Bladder-Preserving Treatment Options
- Patients facing muscle-invasive bladder cancer (MIBC) often have to decide if they want to have their entire bladder surgically removed or attempt a bladder-sparing treatment approach.
- This approach is often called trimodality therapy, and involves removing the tumor through endoscopic scraping then giving chemotherapy and radiation.
- For some patients, that option works well and allows them to continue living active lives. But it also comes with trade-offs, including intensive follow-up care and the possibility that surgery may still be needed later.
- “It sounds very nice in theory,” Dr. Piyush Agarwal, a urologic oncologist at the University of Chicago, tells SurvivorNet. “But that bladder will function differently, and that bladder will require lifetime surveillance.”
MIBC is a serious diagnosis because the cancer has grown into the muscle layer of the bladder wall. Traditionally, the standard treatment for many patients has been removal of the bladder with a surgery known as radical cystectomy.
Read MoreUnderstanding those trade-offs is essential when weighing treatment options.
How Bladder-Sparing Therapy Works
Bladder-sparing treatment typically involves a three-step approach, which is why it is often called trimodality therapy.
The strategy includes:
- Aggressive tumor removal through endoscopic surgery
- Radiation therapy
- Chemotherapy
Dr. Agarwal explains that the first step involves removing as much of the tumor as possible by “scraping aggressively.”
Transurethral resection of bladder tumor (TURBT) is a procedure performed through the urethra using instruments inserted through a scope, allowing surgeons to remove visible tumor tissue from inside the bladder. After the tumor has been debulked, patients are referred to other specialists for additional treatment.
“We would refer them to a radiation oncologist and a medical oncologist who would give them the combined treatment,” Dr. Agarwal says.
Radiation and chemotherapy are then used together to try to eliminate any remaining cancer cells.
Bladder-Sparing Treatment: Risks v. Benefits
For carefully selected patients, bladder-preserving therapy can produce very good outcomes. Some patients experience excellent bladder function and are able to continue living active, normal lives.
Dr. Agarwal says that in the right circumstances, the results can be very positive. This tends to occur when the cancer is relatively limited and can be effectively removed during the initial scraping procedure.
“If they had a small focus of tumor in the bladder and we were able to treat it with radiation and chemotherapy and aggressively debulking the tumor, those patients can have a very functional bladder and live a pretty normal life,” Dr. Agarwal explains.
In these situations, patients may be able to preserve their bladder while still achieving good cancer control.
The trade-off is that bladder preservation comes with lifelong monitoring. Because the bladder remains in place, doctors must watch closely for signs that the cancer might return.
Patients who choose this path typically undergo:
- Regular cystoscopies (bladder examinations using a scope)
- Imaging scans
- Urine tests
“They’re coming in often for surveillance,” Dr. Agarwal explains. “They’re getting imaging to make sure that the tumor is not coming back.”
For some patients, this frequent monitoring is an acceptable trade-off for the chance to keep their bladder, he adds.
The Risk of Recurrence
Bladder-preserving therapy does not work for every patient. In some cases, the cancer may return despite radiation and chemotherapy.
“About 25% of the time the tumor can come back in the bladder,” Dr. Agarwal notes.
If the cancer returns, doctors may attempt to treat it with additional localized therapies. However, in other cases, the bladder may ultimately need to be removed. This means some patients who initially pursue bladder preservation may still require surgery later.
The Challenge of Surgery After Radiation
If bladder removal becomes necessary after radiation therapy, the surgery can be more complicated. Radiation changes the tissues in the pelvis, which can make surgical reconstruction more difficult.
“The problem sometimes is when people have a really bulky tumor and radiation doesn’t work,” Dr. Agarwal says. “… We’ve now got to do surgery in a more complicated radiated field.”
This can affect the types of urinary reconstruction that are possible after bladder removal. For example, surgeons may not be able to construct a neobladder, which is an artificial bladder created from intestinal tissue. Neobladder is one of several urinary diversion approaches meant to redirect urine through a different pathway after bladder cancer surgery, often using a segment of intestine.
“We can’t build a neobladder in that situation,” Dr. Agarwal says. “In those patients, we’ll either give them the urostomy or the pouch.”
Making Treatment Decisions
Bladder cancer treatment is highly individualized. Doctors consider several factors when recommending treatment options.
These include:
- The size and extent of the tumor
- Whether the cancer has spread
- The patient’s overall health
- Personal preferences about quality of life
- Willingness to undergo frequent surveillance
Dr. Agarwal emphasizes that patient preferences play an important role in these decisions, and care must be individualized to accommodate each patient’s unique situation.
For patients who strongly prefer to keep their bladder, doctors will often try bladder-sparing therapy when it is medically appropriate.
“If the patient has a strong preference for bladder sparing, we will try to do the scraping, the chemo, and the radiation,” Dr. Agarwal adds. “I would say about 75% of the time we can get a good cancer outcome.”
Questions To Ask Your Doctor
- Is a bladder-sparing approach an option in my situation?
- What risks should I consider before trying a bladder-sparing approach?
- How often will I need to be monitored?
- What side effects are possible with the “trimodality” approach?
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