Bladder Cancer

Surgery

The type of surgery depends on the stage of the disease. In early bladder cancer, the tumor may be removed (resected) using instruments inserted through the urethra (transurethral resection).

Bladder cancer that has spread to surrounding tissue (e.g., Stage T2 tumors, Stage T3a tumors) usually requires partial or radical removal of the bladder (cystectomy). Radical cystectomy also involves the removal of nearby lymph nodes and may require a urostomy (opening in the abdomen created for the discharge of urine).

In men, the standard surgical procedure is a cystoprostatectomy (removal of the bladder and prostate) with pelvic lymphadenectomy (removal of the lymph nodes within the pelvic cavity). In women with T2 to T3a tumors, the standard surgical procedure is radical cystectomy (removal of the bladder and surrounding organs) with pelvic lymphadenectomy. Radical cystectomy in women also involves removal of the uterus, ovaries, fallopian tubes, anterior vaginal wall, and urethra.

Partial cystectomy (partial removal of the bladder), which is a bladder-preserving procedure, may be used in some cases (e.g., patients with squamous cell carcinomas or adenocarcinomas that arise high in the bladder dome).

Urinary Tract Diversion

Until recently, most bladder cancer patients who underwent cystectomy (bladder removal) required an ostomy (surgical creation of an artificial opening) and an external bag to collect urine. Continent urinary reservoir is a urinary diversion technique that involves using a piece of the bowel (large or small intestine) to form an internal pouch to store urine. The neobladder procedure involves suturing a similar intestinal pouch to the urethra so the patient is able to urinate as before, without the need for a stoma.

The ileal conduit is a urinary channel that is surgically created from a piece of bowel. During this procedure, the ureters are attached to one end of the bowel segment and the other end is brought out of the surface of the abdomen to make a stoma. An external bag is attached to the stoma to collect draining urine.

Chemotherapy

Chemotherapy is a systemic treatment (i.e., affects the entire body) that uses drugs to destroy cancer cells. It is administered orally or intravenously (through a vein) and in early bladder cancer, may be infused into the bladder through the urethra (called intravesical chemotherapy). Chemotherapy also may be administered before surgery (neoadjuvant therapy) or after surgery (adjuvant therapy).

Radiation

Radiation uses high-energy x-rays to destroy cancer cells. External beam radiation is emitted from a machine outside the body and internal radiation is emitted from radioactive "seeds" implanted into the tumor.

Topical Immunotherapy

Immunotherapy, also called biological therapy, may be used in some cases of superficial bladder cancer. This treatment is used to enhance the immune system's ability to fight disease. A vaccine derived from the bacteria that causes tuberculosis (BCG) is infused through the urethra into the bladder, once a week for 6 weeks to stimulate the immune system to destroy cancer cells.

Prognosis

Superficial bladder cancer has a 5-year survival rate of about 85%. Invasive bladder cancer has a less favorable prognosis. Approximately 5% of patients with metastasized bladder cancer live 2 years after diagnosis. Cases of recurrent bladder cancer indicate an aggressive tumor and a poor prognosis.

Bladder Cancer Survival Rates (5year)

T1-T2b diseases 52-70%
Urethral involvement 40%
Lymphnode involvement 4-33%

Recurrent Superficial bladder cancer will progress (worsen) to invasive disease in 10 - 15% of cases,

The Operation

The faculty of the Smith Institute for Urology perform both "open" and robotic radical cystectomy and diversion. Typically, the length of the operation is four to six hours. The open operative is performed through a single incision, starting above the umbilicus and extending down to the pubic bone. The daVinci robotic cystectomy is performed through 5 or 6 small incisions, one of which is hidden in the umbilicus, and an 8 cm incision for reconstruction. With either the open or robotic surgery, several tubes are left in place to allow for proper healing; these include two ureteral stents and a drain. Depending on the type of reconstruction performed, a stomal catheter and/or a Foley catheter may be used.