of the abdomen and they squeeze out Marcaine or ropivacaine, which is a cousin of lidocaine to numb up the muscles in the front. So all around different types of pain medications to help manage the pain. Like you said, it’s not that bad, you’re going to have cramps.

I think patients complain more about the bowel cramps that happen day two and day three, while their bowels are sort of waking up and having a bowel movement than the actual incisional pain. So the incisions are small and not very different. And people ask with robotic surgery, is it less pain because your incisions are smaller? And I think because of what I just mentioned, the answer is not really. The pain scores tend to be the same because you’re having intestinal cramping pain while your bowels are waking up. So we do have good pain management right now, that’s not the number one complaint when patients are going home. I think the number one complaint is still the catheter, the drain, and so just the discomfort and, “I’m just not feeling well. I’m tired” and all those things that we hear all the time. “And food doesn’t taste good, I get full really fast,” and all those types of things tend to be more bothersome than the actual pain.

Rick Bangs:

So now let’s talk about activities. So I think you’re going to want me out of bed pretty quickly.

Dr. Sia Daneshmand:

Yes.

Rick Bangs:

So how quickly before you want me out of bed and why do you want me out of bed? Because I don’t want to get out of bed.

Dr. Sia Daneshmand:

Right, exactly. Before your eyes open, we want you up. So I just woke up from surgery and so there’s a lot of benefits in post-surgery. You see it in cardiac, it’s not isolated to radical cystectomy, but you see it in all surgeries or we want you up. When you’re laying down and recumbent and not breathing well, fluid is accumulating in the lung. You’re not taking deep breaths, your lungs are not expanding, there’s higher chance of infection. We think that ambulation helps. We don’t think. We know that ambulation helps with general recovery and the bowel recovery. So we do want you up and walking. It’s just good for all parts of the body. It’s good for the physiology and those were shown a long, long time ago that early ambulation leads to better outcomes. So it’s just part of the dogma of … Well dogma with evidence, I suppose that early ambulation really does make a difference in patient recovery. The more they do, the better the outcomes.

And we actually again did another pilot study that was very cool. We had patients wear these activity bands. There’s lots of them where you can count the steps and things like that. And we showed that in the hospital in a blinded fashion, we didn’t know how many steps they were taking, they didn’t know, but we collected the data and we showed that the patients who walked more and were doing more activity had less complications. It was another sort of proof of the pudding that, yeah, these things do matter.

Rick Bangs:

Oh wow, it’s a win-win.

Dr. Sia Daneshmand:

Yeah.

Rick Bangs:

Okay. So now some people would be familiar with a nasogastric tube. It’s that tube that comes out of your nose. Am I going to have one of these in 2024? And if so, how long am I going to have that?

Dr. Sia Daneshmand:

Yes, good question. So the answer is a resounding no, you’re not going to have that. So we don’t use NG tubes any longer. That’s again, part of that enhanced recovery after surgery. We do use it intraoperatively. We put an orogastric tube just to keep the stomach empty, but as soon as you wake up, that tube is being removed, actually before you wake up, before you extubate it and getting off the ventilator. And postoperatively, we don’t use it. Like I said, we’re having you eat the first day. So that dogma of keeping the bowel rested and sucking out all the fluid and air and stuff was shown in multiple different studies to actually be counterproductive. And you’re sucking out fluids that the stomach is trying to produce and you’re really not making a difference in terms of return of bowel function.

So no, we don’t use it unless you’re throwing up multiple times and or things are just not moving through and the patient’s getting distended with air and gas and things like that, then yes, we do have to use NG tubes. But I can tell you exactly how many times that happens. We’ve done multiple studies and we showed that the ileus rate, the rate of this happening where the bowels are not moving before ERAS was about 25%, very high. And we showed that it went down to 11% after ERAS. So 1 out of 10 patients still gets it and requires it, but for the most part, 9 out of 10 do not need it.

Rick Bangs:

Excellent, excellent. All right. So mine is a food-centric family. And I remember asking, I remember there was a physician’s assistant and apparently I asked more often than he thought I should, “When was I going to be able to eat?” Which now this is before the surgery, so I’m not even in the hospital. So I heard you say that I’m going to be able to eat on pretty much that first day day. So I think I heard some things that went beyond liquid. So am I pretty much eating … I understand the quantities, you’re going to control a little bit, the quantity that I eat, but am I really eating a regular diet now?

Dr. Sia Daneshmand:

Regular diet, Rick. Absolutely. Now that’s kind of unique to our center a little bit, I think. And some other centers, of course. We’re not the only ones, but we were, I think, one of the very first to introduce this idea of an absolutely regular diet on day one. If you come here, you’ll see they’re getting scrambled eggs and toast on day one. And we showed through our experience that it’s safe, that patients tolerate it, they like it, and also it’s good and they’re having bowel movements sooner. So we published a number of studies on our RRAS protocols that are widely available to everyone to see. Everyone’s afraid of feeding patients on day one, thinking they’re nauseous, they’re going to throw up, but for the most part it doesn’t happen.

Rick Bangs:

Wow. Wow. That’s great. All right, so I’ve got my new diversion and I’m in the hospital and I mean, this is all brand new to me. So what types of procedures am I going to do? We’ll break it into the three major diversions. And am I going to get any training? Because you’re going to discharge me at some point. So am I getting any training? So let’s start with the ileal conduit, which is the most common choice, and then we’ll talk about neobladder and Indiana pouch. So what’s the process?

