What is surgery?
For many patients, surgery will be combined with other cancer treatments, such as chemotherapy, radiation therapy or hormone therapy. These nonsurgical treatments may be administered before surgery (neoadjuvant therapy) or after surgery (adjuvant therapy) to help prevent cancer growth, spread or recurrence.
Surgery for Bladder Cancer
Surgery is typically the first treatment option for early-stage bladder cancers because tumors have likely not spread to other areas of the body. We may perform surgery for bladder cancers that have recurred or metastasized. For some patients, a bladder-preserving approach may be the best option. For others, removal of the entire bladder may reduce the risk of a subsequent cancer. Your doctor will discuss all of your treatment options, so that you can make the best decision for your care. Our surgical oncology experts are experienced in a variety of procedures and we proactively manage the side effects of bladder cancer surgery.The type of surgery done for bladder cancer will depend on its stage.
Transurethral surgery
For early-stage or superficial (non-muscle invasive) bladder cancers, a transurethral resection (TUR), also known as a transurethral resection of the bladder tumor (TURBT), is the most common treatment. Most patients have superficial cancer when they are first diagnosed, so this is usually the first treatment they receive. This surgery is done using an instrument passed up the urethra, so it does not require cutting into the abdomen. You will get either general anesthesia (where you are asleep) or regional anesthesia (where the lower part of your body is numbed).
For this operation, a type of rigid cystoscope called a resectoscope is placed into the bladder through the urethra. The resectoscope has a wire loop at its end to remove any abnormal tissues or tumors. The removed tissue is sent to a lab to be looked at by a pathologist. After the tumor is removed, more steps may be taken to try to ensure that it has been destroyed completely. Any remaining cancer may be treated by fulguration (burning the base of the tumor) while looking at it with the cystoscope. Cancer can also be destroyed using a high-energy laser through the cystoscope.
The side effects of transurethral bladder surgery are generally mild and do not usually last long. You might have some bleeding and pain when you urinate after surgery. You can usually return home the same day or the next day and can resume your usual activities in less than 2 weeks.
Unfortunately, even with successful treatment, bladder cancer often recurs (comes back) in other parts of the bladder. If transurethral resection needs to be repeated many times, the bladder can become scarred and lose its capacity to hold much urine. Some people may have side effects such as frequent urination, or even incontinence (loss of control of urination). In patients with a long history of recurrent, non-invasive low-grade tumors, the surgeon may sometimes just use fulguration to burn small tumors that are seen during cystoscopy (rather than removing them). This can often be done using local anesthesia (numbing medicine) in the doctor’s office. It is safe but can be mildly uncomfortable.
Cystectomy
This bladder cancer surgical procedure may be used to remove either the entire bladder or portions of it. Sometimes, the bladder may be accessed through an incision in the abdomen. It may also be possible to do laparoscopic surgery. With this approach, several small incisions are made using long, thin instruments, one with a video camera on the end that enables the surgeon to see inside the pelvis. Laparoscopic surgery, also called keyhole surgery, may reduce pain and shorten recovery time. However, because this type of surgery for bladder cancer is newer, there is less evidence of its long-term benefit in treating bladder cancer.
There are two types of cystectomies:
• Partial cystectomy: If cancer has invaded the muscle layer of the bladder wall, but is not large and is confined to one region of the bladder, then it may be possible to treat the cancer by removing only part of the bladder. With this procedure, the portion of the bladder where there is cancer is removed, and the hole in the bladder wall is then closed.
• Radical cystectomy with extended lymph node dissection: If the cancer is larger or is in more than one part of the bladder, a radical cystectomy with extended lymph node dissection will be needed. This operation removes the entire bladder and nearby lymph nodes. In men, the prostate is also removed. In women, the ovaries, fallopian tubes (tubes that connect the ovaries and uterus), the uterus (womb), and a small portion of the vagina are often removed along with the bladder.
General anesthesia (where you are in a deep sleep) is used for either type of cystectomy.
Typically, these procedures are done through a cut (incision) in the abdomen. You will need to stay in the hospital for about a week after the surgery. You can usually go back to your normal activities in 4 to 6 weeks.
In some cases, the surgeon may operate through several smaller incisions using special long, thin instruments, one of which has a tiny video camera on the end to see inside the pelvis. This is known as laparoscopic, or “keyhole” surgery. The surgeon may either hold the instruments directly or may sit at a control panel in the operating room and maneuver robotic arms to do the surgery. Laparoscopic surgery may result in less pain and quicker recovery because of the smaller incisions. But it has not been around as long as the standard type of surgery and it’s not yet clear if it is equally as effective.
It is important that any type of cystectomy be done by a surgeon with experience in treating bladder cancer. If the surgery is not done well, the cancer is more likely to come back.
Reconstructive surgery after radical cystectomy
If your whole bladder is removed, you will need another way to store and remove urine. Several types of reconstructive surgery can be done depending on your medical situation and personal preferences.• Continent diversion: Another way for urine to drain is called a continent diversion. A valve is created in a pouch made from the piece of intestine attached to the ureters. The valve allows urine to be stored in the pouch. You then empty the pouch several times each day by placing a drainage tube (catheter) into the stoma through the valve. Some people prefer this method because there is no bag on the outside.
• Incontinent diversion: One option may be to remove a short piece of your intestine and connect it to the ureters. This creates a passageway, known as an ileal conduit, for urine to pass from the kidneys to the outside of the body. Urine flows from the kidneys through the ureters into the ileal conduit. One end of the conduit is connected to the skin on the front of the abdomen by an opening called a stoma (also known as a urostomy).
After this procedure, a small bag is placed over the stoma to collect the urine, which comes out continuously in small amounts. The bag then needs to be emptied once it is full. This approach is sometimes called an incontinent diversion, because you no longer control the flow of urine out of the body.
• Neobladder: A newer method routes the urine back into the urethra, restoring urination. One way to do this is to create a neobladder – basically a new bladder made of a piece of intestine. As with the incontinent and continent diversion, the ureters are connected to the neobladder. The difference is that the neobladder is also sewn to the urethra. This lets the patient urinate normally. Over several months, most people regain the ability to urinate normally during the day, although many people might still have some incontinence at night.
If the cancer has spread or can’t be removed with surgery, a diversion may be made without removing the bladder. In this case, the purpose of the surgery is to prevent or relieve blockage of urine flow, rather than try to cure the cancer.
Bladder cancer surgeries