Surgery
Let’s start by discussing the procedural options for bladder cancer treatment.
Transurethral Resection Bladder Tumor (TURBT)
The first step in treating non-muscle invasive bladder cancer—meaning the tumor is contained within the bladder and has not penetrated its thick muscular layer—is a type of surgery called transurethral resection bladder tumor, or TURBT. This procedure removes the tumor from the bladder.
During a TURBT, a urologist places a rigid, thin instrument with a light and camera on it (resectoscope) through a person’s urethra into his or her bladder. The resectoscope contains a wire loop that allows the doctor to remove the tumor.
This procedure is usually done in an operating room and sometimes a second TURBT is required weeks after the first to ensure that none of the tumor was missed.
Radical Cystectomy
Standard treatment of muscle-invasive bladder cancer—meaning the tumor is not contained and has penetrated the bladder’s thick muscular layer—is a surgery called radical cystectomy. This procedure entails removing the bladder and surrounding organs—prostate and seminal vesicles in men; uterus, cervix, fallopian tubes, ovaries, and the upper part of the vagina in women.
Only sometimes is radical cystectomy recommended for bladder cancer that has not invaded the muscle layer yet has other worrisome, aggressive features. It’s also generally recommended for people who have persistent or recurrent non-muscle invasive bladder cancer after treatment with intravesical immunotherapy (see below).
Urinary Diversion and Reconstruction
After the bladder is removed, a surgeon must devise a new place for urine to be stored. There are a few options to consider:
A new bladder can be created from part of a person’s intestines (neobladder) that is connected to a person’s urethra so they can urinate as before. A pouch can be created inside the body using tissue from the stomach or intestines. One end is connected to the ureters and the other to an opening in the skin on the abdominal wall (stoma). A catheter can then be used to empty the urine through the stoma during the day, but the pouch ultimately stores the urine, like a bladder would. Instead of a pouch, a piece of intestines is connected to the ureters. With this type of surgery, urine flows from the kidneys to the ureters through the piece of intestines and into the stoma. Finally, it drips into a small collection bag located outside the body.
Potential Risks of Surgery
Radical cystectomy and creating a new bladder or pouch is a complex surgery. In other words, it is a big deal. So, it’s important you understand all the risks and benefits involved—the good and the bad, so to speak.
With that, the likelihood of surgical complications depends on a number of factors, like the surgeon’s experience, the patient’s age, and whether the patient has any underlying medical problems. Still, examples of potential surgical complications include:
Bleeding Infection Blood clotting in the lungs
Another issue to address with your surgeon is the potential for sexual side effects, like erectile dysfunction or changes in sexual arousal, and how to cope with it.
Chemotherapy Prior to Surgery
If a person is healthy enough, he or she will also receive chemotherapy prior to surgery to improve his or her chances of surviving. The purpose of chemotherapy is to kill cancer cells that are in the body but are yet to be seen.
Two common chemotherapy regimens used prior to surgery for urothelial bladder cancers are:
MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin)GC (cisplatin and gemcitabine)
Your oncologist, or cancer doctor, will administer these chemotherapies in cycles. This means, that after each treatment, you will rest and be monitored for any adverse side effects. Examples of side effects that may be seen with the above regimens include:
Fatigue Increased risk of infection Bleeding or bruising more easily Hair loss Mouth sores Nausea and vomiting Hearing loss Numbness and tingling in the hands or feet Blood in the urine
Intravesical Therapy
Even though the survival rates are favorable in people with non-muscle invasive bladder cancer, two major concerns doctors have even after the tumor is removed are:
Recurrence (the cancer comes back)Progression (the cancer spreads into the muscle or further into the body)
So, let’s now take a look at non-surgical treatment options.
Intravesical Chemotherapy
The above two reasons are why most patients undergo additional therapy after the tumor removal with an intervention called intravesical chemotherapy. With this type of therapy, medication is administered directly into the bladder through a catheter. The purpose of the chemotherapy is to destroy any leftover, non-visible cancer cells.
Mitomycin is often the chemotherapy of choice administered. It may cause some burning in the bladder as well as frequent and/or painful urination.
Intravesical Immunotherapy
Sometimes, instead of intravesical chemotherapy, a person will receive an intravesical immunotherapy called Bacillus Calmette-Guerin (BCG). This type of therapy triggers a person’s immune system to kill cancer cells.
It’s interesting to note that Bacillus Calmette-Guerin (BCG) was initially developed as a vaccine for tuberculosis. But, in the 1970s and 1980s, it was found to kill bladder cancer cells, too.
While very effective, intravesical BCG can cause side effects for up to two days which may include:
Fever, chills, and body achesFatigueExcessive urinationBlood in the urinePain when urinatingBurning within the bladder
Bladder Preservation
Despite radical cystectomy being the standard treatment for muscle-invasive bladder cancer, sometimes a person with invasive bladder cancer may not have their entire bladder removed. Rather, they may undergo a partial removal of their bladder or a more extensive TURBT. Like any form of treatment, in these unique cases, the risks and benefits need to be carefully analyzed.
A whole-body infection is a serious medical emergency and requires immediate medical attention.
Radiation Therapy
Radiation therapy, which is delivered by a radiation oncologist, is usually combined with chemotherapy and TURBT in bladder-preserving protocols, as it is not considered an adequate sole form of therapy. Radiation kills cancer cells and treatment sessions typically last five days a week for several weeks.
Monitoring After Treatment and Adjuvant Treatment for Localized Disease
About three months after treatment with intravesical therapy (and at specific intervals after that), a doctor will perform a cystoscopy to ensure there is no bladder cancer recurrence. For intermediate to high-risk patients, urine cytology to look for cancer cells and imaging of the upper urinary tract (i.e. CT scan) will also often be done periodically as a further means of monitoring.
If a suspicious area of the bladder is seen, it will be biopsied and removed with TURBT. If cancer has indeed recurred, a person will generally undergo more intravesical therapy or have their bladder removed with cystectomy surgery.
If there is no evidence of recurrence, a person may undergo maintenance therapy with BCG in order to further prevent any cancer recurrence. The duration of maintenance therapy (for example, one year versus three years) depends on a person’s risk, which is assessed by his or her cancer team.
Metastatic Bladder Cancer
For bladder cancer that has spread to other parts of the body, like the lymph nodes or other organs (lungs, liver, and/or bones), chemotherapy is usually the preferred first option to slowing cancer growth.
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If a patient’s cancer continues to worsen during or after chemotherapy, immunotherapy is generally the next approach. Immunotherapy is also considered if a patient cannot take chemotherapy.
There are five immunotherapy drugs approved for metastatic bladder cancer. All of these drugs are checkpoint inhibitors. This means that they target specific proteins located on immune system cells called “checkpoints,” in order to help a person’s body attack cancer cells.
The five immune checkpoint inhibitors approved for metastatic bladder cancer include:
Tecentriq (atezolizumab)Imfinzi (durvalumab)Bavencio (avelumab)Opdivo (nivolumab)Keytruda (pembrolizumab)
Sometimes, radiation is given or surgery (TURBT or cystectomy) is performed on a person with metastatic bladder cancer, too.
In other words, a shorter duration of time may be more fulfilling than a longer period of uncomfortable treatments. This, of course, is an extremely personal and unique decision.