Dr. Sia Daneshmand:

So the process is absolutely, you get training first of all in the hospital and the nurses come around on that day 1, 2, 3. And it’s very important in those first few days because the patient’s sort of concentrating on trying to recover from the surgery. But the patients are getting training in the hospital, they’re watching videos and then post-op, the home health nurse is going over. So they’re doing the bag changes and eventually teaching the patient and the family how to change the wafers and stuff as part of the recovery process. And many of them have home health nurses keep coming to their house beyond the first 30 to 60 days even. But most patients or their families can manage those bag changes quite easily. It’s not rocket science. You just need to learn how to take off the wafer, put on the wafer. But we have multiple teaching sessions with patients and families.

Rick Bangs:

All right, and what about with the neobladder? So you mentioned irrigation, which I remember was like flushing with some sterile saline.

Dr. Sia Daneshmand:

Yeah.

Rick Bangs:

So I’m flushing out mucus, I believe was what I was flushing out.

Dr. Sia Daneshmand:

Exactly.

Rick Bangs:

So I’m going to be irrigating while I’m in the hospital, I assume because I’m going to be irrigating when I leave, so I ought to know how to do that.

Dr. Sia Daneshmand:

Exactly. Yeah, exactly. So it’s the same concept. We’re having the nurses teach you neobladder irrigation. Again, it’s not something too difficult. Exactly as you described, you’re pushing in saline into the neobladder and then aspirating it out to get rid of the mucus and blood clots. And we don’t want this catheter to get clogged. So we want this to be irrigated. The bowel produces mucus, this white thready stuff that accumulates in the neobladder and it doesn’t readily come out. So irrigating is very important. You’re doing it three, four times a day and when you go home, you’re doing that a few times a day. Once the catheter comes out, you don’t need to irrigate as much. I do teach the patients how to self catheterize and for the first few weeks at least self irrigate the neobladder. But not everybody does that. It’s not entirely necessary either. I think once the catheter is out, most of the time most patients are voiding all the mucus out, and over time that mucus production will decrease. It’ll never go away, but it’ll decrease substantially.

Rick Bangs:

Okay. So what about the Indiana pouch, which is kind of sort of a hybrid between the neobladder and the ileal conduit. What procedures and training might happen at the hospital?

Dr. Sia Daneshmand:

Yeah. So typically the patients are waking up with a couple of catheters into the pouch. So one is a temporary tube that drains the pouch. It’s a larger tube to make sure the mucus and bloody urine and clots and things like that get out. And then there’s the channel usually at the belly button or the umbilicus. There’ll be a smaller catheter and that’s going to be the channel they’re going to be using to self catheterize. And that’s a smaller one that typically we just leave alone for a few weeks, let that track heal while the temporary tube on the side is draining the urine. And similar to the neobladder, they’re learning irrigation techniques. So they’re learning to irrigate the pouch through the bigger catheter several times a day to help eliminate the mucus that builds up.

Rick Bangs:

Okay. All right. So now I’ve had my surgery and I’m really, really keenly interested in seeing my pathology report or any insights that you can provide as the surgeon. So when might that happen?

Dr. Sia Daneshmand:

That usually [inaudible 00:19:19] really hospital dependent, and it depends on how many cases they have of course, but you have to realize that’s a lot of tissue to look at. They’re looking at the bladder and then, in men, the prostate, and in women, sometimes the additional female genital urinary organs, the vagina, cervix, uterus, ovaries and things like that. And of course there are the lymph nodes. So all this takes time to create slides and have the pathologist review all these slides and give us a stage. So at the earliest, usually 4 days, but I tell the patients, give it a good week or 10 days before we get the report back and report back. Then we can tell them about the actual stage of the cancer at that time.

Rick Bangs:

Okay. And so you mentioned two catheters for the Indiana pouch. Obviously there’s a catheter for the neobladder. So I remember leaving the hospital with a catheter, I’m assuming the Indiana pouch folks leave with at least one of the two catheters. So how long am I running around with a catheter, which is not my favorite thing, by the way? And is there a difference if I get an Indiana pouch versus a neobladder, how long I’m wearing the catheter?

Dr. Sia Daneshmand:

So generally both of them are three weeks. That tends to be our general rule for these types of tubes to stay in for three weeks. Now the Indiana pouch is a tube through the side of the abdomen, not as uncomfortable as it would be through the penis as you explored in your journey.

Rick Bangs:

Yes.

Dr. Sia Daneshmand:

What I tell the patients though, the first thing they think of when we talk about catheters is the experience they had with the TURBT shortly before the bigger surgery. And I tell them, “Look, it’s a little bit different. In men, the prostate’s no longer in place. The neobladder has no sensation, and so you’re not going to be feeling those contractions of the bladder and those spasms that can be quite painful.” So the discomfort is certainly still there at the tip of the penis, but you don’t again have those bladder spasms and contractions, which can be really difficult for patients. So a little bit different experience there. And that stays in for three weeks. Now, during this time, certainly the patients are walking around and they have a catheter, they can have a leg bag. They’re not bed bound or anything like that. We actually, in fact, quite the opposite. We want them to be as active as possible. But yeah, it’s not comfortable. They’re happy to get that out.

Rick Bangs:

Yeah, yeah. And the walking is key.

Dr. Sia Daneshmand:

Exactly.

Rick Bangs:

Walk a lot in the hospital and certainly when you’re home.

Dr. Sia Daneshmand:

Yeah.

Rick Bangs:

That’s all the time we have today for part two of my three part fascinating conversation with Dr. Sia Daneshmand about radical cystectomy. We invite you to tune in and in case you missed it, listen to part one of this episode wherever you get your podcasts.

Voice over:

Thank you for listening to Bladder Cancer Matters, a podcast by the Bladder Cancer Advocacy Network or BCAN. BCAN works to increase public awareness about bladder cancer, advance bladder cancer research, and provide educational and support services for bladder cancer patients. For more information about this podcast and additional information about bladder cancer, please visit bcan.org.