My bladder built from my bowel is as good as the one I was born with, by Dame Mary Archer
00:32 GMT, 4 December 2012
Around 11,000 people are diagnosed with bladder cancer each year.
The usual treatment for aggressive cancer is removing the bladder.
Dame Mary Archer, 67, who was diagnosed in 2010, opted for a newer procedure which she had at Addenbrooke’s Hospital, Cambridge, where she is chairman of the NHS Trust.
'The risk factors for bladder cancer are smoking, drinking heavily and being male, and none of these applied to me,' said Dame Mary Archer
The morning after my son William’s wedding, in October 2010, I noticed a small amount of blood in my urine.
The following morning it happened again.
Through recent work at Addenbrooke’s I knew this was probably one of two things — an infection or cancer.
However, I didn’t have a raised temperature which you’d get with an infection and I didn’t feel unwell. I began to feel apprehensive.
A colleague at Addenbrooke’s arranged for me to see consultant urologist Bill Turner.
My husband Jeffrey and I went together. I had an ultrasound scan and as I watched the screen I could clearly see a pale patch, a mass.
Mr Turner carried out a cystoscopy that day, using a camera to look inside the bladder and confirmed that the mass was a 7cm tumour above my urethra — the exit point of the bladder.
Everything happened so quickly and I was probably in a state of shock.
But I knew I had to stay calm and go along with what the doctor was telling me to do.
I did have a few moments of ‘why’ My father had died of lung cancer but he had smoked and there was no other real history of cancer in my family.
The risk factors for bladder cancer are smoking, drinking heavily and being male, and none of these applied to me.
But I had been a chemist for most of my life and there is a higher rate of some types of cancer among my profession because some of the chemicals we worked with may have been irritants to the immune system.
The next day, Jeffrey and I went together to the hospital where Mr Turner removed the tumour along with several little tumours he found, which were all sent off to the lab.
The results showed the main tumour was grade II and the smaller ones all grade I, which meant the cancer hadn’t spread.
Unfortunately, six weeks later a follow-up cystoscopy found two tiny pinheads of suspicious cells, which were sent off for analysis.
This time tests showed that these little specks were grade III — highly aggressive.
Now we were into new territory. This was no longer a nuisance, it was a real threat to my health. That was hard to take — I thought I had got away with it.
I had a six-week course of immunotherapy, using a drug which stimulates the immune system to fight against abnormal cells.
It is administered via a catheter directly into the bladder and is effective in warding off cancer for three months in around 80 per cent of cases and for over five years in around 40 per cent of cases, which seemed like good odds to me.
Six weeks later, a routine check showed the two growths were back in the same place.
It was at this point Jeffrey and I told our sons William, 40, and James, 38. Up until then I hadn’t wanted to worry them.
'Eighteen months on I am completely used to my new bladder – I rarely think about it. It does as good a job as the old one,' said Mary (pictured with husband Jeffrey)
We had to prevent the cancer from spreading outside the bladder, which meant removing the bladder altogether, and soon. I wanted to avoid having a stoma bag if possible.
I had already Googled my condition and found out about ileal orthotopic bladder substitution, where a part of the lower bowel is used to reconstruct the bladder.
At the same time they do a full hysterectomy including the womb, fallopian tubes and ovaries to remove any chance I may get gynaecological cancer at a later date (either because of the proximity of the bladder or because being a woman I am at a small risk of gynaecological cancer).
On April 15 — Jeffrey’s birthday, and a month after I had got the news that my immunotherapy had failed — I went into Addenbrooke’s to have the six-hour operation. I woke up to see my family standing around my bed, which was lovely.
I had a large glued-up scar which ran from my sternum down to the pubic bone, but was in very little pain.
Two days after the operation I started walking. I couldn’t use my new bladder until it had healed up properly, so instead I had two catheters.
I was given drugs to ease the pain and by day six I was allowed to go home.
It was beautiful weather so the boys made a bed and put some chairs out in the garden, where I rested for the first few days.
