INFORMATION FOR PATIENTS FOLLOWING BLADDER SUBSTITUTION

Following the operation you will have to change your daily routine. Although this may be difficult at the start, with time you will learn to integrate these changes into your daily life. This information brochure has been developed to assist you with these changes and provide you with information regarding your bladder substitute. If you remain uncertain and have further questions after reading this please contact the nurses specialized in long-term management of patients following bladder substitution or the urologist.

What is a "new" bladder ?

Following removal of bladder a reservoir or neo-bladder is created to store urine. There are many technique to design a neo-bladder Mr Puri uses the Studer technique named after Urs Studer, the surgeon who described this technique.

During the operation a 55cm piece of bowel has been taken to construct a bladder reservoir which allows urine to be stored. In the beginning this bladder has a very small capacity (80-100ml). With specific urethral sphincter muscle training and increasing pressure the bladder stretches and increases in capacity. In several weeks time the capacity will reach normal values of 400-500ml. There are certain points one must be aware of following a bladder substitution:

  1. Emptying
  2. Continence
  3. Hygiene
  4. Metabolic changes
  5. Sexuality
  6. Miscellaneous

1. Emptying

What happens following discharge from hospital?
In the beginning you should empty the neobladder every 2 hours. This will take 6 to 8 minutes. To fully empty your bladder you must actively assist with certain manoeuvres. At the beginning you must sit down to urinate. Otherwise incomplete bladder emptying may occur. Men can void standing in 3 to 6 months time.

To assist you in emptying your bladder:

■ Fold your hands over your lower abdomen

■ Relax your pelvic floor

■ Press your hands over the lower abdomen and bend your body forward

■ Straighten up and repeat this procedure until the bladder is empty

■ Following this bend your body in all direction

■ Massage the groin and lower abdomen regions with gentle movement and pressure from outside. This often leads to further bladder emptying.

When you feel that your bladder is empty stand up and stretch. Sit down again and repeat the above procedure again. With the change of position and stretching further residual urine from the bladder may be emptied.

Bladder emptying at night
In the beginning the bladder needs to be emptied twice during the night. After a few weeks or months it can be done only once. You must remember that the feeling of urgency that existed before the operation and awakened you to void does not exist anymore. Use a separate alarm clock for each void at night. You can awaken to one alarm clock, empty the bladder and go back to sleep again without having to reset the alarm clock. The second alarm clock will already have been set. This makes it easier to fall asleep again.

Post void residual urine
If you empty your neobladder insufficiently some urine will remain. This residual urine is a breeding ground for bacteria resulting in urine tract infections. These bacteria can pass through the ureters up to the kidney and cause a kidney infection.

2. Continence
Involuntary loss of urine is quite normal in the beginning. This incontinence will remain until your sphincter training has resulted in sufficient muscle strength to withstand the pressure from your neobladder. The strengthened sphincter muscle combined with the increased capacity of the neobladder will eventually result in continence. Effective sphincter training will be demonstrated to you.

Where is the pelvic floor and what are the differences between man and women?
The pelvic floor stretches across the pelvic opening like a sheet of muscle extending from the pubic bone to the sacrum. It is larger in women than it is in men. The muscle is penetrated by the rectum and the urethra in men and additionally by the vagina in women.

Pelvic floor/sphincter exercises
Contract your urethral sphincter muscle for a few seconds as if you were preventing urine and stool from escaping. The abdominal and buttock muscles should remain relaxed. Initially contract your anal sphincter ten times an hour for six seconds each time. This is an excellent exercise which can be performed in every position without anyone being aware of it. Regular practice, preferably when performing daily tasks such as brushing your teeth, breakfast etc., increases success.

Sit slightly forward , so that the pressure is applied to the front portion of the pelvic floor. Contract as strongly and as long as possible.

Be very conscious of your breathing when exercising. While contracting your muscles you should breath out and while relaxing breath in.

Reaching adequate bladder capacity
As soon as you can remain continent for 2 hours, you may increase your voiding intervals by 30 minutes at a time until you reach the 4 hour mark. It is important during this phase of your training to withhold your urine by contracting your sphincter muscle even if a little urine escapes. This is only way to reach the desired capacity of 400-500ml.

Milking the urethra
In men urine may remain in the urethra following voiding. This may dribble out into the underpants a short time later falsely indicating incontinence. To prevent this from happening the urethra should be milked from the base of the penis (perineum) to the tip of the penis.

Sleeping tablets

Sleeping tablets will relax your muscles including the pelvic floor. This may increase the risk of involuntary loss of urine.

Drinks/alcoholic drinks
Cold and alcoholic beverages can increase involuntary urine loss, especially at night.

3. HygieneThere is a large selection of sanitary aids which can assist you in your care.

Incontinence pads
Migros has a large selection of different pads under the name of "Secure" as does Coop under the name of "Tena". These are available in most branches. Drug stores and sanitary stores all have similar products. Publicare AG in Dättwil has a large selection of incontinence pads that are available at reasonable prices. We are more than happy to give you advice on these products and assist in ordering them.

