Bladder Cancer

High grade, muscle invasive bladder cancer is a very aggressive disease that will progress without treatment. Therefore, the standard of care for these patients remains surgery to remove the bladder (cystectomy). However, there are a few non-surgical options. The main non-surgical option is a combination of repeat transurethral bladder resection (TURBT), chemotherapy and radiation to the bladder, called tri-modality therapy. This is a very intensive treatment regimen that involves another aggressive transurethral resection of the bladder tumor area, followed by several courses of chemotherapy, and finally radiation. After this additional chemotherapy and radiation, again there is inspection and biopsy of the bladder. If the cancer has progressed, then the bladder should be removed. If the cancer has not progressed, consolidation treatment with additional chemotherapy can be given. Unfortunately, patients who undergo this treatment still have 30-40% likelihood of having their bladder removed because of lack of treatment response. This delay in adequate treatment can increase the risk of the cancer progressing, and there still remains a significant likelihood of cancer recurrence within the bladder in the future. At times, this recurrence is superficial or low risk bladder cancer that can be managed with transurethral resection alone. Other times, the recurrence can be invasive bladder cancer that will then require the bladder to be removed. The other non-surgical option is to receive chemotherapy alone, although this is usually reserved for patients who are not good surgical candidates because of other health issues.

In certain situations, a partial cystectomy can be performed, which removes only part of the bladder where the tumor is located. The reason it is performed rarely is because most bladder cancers exist as a “field defect” where multiple areas of the bladder are involved. Therefore, partial cystectomy is reserved for patients with very specific types of bladder cancer that are either localized to one area of the bladder or are inside a bladder diverticulum (hernia of the bladder wall). The main benefit of this surgical option is that patients are able to preserve their bladder, however, the main downside is cancer control rates are much lower. Recurrence rates after partial cystectomy can range from 30-50%. As a result, the standard of care for most cases of high grade invasive bladder cancer is to remove the entire bladder, and partial cystectomy is rarely performed. One other minimally invasive surgical option is to perform another transurethral resection of the bladder tumor without any invasive surgery, although this is usually combined with chemotherapy and/or radiation.

Radical cystectomy is a major abdominal surgery that can have major impacts on your short- and long-term quality of life. Regardless of surgical approach (robotic vs open), full recovery following radical cystectomy can take up to several months. In the long-term, urinary function changes will vary depending on the specific urinary diversion that you receive. Patients who have ileal conduit urostomy diversions will learn to manage a stoma appliance, while patients with neobladders will need to re-learn how to urinate again, sometimes even needing to self-catheterize to empty the neobladder. Bowel function and electrolytes may also be altered in the long-term. For some men, erectile function may be compromised after surgery, whereas all men will lose the ability to ejaculate fluid. Orgasm is usually unaffected. Sexual function can be maintained in women, although depending on the extent of cancer, the vagina may be foreshortened making sexual intercourse difficult. With all that said, despite these possible quality of life changes after surgery, the vast majority of patients adapt and live very fulfilling and comfortable lives that was afforded by the best cancer control outcomes of surgery.

All surgeries carry a risk of bleeding, possible need for blood transfusion, infection, wound healing problems, damage to adjacent structures, and the risks of general anesthesia itself. The risks of general anesthesia include the risks of blood clots in the legs that can travel to the lungs, heart attack (myocardial infarction), stroke and even rarely, death. Again, these are rare complications of anesthesia. Possible complications related specifically to radical cystectomy include urine leak, urinary incontinence, stone formation in the diversion, ureteral stricture and scarring, fistula, pouch complications, deterioration of upper tracts and kidney function, and possible need for immediate or delayed surgical re-exploration. As discussed previously, there is a risk of bowel function changes as well as sexual dysfunction, including erectile and ejaculation dysfunction. Your urinary function following this surgery will depend on the type of urinary diversion you choose.

Bladder cancer is an aggressive disease. In most cases of high grade muscle invasive disease, neoadjuvant (before surgery) chemotherapy is recommended to be completed before surgery. After chemotherapy is complete, surgery is usually performed within 6-8 weeks. Overall, treatment is recommended to be initiated within 3-4 months after your original diagnosis.

Following surgery, the entire specimen is sent to a physician specialist known as a pathologist, who examines the entire specimen under the microscope. Based on this examination, they will determine the final grade and stage of the cancer, including if there was an adequate margin around the edge of the cancer. They will evaluate if the cancer has spread into any adjacent fat or organs, including any spread to the local lymph nodes. This information will help determine the prognosis, as well as if any additional treatment is necessary following your surgery.

Removal of lymph nodes is standard practice for radical cystectomy because they tend to be the first site of cancer spread beyond the bladder. At our institution, Dr. Yu believes that performing extended pelvic lymph node dissections for bladder cancer offers additional prognostic and therapeutic benefits over the traditional/standard lymph node dissection. There are many retrospective studies that have shown improved survival for patients undergoing extended dissections. Unlike lymph node dissections in other areas of the body, pelvic lymph node dissection usually does not lead to any functional consequences for the patient.