The mainstay of treatment for muscle-invasive bladder cancer is surgical removal of the urinary bladder.
Your doctor has several reasons for recommending removal of the whole bladder:
- Presence of a muscle-invasive tumour
- Presence of a tumour that grows aggressively (high grade), that has multiple cancerous areas (multifocal), or that is superficial, but has recurred after chemotherapy or immunotherapy
- Failure of or recurrence after a bladder-sparing approach (chemoradiation) or the occurrence of major side-effects
- Symptoms like bleeding or pain in patients with incurable disease
To evaluate and weight your individual risk of undergoing removal of the bladder, work with your physician to consult a multidisciplinary team (for example, urologist, surgeon, anaesthesiologist, nurse practitioner, general practitioner, cardiologist).
Factors like your biological age (your body’s performance as it ages, measured as performance status or life expectancy) and other diseases that you have (diabetes, heart disease, high blood pressure) are also important. Patients older than 80 years of age have more problems recovering from such an operation. Physicians use special indexed scores to assess the risk of patients undergoing this stressful operation.
Prior abdominal surgery or radiotherapy makes surgery more difficult but is rarely a reason not to have surgery. Being overweight does not influence survival after surgery but does influence the risk of complications from wound healing.
Removal of the urinary bladder includes removal of the bladder, the endings of the ureters and the pelvic lymph nodes. Depending on factors like tumour location and type of urinary diversion part of the adjacent gender-specific organs (the prostate and seminal vesicles in men; the entire urethra, adjacent vagina, and uterus in women) are removed. Men should be aware that prostate cancer is sometimes found in removed prostates but generally does not affect long-term survival or treatment.
How is the bladder removed?
Removal of the urinary bladder is performed through an incision in the abdomen (open) with the patient under general anaesthesia (combination of intravenous drugs and inhaled gasses; you are ‘asleep’). The bladder, the ends of the ureters close to the bladder, the pelvic lymph nodes, and (part of) adjacent gender-specific organs are removed. Now another way to store and empty urine must be created (urinary diversion).
The standard procedure at the moment is open surgery. However, it can be done as a minimally invasive procedure (laparoscopically or robotic-assisted) at centres that treat a lot of patients and have experienced and specialised surgeons. Currently, a minimally invasive approach is considered experimental for bladder removal.
How to prepare for the procedure
You are admitted to the urology ward 1 day prior to the operation. A physician or nurse will talk you through the operation and explain what happens before and especially after the surgery.
Part of your intestines will be used to create the urinary diversion. Your doctor will advise you in detail about how to prepare for the procedure.
Before surgery, your doctor will inform you in detail how to prepare for anaesthesia. If you are taking any medications, discuss them with your doctor. You may need to stop taking medications for several days before surgery.
After the procedure
For the first few days you will be closely monitored. Your doctor will inform you in detail about the post-operative routine.
During hospitalisation, you will learn how to manage the urostomy or neobladder. Once you have learned how to use and empty the urostomy or internal urine pouch, a date for your discharge will be set.
Chemotherapy before removal of the bladder
Chemotherapy is administered before bladder removal to potentially shrink the tumour and kill cells that have already entered the blood or lymph nodes.
Chemotherapy before the operation may be recommended for patients with muscle-invasive disease. Itis also necessary if tumours are large (>3 cm) or if signs indicate that cancer has spread to the lymph nodes (metastatic disease) and the goal is treatment of the disease. The decision to administer chemotherapy is made by a multidisciplinary team (including an oncologist, a urologist, and a radiologist).
Adequate kidney function is necessary. Potential side-effects are usually monitored and managed by an oncologist.
A good response to chemotherapy improves survival but does not change the need for surgery. Although neoadjuvant chemotherapy is currently advised, physicians are unable to identify who will definitely benefit from chemotherapy before removal of the bladder.
Chemotherapy after removal of the bladder
If a tumour is large (>3 cm), or could not be fully resected, or if cancer has spread to the lymph nodes (determined by the pathologist), chemotherapy after removal of the bladder is an option. Cancer that has spread to the lymph nodes indicates systemic disease and may need systemic treatment (with chemotherapy) in certain cases.