4. Metabolic changes
The mucosa of the bladder reservoir continues to produce mucus which can be seen as yellow turbidity in the urine.

Your neobladder which has been constructed from small bowel retains residual bowel functions which will diminish over the years.

The mucosa of the neobladder can absorb substances from the urine and secret them into the blood. Conversely, substances can be taken from the blood and excreted in the urine. Subsequently you can no longer determine the concentration of your urine from the colour as there is a constant exchange substances between the blood and the urine.

This process is comparable with water absorption by a plant. Here the water rises from the root to the leaves by a concentration differential. A similar process occurs in the neobladder. A concentration equilibrium is reached which results in the urine staying the same colour irrespective of the amount you drink. For this reason it is imperative that you drink at least 3 litres a day for the first 3 to 6 months to reduce the chances that this exchange phenomenon will have any serious consequences. After a while you can reduce your daily fluid intake to 2 litres. You are free to drink any sort of beverage that you wish. If you are not used to drinking a lot, a regulated drinking schedule may help.

You must be aware that you will lose salt via the neobladder. The salt is bound to water which leads to excess urine production. To compensate for this salt loss you should consume extra salt and salt products during your meals (eg. Broth, dried meats, salt pretzels) and snacks between meals.

Inadequate fluid or salt intake could lead to a metabolic abnormality which presents weight loss or tiredness. An acid base abnormality in the blood could lead to metabolic acidosis resulting in loss of appetite, nausea, dyspepsia and indigestion. In the worst case it could lead to repeated nausea and vomiting. Despite these difficulties one must urgently consume more fluids to excrete these acid elements in the urine and correct the acidosis.

Should these symptoms occur call us immediately on . We can then discuss this problem with you and institute the appropriate measure.

5. Sexuality
In men the nerves responsible for erection may be impaired during the operation resulting in erectile dysfunction. As a rule it is possible with the use of appropriate measures and aids to achieve erections again and subsequently perform intercourse. We are more than ready to discuss any such difficulties encountered and provide you with further information and therapy options. Please do not hesitate to make use of this service.

The following therapeutic options are available:

■ Injections into the penis shaft

■ MUSE is a preparation which is inserted into the urethra

■ Vacuum pump

■ Viagra and Uprima are oral tablets used for erectile dysfunction

In females the vaginal length may be shortened and lubrication may be reduced. Certain lubricants may be used for this (eg. KY Gel Ė available through pharmacies or drug stores). Most larger department stores will also stock lubricating gels.

Sexual intercourse may be resumed 3 months following the operation.

6. Miscellaneous

Eating

Following the operation a stepwise increase in diet will occur. With time you will be able to resume your normal diet. Foods which tend to bloat should initially be avoided as they may induce abdominal pain, cramps and possibly diarrhoea.

Bowel habits

To ensure optimal recovery during your hospital stay and immediately following you will have been given several antibiotics. This could lead to a disturbance of your intestinal flora and result in changes in your bowel habits eg. constipation or diarrhoea. To rebuild your bowel flora we would recommend eating unpasturised yoghurt. If further antibiotic treatment is necessary it may be taken with or following your meals/

In the first few months following the operation you may suffer from constipation or diarrhoea.

Activities following the operation

The resumption of physical activity can best be judged from your own feeling of well-being and physical strength. For the first several weeks you should avoid lifting heavy objects (over 10kg), or exerting excessive pressure on your abdomen while emptying your reservoir. Such actions could result in wound hernias. It takes about 3 months for a complete wound healing.

Follow-up and management

The first follow up will take place one week after discharge from the hospital. As a rule this consist of a blood test to determine your blood acid level, a urine analysis as well as an ultrasonography of the kidneys and neobladder. These results will determine whether you will require a further short-term follow-up.

Otherwise the routine follow-ups will occur at regular intervals. The next 2 will take place in 3 and 6 months thereafter.

Donít forget:

For your well being and for the flawless function of your neobladder a regular follow up and your full co-operation are indispensable!

Individual follow ups and management

If you have questions or are uncertain about anything following discharge from hospital you may contact the nurses specialized in long-term management of patients following bladder substitution by telephone number. If on exception this number if not answered you may request to speak to the doctor on call in the Urology Department on telephone number .

We hope that this pamphlet has clarified any questions you may have had and wish you and your family all the best for the future.

Life after bladder reconstruction

Useful addresses and telephone numbers
Website www.urol.co.uk Email rp@urol.co.uk
Website www.urol.co.uk Email rp@urol.co.uk

 

Uro-oncology nurse specialists

BRI Yorkshire Clinic
Mr David Tyson 01274 382079 Mrs Lyn Taylor 01274 550600
Miss Zoe Scaife

 

Ward 14 Ward 1
Bradford Royal Infirmary Yorkshire Clinic
Tel (01274) 364383 Tel (01274) 560311

Secretary to Mr R. Puri
Bradford Royal Infirmary Yorkshire Clinic
Duckworth Lane Bradford Road
Bradford BD9 6RJ Bingley BD16 1TW
Tel (01274) 382655 Tel (01274) 564521

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