Questions about treatment

Questions about treatment

How is bladder cancer treated?

Bladder cancer treatment is based on your risk of recurrence and progression. This risk is determined by your personal characteristics, your disease stage and grade, and your risk group.

Non–muscle-invasive bladder cancer is treated by complete removal of all visible tumours with TURBT, often followed by washing of the bladder with drugs to prevent the growth or spread of cancer cells (chemotherapy). For patients with increased risk of recurrence, additional chemotherapy or immunotherapy may be used.

The mainstay of treatment for muscle-invasive bladder cancer is surgical removal of the bladder (radical cystectomy), followed by construction of a new way to store and regulate the flow of urine (urinary diversion). Bladder-sparing treatments are available for patients who are not candidates for surgery or who do not want surgery, but they have side effects and require a high level of patient compliance with treatment and follow-up. About a third of patients undergo bladder removal after failure of a bladder-sparing treatment.

What is TURBT?

TURBT is the surgical removal of bladder tumours. It used to take tissue samples for diagnosis and, if appropriate, to treat non–muscle-invasive disease. TURBT is performed by the insertion of a rigid endoscope through the urethra into the bladder, with the patient under general anaesthesia (combination of intravenous drugs and inhaled gasses; you are ‘asleep’). TURBT usually takes no longer than 1 hour and requires a short hospital stay. After the operation, in some cases, a transurethral catheter is placed for a few days.

As with any surgical procedure, there are risks of complications. Complications after TURBT include bleeding, infection, perforation of the bladder wall (rare but can happen when the tumour is removed from deep within the bladder), blood in the urine, and blockage of the urethra due to blood clots.

What is radical cystectomy?

Radical cystectomy is the surgical removal of the whole bladder and is used to treat muscle-invasive bladder cancer. It includes removal of the bladder, the endings of the ureters, the pelvic lymph nodes, and adjacent gender-specific organs (the prostate and seminal vesicles in men; the entire urethra, adjacent vagina, and uterus in women). Radical cystectomy is done in tandem with urinary diversion to construct a new way of storing and regulating the flow of urine.

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 recurs after chemotherapy or immunotherapy
  • Failure of or recurrence after a bladder-sparing approach or the occurrence of major side effects
  • Symptoms like bleeding or pain in patients whose tumours cannot be removed

Before undergoing this procedure, your biological age (performance status), other diseases, and eligibility for chemotherapy before surgery should be assessed. Chemotherapy is administered before bladder removal to potentially shrink the tumour and kill cells that have already entered the blood or lymph nodes. In addition, if a tumour is large (>3 cm) or if cancer has spread to the lymph nodes (determined by the pathologist), chemotherapy after bladder removal is recommended.

As with any surgical procedure, there are risks of complications including bleeding and infection. In addition, functioning must be observed and controlled. Functional complications after bladder removal include vitamin B12 deficiency, high acid levels in the blood (metabolic acidosis), worsening kidney function, urinary infections, urinary stone formation, tightening of stoma openings, stoma complications in patients with ileal conduit diversions, neobladder continence problems, and emptying dysfunction. Ask your doctor for information about the major symptoms of these complications and their prevention.

What is urinary diversion?

Urinary diversion is the surgical construction of a new way of storing and regulating the flow of urine. This can be achieved with several techniques.

Continent urinary diversions store urine inside the body:

  • Creating a pouch or reservoir inside the body (cutaneous urinary diversion)
  • Attaching the ureters to the rectum (ureterocolonic diversion)
  • Forming a new bladder from small intestine (orthotopic neobladder)

Incontinent urinary diversions collect urine outside the body through a new opening in the abdomen (urostomy):

  • Rerouting ureters through the skin (ureterocutaneostomy)
  • Placing a piece of small intestine between the ureters and the skin (ileal conduit)

During recovery in the hospital, you will learn how to manage your urinary diversion. Once you have learned how to use and empty the urostomy or internal urine pouch, a date for your discharge will be set.

What are bladder-sparing treatments?

Bladder-sparing treatments attempt to preserve the bladder as well as the patient’s quality of life without compromising the outcome for the cancer. They can be a reasonable alternative for patients who are not candidates for bladder removal or who do not want surgery.

Chemoradiation, the combination of radiation therapy and sensitizing chemotherapy, has shown acceptable results. Radiotherapy alone is not as effective for controlling muscle-invasive disease as bladder removal, and chemotherapy is not recommended as a sole treatment. TURBT is possible if the tumour invades only the inner muscle layer of the bladder but cannot be considered a good option for controlling the disease long term.

What is a clinical trial?

If you have metastatic bladder cancer, your doctor may suggest you participate in a clinical trial. This is a type of study in which new drugs are evaluated. It could also be a study on the sequence or dose of existing drug treatments.

Your doctor will provide all information you might need before participating in a trial. Your symptoms and general condition will be monitored more often and more closely than during regular treatment.

It is important to know that you can stop your participation in a clinical trial at any time. You will not need to explain your reasons.

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