Bladder Cancer Treatments and Surgeries

Bladder cancers treatments and surgeries at a glance

• The treatment for bladder cancer depends on the stage of the cancer and if the patient is a good candidate for surgery.
• The most common treatment process starts with chemotherapy and is followed up by surgery to remove the bladder.
• Depending on the success of those two treatments, if additional treatment is needed the patients may go back on chemo or start immunotherapy.
• Treatment for bladder cancer for men and women can lead to the common side effects experienced from chemo, immunotherapy and surgery.

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Treatments for bladder cancer

A urologist or an oncologist can diagnose a person with bladder cancer. Once diagnosed the discussion of treatments will begin. Bladder cancer treatment varies depending on the stage of the cancer and if it has metastasized (spread to other parts of the body).

Learn more about bladder cancer

Below we cover the main treatment options for patients with bladder cancer. At Urology Associates we follow the National Comprehensive Cancer Network guidelines to give our patients the best outcomes. These guidelines are updated yearly, and show that doctors who follow these protocols have 15% better outcomes than the national average.

Some treatments for bladder cancer require an oncologist. The Urology Associates team will work with each patient to make a smooth transition between the oncologist and our practice, making the treatment process as easy as possible for the patient.

Most treatments for bladder cancer do involve surgery, which is performed by a urologist. But for those who are not a right fit for surgery due to age, weight or other medications, we do have alternative treatment methods available that are personalized for each patient.

Chemotherapy for bladder cancer

When it comes to treating bladder cancer, chemotherapy (chemo) may be used:

• Before surgery to shrink large tumors.
• After surgery to kill remaining cancer cells that are not visible or that surgery missed.
• With radiation to improve its effectiveness.

Most patients will start with chemo as the first line of treatment prior to surgery. This method of chemo and then surgery has been found to increase survival rates by 10%. An oncologist will administer a patient’s chemo treatment, which normally takes around three months.

Depending on the patient, after surgery some people will need to go back to the care of their oncologist to have additional chemo treatments.

Surgery for bladder cancer

As mentioned above, it is common to be treated with chemo prior to surgery. Once the chemo treatment sessions have ended, the patient’s care is transferred to a urologist. The patient usually waits four weeks from when the chemo ended before the urologist performs the surgery.

Depending on the size of the cancer, one of the following surgical options will be used.

Transurethral bladder tumor resection (TURBT)

TURBT, also known as transurethral resection (TUR), can be used as a treatment option for those with cancerous polyps in their bladder, early-stage cancer, or as a diagnostics tool for those with more advanced cancer.

TURBT involves a thin cystoscope, called a resectoscope, being inserted through the urethra. This tool has a camera, light and wire loop at the end to remove abnormal tissues or tumors. Using the urethra as the entrance point for the resectoscope allows for access to the bladder without needing to cut the abdomen.

After removal of any polyps or cancerous cells, Dr. Wilson will add mitomycin (a type of chemo) or the intravesical immunotherapy Bacillus Calmette-Guerin (BCG) into the bladder to decrease the chance of recurrence.

Following a TURBT treatment, a patient may experience bleeding and pain when urinating.

Cystectomy (bladder removal)

Cystectomy is the removal of all or part of the bladder in cases of invasive bladder cancer.

• Radical cystectomy removes the entire bladder and lymph nodes in the area. This is for cancers that are in more than one part of the bladder or for large tumors. Radical cystectomy for men may also include the removal of the prostate. For women, a radical cystectomy at times includes removal of the ovaries, the uterus, the fallopian tubes and a section of the vagina. Dr. Wilson aims to remove the cancer while leaving as many organs as possible to reduce any negative effects on sexual function (learn more below).

We complete radical cystectomies though an abdominal incision, laparoscopically or robotically. Our bladder cancer specialist will work with each patient to find the best option for him or her.

• Partial cystectomy removes just the area of the bladder where the cancer has penetrated the muscle layer. The main benefit is that patients keep the use of their bladder and do not need reconstructive surgery. Only 1% of bladder cancer cases should be completed through a partial cystectomy, which is ideal when the cancer is only in the dome of the bladder.

Bladder reconstructive surgery

Reconstructive surgery is required after radical cystectomy in order for the patient to store and expel urine in the absence of a bladder. Different types of reconstructive surgery follow.

