Recovery After
Robotic Radical Cystectomy

Care after bladder removal follows an enhanced recovery pathway: a set of steps before, during and after surgery that help the body return to normal sooner. It means eating and drinking earlier than used to be the case, getting out of bed on the day of surgery, and using pain relief that avoids heavy use of opioids, because opioids slow the bowel.

Robotic surgery with the reconstruction performed inside the body supports this. In a randomised trial comparing it with open surgery, patients spent more days alive and out of hospital in the first 90 days, and had fewer blood clots and fewer wound problems.

You will be helped to sit out in a chair for a few hours on the day of surgery, and to start walking soon afterwards. Aim for short walks around five times a day, with breathing exercises using a spirometer and simple leg exercises. This is one of the most effective ways to reduce the risk of chest infections and clots.

A tube passed through the nose into the stomach during the operation is removed before you wake, and is not usually needed afterwards. Eating and drinking restart in stages:

• sips of fluid on the evening of surgery
• clear fluids on the first day, with a daily limit set by the team
• a full liquid diet on the second day
• once you pass wind, usually the night of the second day, soft food and then a normal diet

Fizzy drinks are avoided because they cause bloating. A gentle laxative is used until the bowel settles, and simethicone helps with trapped wind. Alongside pain relief, you may be given medicines that help the bowel start working again.

Antibiotics are given for about 48 hours. Injections to prevent clots begin in hospital and continue for a total of about 30 days, usually as a tablet after you go home.

A drain is left near the site of the operation and is removed once it settles and tests confirm there is no urine leak.

If you have an ileal conduit (urostomy), fine tubes called stents protect the join between the ureters and the conduit. They are removed at a clinic visit about 7–10 days after surgery, which is quick and painless.

If you have a neobladder, the catheter and the stents stay in longer, usually around three weeks, and are removed after a CT scan (CT cystogram) shows the new reservoir has healed. An antibiotic is started the day before removal and continued for three days.

The typical stay in hospital is 4–6 nights. The most common reason for staying longer is the bowel being slow to restart, which usually settles with time and conservative measures. Where the delay is significant, intravenous nutrition may be used in the meantime to avoid malnutrition.

The stoma is swollen and tender at first and usually settles over two to three weeks. It will look red and moist, which is normal.

• empty the bag when it is about one third full, roughly every four to six hours, and before bed
• use a larger night bag so you are not woken
• check the skin around the stoma at every bag change, and measure the stoma as it shrinks in the early weeks
• expect mucus strands in the urine: this comes from the bowel segment and is normal
• urine may look pink for the first few weeks

Your stoma nurse will teach you all of this before discharge and will keep supporting you afterwards. Most people become confident with bag changes within a few weeks.

A neobladder has to be trained, and continence improves gradually over months rather than weeks.

• flush the neobladder daily as taught, to clear mucus
• pass urine by the clock at first, roughly every two to three hours in the day, rather than waiting for a sensation
• set an alarm to empty the neobladder once or twice at night, as leakage while asleep is common early on and improves with time, although some people continue to have night-time leakage
• relax the pelvic floor and use the abdominal muscles gently to empty, rather than straining; sitting to pass urine works better than standing
• pelvic floor exercises support daytime control

Some people do not empty the neobladder fully and are taught to pass a catheter themselves from time to time. This is a normal part of neobladder care, not a sign that something has gone wrong.

Bowel habit can be unpredictable for a while, either loose or constipated, because part of the bowel has been used for the reconstruction. Drink enough to keep the urine pale, and eat regular balanced meals, building portion sizes back up gradually; smaller, more frequent meals are easier than large ones. Tell the team if you cannot keep fluids down, as intravenous fluids are sometimes needed if oral intake is not keeping up.

Walk a little every day and increase gradually. Avoid heavy lifting and strenuous exercise for about six weeks so the wounds and internal joins heal.

Many people return to desk work between four and six weeks, and to physical work later. Full recovery of energy commonly takes around three months, and daytime naps are normal at first.

Driving can restart when you are off strong painkillers, can wear a seatbelt comfortably, and could make an emergency stop. Check the position with your insurer.

Bladder removal affects sexual function in both men and women. Where it is oncologically safe, nerve-sparing and organ-sparing techniques are used to reduce this. Changes are common, treatments and support are available, and this is worth raising at follow-up rather than waiting to be asked.

The first review is usually 1–2 weeks after discharge, when the pathology results are discussed. After that, follow-up combines scans and blood tests on a schedule set by the stage of the cancer.

Long-term checks also cover kidney function, the salts in the blood and vitamin levels, because urine is now in contact with a segment of bowel. Late problems can include narrowing where a ureter joins the conduit or neobladder, urinary infections and, in neobladder patients, incomplete emptying. Bacteria are often found in the urine of people with a urostomy or neobladder without causing harm, and are treated only when there are symptoms: a positive urine culture without symptoms does not need treatment.

Contact the clinic, or go to the Emergency Department at Subang Jaya Medical Centre if it is outside working hours, if you have:

• no urine draining into the bag, or an inability to empty the neobladder
• fever, shivering or feeling generally unwell
• worsening abdominal pain, vomiting, or no wind or bowel movement
• heavy bleeding, or urine that becomes cloudy and foul-smelling with pain in the back or side
• a wound that is red, hot or leaking fluid
• calf pain or swelling, chest pain or breathlessness