Surgical Options for Bladder Cancer
- Surgery for bladder cancer often offers the best chance for a cure. There are various surgical options depending on the location of your bladder cancer.
- A radical cystectomy is the surgical removal of the bladder as well as nearby lymph nodes in the pelvis. A partial cystectomy preserves part of the bladder. Transurethral resection of visible bladder tumor (TURBT) is a procedure in which a surgeon inserts a camera into the bladder and removes the visible cancer.
- Patients may require a urinary diversion procedure following surgery for bladder cancer. During this procedure the surgeon uses one of three options to reroute urine out of the body.
Transurethral resection of visible bladder tumor (TURBT)
For patients with non-muscle invasive bladder cancer, treatment will most likely consist of transurethral resection of visible bladder tumor (TURBT). During this procedure, the surgeon gently inserts a surgical instrument containing a camera into the urethra and pushes it upward until it reaches the bladder. The instrument is then used to remove all the tumor that the surgeon can see, down to the first muscle layer. Sometimes, the surgeon will take biopsies of surrounding areas as well. The main tumor and surrounding samples are sent to pathology for testing.Read More
Depending on the aggressiveness of your tumor, cystoscopy will be required to check the area once a year, or as frequently as every few months for the first few years after treatment. This is combined with routine imaging of the urinary tract.
What is TURBT?
A Note about TURBT for patients with muscle invasive bladder cancer
Although many patients with muscle-invasive disease want to preserve their natural bladder, it is important to understand that cancer has a high risk of coming back when the entire bladder is not removed. However, a small minority of patients may qualify for bladder-preserving surgery if they meet certain criteria. For example, if the cancer is confined to the bladder with limited invasion into the muscle, and there is no evidence of “pre cancer” or “cancer in situ” surrounding the tumor, and the urinary tract is otherwise healthy without signs of urine backing up into the kidneys, TURBT can be considered. In these cases, chemotherapy and radiation are usually offered after to further lower the risk of cancer recurrence.
Cystectomy: Radical and Partial
“Radical cystectomy” is the surgical removal of the bladder as well as nearby lymph nodes in the pelvis. Total removal of the bladder is recommended for patients with muscle-invasive bladder cancer, and the goal is to cure the cancer. Imaging and/or biopsies may be needed prior to surgery to evaluate whether the lymph nodes are involved.
For men, radical cystectomy typically includes removal of the prostate and seminal vesicles as well. This can lead to side effects such as erectile dysfunction which should be discussed with your doctor both before and after the procedure. In women, involvement of the reproductive organs is less common, so the ovaries and uterus are not routinely removed, unless there is a concern for cancer involving these areas.
Radical cystectomy requires several days of hospitalization, where you will be monitored, and taught how to care for your catheter or stoma, depending on your specific surgery. Chemotherapy is usually recommended before cystectomy. Giving chemotherapy prior, or “neoadjuvantly” has been shown in large trials to improve survival in bladder cancer.
Partial cystectomy is an option for some patients that have one muscle-invasive tumor located in a lower-risk area of the bladder. Like a radical cystectomy, the surrounding pelvic lymph nodes can be removed. Since the bladder is saved, this option avoids the need to drain the urine through another method, known as urinary diversion. Because the bladder is physically opened during the procedure, (unlike radical cystectomy, where the bladder is removed in its entirety), there is a risk of cancer coming back in the abdominal cavity or near your scar, where it was removed. As with TURBT, whenever the bladder is left in place, there is a risk of the cancer coming back elsewhere in the bladder. Neoadjuvant chemotherapy is usually recommended before having this procedure. Your surgeon will discuss if partial cystectomy is possible in your specific case.
What is a radical cystectomy?