• A neobladder involves creating a substitute bladder with a piece of intestine that is sewn to the urethra that exits the body. This allows the patient to learn to urinate normally during the daytime, but he or she will experience nighttime incontinence. This is the most common bladder reconstruction surgery.
• Ileal conduit, also known as urostomy or incontinent diversion, uses a piece of the intestine to create a passageway from the kidney to a hole in the abdomen where a small bag collects the urine. Urine constantly leaks out (incontinence), and the bag where the urine is diverted needs to be emptied regularly.
• Continent diversion, also known as Indiana pouch or continent cutaneous diversion, involves a pouch inside the abdominal cavity made of the intestine piece with a valve that allows it to store urine. The valve can be closed, stopping urine drip so the bag can be emptied via a drainage tube.

After surgery

After surgery when a patient is in the hospital, he or she will see Dr. Wilson every day. A follow-up appointment takes place a week or two after surgery to remove the catheter. At that time the patient is also told to start bladder training with a physical therapist. We help our patients find a physical therapist who works with their location, insurance and personal preferences.

There are multiple possible next steps for a patient following surgery:

• Some patients return to the care of their oncologists for additional chemotherapy.
• For those whose cancer metastasized to the lymph nodes or fat around the bladder, they will go back to their oncologist and start an immunotherapy treatment.
• If a patient has good results after surgery, he or she can be monitored by Dr. Wilson, another urologist or his/her oncologist.

Immunotherapy

Immunotherapy, or biologic therapy, is frequently used after surgery in patients where the cancer has spread to the lymph nodes or the fat around the bladder. This treatment option boosts the patient’s natural defense in order to fight the cancer.

We partner with Rocky Mountain Cancer Center for clinical trials that aim to learn additional ways immunotherapy can be used for bladder cancer.

The most common immunotherapies used for bladder cancer are:

• Bacillus Calmette-Guerin (BCG).
• Interferon (Roferon-A, Intron A, Alferon).
• Immune checkpoint inhibitors.

Targeted therapy

Another treatment option currently being evaluated in clinical trials is targeted therapy. This treatment option targets the cancer genes, proteins or the tissues that contribute to the cancer growth and survival. This is done by blocking the growth of cancer cells while limiting the damage to healthy cells.

The most common treatment is a FGFR inhibitor, which would be provided by an oncologist.

Radiation therapy

This therapy, which is being used less and less, uses high-energy radiation to kill or shrink cancer cells. External-beam radiation, which focuses radiation from outside the body, is most often used on bladder cancer. Radiation is used for bladder preservation in people who are not good candidates for surgery.

Risks of treatment for bladder cancer

Chemotherapy, radiation therapy, immunotherapy and targeted therapy carry risks of side effects caused by the destruction of healthy cells along with cancerous cells. These include nausea, hair loss, mouth sores, loss of appetite and fatigue, among others.

A cystectomy and reconstructive surgeries can lead to losing control of urinary function, which can also result in psychological and emotional issues. Other risks, similar to those in most surgeries, include:

• Loss of blood.
• Infection.
• Damage to tissue or organs.
• Reaction to anesthesia.
• Scarring.
• Blood clots.
• Pain.

Sexual dysfunction after a cystectomy

After a cystectomy both men and women can have an altered sexual life. This concern is the source of many patient questions, and Dr. Wilson thoroughly addresses this concern.

To reduce the prospect of such issues, Dr. Wilson provides nerve sparing cystectomies whenever possible to preserve sexual function. She also uses the latest surgical techniques to further reduce those risks.

If an ileal conduit procedure was performed, it can also affect a person’s sex life. Emptying the pouch prior to sexual intercourse can reduce the chances of leakage. During intercourse it may be easier to wear a tight shirt or put on a smaller pouch to keep the daily pouch out of the way. A person may also need to try other sexual positions to keep their partner’s weight from rubbing against the pouch.

Sexual dysfunction in men

After a cystectomy, a man’s ability to have an erection might be affected for the first three to six months because the nerves are shocked. With time, practice and Viagra, most men can get back to where they were before surgery. The younger the man the more likely he is to regain the ability to have a full erection.

On top of providing nerve-sparing surgery, Dr. Wilson also aims to leave the prostate intact if the cancer has not spread to that section of the body. If the prostate gland is removed, the man will no longer be able to make semen. He can still have an orgasm but it will be dry.

Sexual dysfunction in women

To reduce the chance of sexual dysfunction after surgery, Dr. Wilson only removes organs that are affected by the cancer. At times, part or all of the vagina will need to be removed. This can lead to sex being less comfortable, though most of the time it is still possible. If the vagina is fully removed, a woman can discuss with Dr. Wilson options to have her vagina rebuilt.

A woman’s orgasm could also be affected by a radical cystectomy if the nerve bundles on the side of the vagina are damaged or if the blood supply to the clitoris is reduced. In surgery, Dr. Wilson will take steps to reduce the possibility of such damage.