The worst thing was that while your bowel is healing — which takes a week — it doesn’t want to work, so you get constipated and uncomfortable.
A week later the catheters were taken out and then I spent five days in hospital to learn how to work with my new bladder.
Basically there is no message from the bladder telling your brain that it is full, so you don’t get that sense of urgency — which incidentally I certainly don’t miss!
Instead you have to learn to recognise a stretching feeling inside your pelvis as the bladder fills up.
The new bladder has to be stretched out over time, so you go to the loo every two hours, then three, then four. In hospital they set the alarm for you at night, so it is very tiring.
You also have to learn a new way of emptying your bladder, bearing down towards your rectum to put pressure on your bladder.
There was a lot of trial and some errors, but within a few weeks I had got the hang of it.
Six weeks later, I was swimming in the sunshine in our house in Majorca and the scar was already beginning to fade.
I only cried once — when Mr Turner told me a few weeks after the operation that the tests had come back clear on all the surrounding tissue that had been removed.
If it hadn’t been for my work at Addenbrooke’s, I might not have been so quick to get the blood in my urine checked out and who knows, the cancer might have spread. I knew I had been very lucky.
Eighteen months on I am completely used to my new bladder — I rarely think about it. It does as good a job as the old one.
In fact, it feels like just another episode in my life to look back on.
Bill Turner is a consultant urologist at Addenbrooke’s Hospital, Cambs. He says:
Although this operation was first devised in the mid-Eighties and is available at several centres in the UK, relatively few eligible people opt for bladder replacement, deciding instead to have a stoma bag.
This may be because with bladder reconstruction you have to be motivated to work hard to learn the new techniques of dealing with your replacement new bladder.
A stoma bag has a much shorter recovery period and people can get on with their lives pretty much straight away.
Having said that, I am not sure all suitable patients are being offered the reconstruction and I’m concerned some patients may be missing out as a result.
Patients like Dame Mary are excellent candidates for the operation.
Not only was she fit and motivated, her cancer was also not affecting her urethra, which needs to be functioning properly for the reconstruction to work.
The other criterion is that the patient has not had radiotherapy in their pelvis, as this makes surgery less likely to be successful, or any disease such as Crohn’s, which may have damaged the bowel.
Their kidneys have to be functioning well, as acidic substances pass through the reconstructed bowel wall and into the blood supply, making it acidic.
The first thing we do is to open up the patient’s abdomen through a vertical line running from just above the navel to the pubic bone. We remove the bladder and, if the woman is post menopausal, we also remove the womb, fallopian tubes and the ovaries.
We also removed all of Dame Mary’s lymph nodes in her pelvis, to check whether the cancer had spread. With men we remove the prostate.
We then take about 50cm from the end of the small intestine — the ileum.
The rest is joined back up to the large bowel to carry on functioning in the usual way — we can live perfectly normally without this section of the small intestine.
Next, the bottom two-thirds of the removed section of bowel are folded over and fashioned into a round closed pouch, to make the artificial bladder.
Then we make a six to 8mm incision at the bottom of this pouch and re-attach the urethra. The top of the pouch is formed into a ‘chimney’ — the ureters, the two tubes which bring urine down from the kidneys, are then sutured to it.
Two weeks after the operation we have the patient back into hospital to teach them how to learn to use their new bladder.
Fortunately adults — unlike some toddlers — tend to be very quick learners.
Most of the complications are the same whether the patient chooses a stoma or a bladder substitute, for example loss of erectile function in men and some sexual difficulties in women. Rarely the pouch may leak, which would be remedied surgically.
And there’s a chance of bladder stones forming because of the inability of the replacement bladder to deal with the minerals which form stones.
If the bladder is continually allowed to get too full it may overstretch and not fully empty, which means you start to get infections.
In this case, the patient may have to use a catheter. This is another reason why good training and meticulous follow-up is important in this operation.
If the operation is done at a centre with experience and skill, around 90 per cent of patients are reporting themselves as dry during the day and 80 per cent at night.
The surgery and diagnostic tests cost the NHS around 7,800.