Open vs. Laparoscopic and Robotic Assisted Surgery (for Radical Cystectomy)
Traditionally, radical cystectomy has been performed using an open approach, meaning a surgical cut is made through the skin, muscle, and other tissue layers, and the surgery is done through this incision. However, minimally-invasive techniques, which are laparoscopic and usually performed with robot assistance, are gaining popularity. These techniques can still successfully remove cancer, while decreasing surgical complications, blood loss, and recovery time. In robotic surgery, your surgeon controls a robot and removes your bladder and lymph nodes through several small incisions in the abdomen. This technique continues to be studied and refined at major surgical centers in the United States. So far, studies reviewing open vs. robotic assisted cystectomies have shown similar complication rates as well as cancer outcomes. After the bladder is removed, the urinary diversion part (discussed separately) can sometimes also be done laparoscopically and robotically. In other cases, this portion will need to be done through a traditional open incision.
Open vs. Robotic-Assisted Surgery
Urinary diversion: How do I urinate after surgery?
Patients facing radical cystectomy will sit down with their doctor to discuss options for urinary diversion. Diversions can be continent, meaning you are still able to control when you release urine (cutaneous reservoir and orthotropic neobladder) or incontinent (ileal conduit), meaning the urine will leave the body through a collection tube and bag. The choice between surgeries involves factors such as kidney and liver function, length of your intestines, your ability to drain your own urine using a tube (known as self-catheterization), whether the cancer is touching the border of the urethra (tube where the urine leaves the body). Given these factors, your surgeon may recommend one option over another. However, some patients are candidates for multiple options. There are no large studies showing that one technique is associated with a better quality of life compared to the others. Thus, the decision for many people comes down to personal preference and lifestyle goals.
Ileal Conduit with Urostomy
In this procedure, the surgeon takes the ureters, which are two tubes that drain urine from the bladder and connects them to a part of your small intestine, which then connects to an opening protruding through the abdominal wall, called a stoma. A bag is attached to the stoma to collect the urine. The bag is taped and concealed by clothing. Your medical team will show you how to care for the stoma and change the collection bag. In this option, urine drains into the bag continuously, and the patient does not need to insert any instruments. The bag is emptied several times a day and replaced with a new bag every few days.
This procedure involves your surgeon using your intestine to build a pouch, called a “neobladder” which connects to your urethra. The goal of this procedure is for the patient to urinate “normally” by contracting their abdominal muscles. After surgery, you will have an indwelling foley catheter for a few weeks. This is then removed at a post-operative office visit. In the first few weeks to months, it is normal to experience leakage of urine, which is temporary in most cases. Regaining control of urine after this procedure will involve a routine of pelvic muscle exercises, doing timed voiding with an alarm clock, keeping a log of how much urine comes out of the neobladder, and going to frequent doctor appointments to monitor your progress. In the first few months and even years after surgery, the neobladder continues to get stronger, and continence over urine in the day and night continues to improve for the majority of patients. The degree of continence that can be achieved depends on how much the nerves were affected during surgery, and other factors including gender. Women on average achieve slightly lower rates of continence than men, with studies showing a daytime continence rate of 87-100% and 75-93% respectively. This is due to differences in anatomy of the urethra between genders. However, night continence is more comparable for men and women, 70-95% and 72-84% respectively. During the recovery process, you will monitor yourself for signs of urine retention, and will likely need to insert a catheter at times to drain any residual urine. As your neobladder grows stronger and more flexible, many people can decrease the frequency of having to catheterize, and many can stop doing this completely.
Creating an orthotropic neobladder is the method that most closely approximates normal urinary function. However, it requires patience and long-term commitment to the rehabilitation process.
Cutaneous continent reservoir, also known as an “Indiana Pouch”
To create a reservoir, the surgeon removes some intestinal or stomach tissue, and uses it to create a pouch inside your body to hold urine. After the bladder is removed, the ureters connect the kidneys to this new pouch. It is sewed to an opening in the skin on the abdominal wall. If you have this procedure, you will learn to use a catheter (thin tube) to empty the pouch from the outside. The benefit of this procedure Is that patients are dry from the beginning, and do not need pads or any external device or bag.
Understanding Lifestyle Changes After a Radical Cystectomy