The optimal treatment of bladder cancer may require involvement of several different physicians, including a urologist, medical oncologist and/or radiation oncologist. Medical oncologists are specialists in the management of cancer and use of anti-cancer treatments such as chemotherapy. Radiation oncologists are specialists in the use of radiation to treat cancer and urologists are surgeons and experts in the management of cancers involving the urinary system. There are several different surgical procedures that are performed by urologists for the diagnosis and treatment of the different stages of bladder cancer.

Transurethral Resection (TUR)

A transurethral resection (TUR) is an operation that is performed for both the diagnosis and management of bladder cancer. During a TUR, a urologist inserts a thin, lighted tube called a cystoscope into the bladder through the urethra to examine the lining of the bladder. The urologist can remove samples of tissue through this tube or can remove some or all of the cancer in the bladder. The urologist can also use electrical (cautery or fulguration) or laser thermal destruction of stage 0-I superficial bladder cancers. A TUR causes few problems, although patients may have some blood in their urine and difficulty or pain when urinating for a few days afterward.

TUR is used to treat patients with superficial bladder cancers (non-invasive papillary carcinoma and carcinoma in situ). Repeated TURs are frequently performed throughout the life of patients with superficial bladder cancers. At the time of TUR, chemotherapy agents and biological agents, such as BCG, are often instilled into the bladder. Surgeons can also cauterize (electrical heat) or apply a laser for heat to kill visualized superficial cancers during a TUR.

TUR can also be utilized to remove all or a part of stage II-III bladder cancer in patients scheduled to receive chemotherapy and radiation therapy for bladder-sparing therapy approaches.

Radical Cystectomy (Complete Surgical Removal of the Bladder)

A radical cystectomy consists of the surgical removal of the bladder as well as the tissue and some of the organs around it. For men, the prostate and the seminal vesicles, and possibly the urethra, are often removed. For women, the uterus, ovaries, fallopian tubes, part of the vagina, and the urethra are often removed. A pelvic lymph node dissection, removal of the lymph nodes in the pelvis, may also be performed to determine whether the cancer has spread to these lymph nodes. Pelvic lymph node dissection adds little to the overall side effects of radical cystectomy, improves staging accuracy and may be curative in some patients with minimal lymph node involvement.

Because the bladder is removed, doctors must design an alternate way for the body to store and pass urine. This is often referred to as a urinary diversion technique and is described in complete detail below in the section entitled “Creation of Alternative Bladders and Neobladders.” Radical cystectomy with preservation of sexual function can be performed in some men and new forms of urinary diversion can obviate the need for an external urinary appliance.

Previous clinical trials have demonstrated that the removal of cancer through a TUR in select patients with muscle-invasive bladder cancer can produce 5-year survival rates comparable to that of a radical cystectomy. However, physicians are hesitant to use TUR as definitive treatment for muscle-invasive bladder cancer for a few reasons: 1) optimal treatment and surveillance schedules have not yet been established, 2) specific patient characteristics defining who would benefit most from this procedure have not been determined and 3) lack of definitive information exists regarding this issue.

Recently, long-term results have been reported from a clinical study evaluating the use of TUR as treatment for muscle-invasive bladder cancer. Patients in this study underwent an initial diagnostic TUR, at which time their cancer was removed. All patients had cancer that invaded only the inner muscular layer of the bladder. Patients were then advised to undergo a second TUR to determine if their cancer had returned. Physicians removed a sample of tissue from the location of the initial cancer, as well as from healthy looking tissue layers surrounding the area to test for the recurrence of cancer. If patients had a muscle-invasive recurrence, they were advised to undergo an immediate radical cystectomy. If patients had no recurrence or a recurrence of cancer in superficial layers only (invading only the innermost layers lining the cancer prior to the muscle), they had a choice of an immediate radical cystectomy or follow-up bladder examinations every 3 to 6 months (and repeat TURs as necessary) for at least 10 years.

Ten years following initial treatment, patients who had no cancer recurrence as determined by the follow-up TUR achieved an 82% survival rate when treated with bladder-sparing surgery, compared with a 65% survival rate in patients treated with cystectomy. In addition, nearly 70% of the group of patients treated with bladder-sparing therapy were able to keep their bladder for over ten years. Conversely, in patients who had a superficial cancer recurrence, those treated with bladder-sparing surgery achieved a 10-year survival of 57%, compared with 76% for those treated with cystectomy. Only 27% of these patients treated with bladder-sparing surgery were able to keep their bladder for over 10 years.

These results are exciting in that they indicate that bladder-sparing procedures may be just as effective in achieving long-term survival for patients as a radical cystectomy. However, it is crucial to understand that if muscle-invasive cancer returns following initial treatment, more radical measures, such as cystectomy, appear to be necessary in order to provide superior long-term outcomes.

Segmental or Partial Cystectomy

A segmental or partial cystectomy is an operation during which a portion of the bladder is removed and the ends are sewn back together. It is sometimes performed for treatment of patients with multiple superficial cancers or large superficial cancers in an attempt to avoid removing the entire bladder. However, there are very few situations where this is done.

The application of segmental or partial cystectomy to the treatment of invasive bladder cancer remains controversial. In selected cases with small cancers, the results may be similar to those observed after radical cystectomy. However, the potential for development of cancer in the remaining bladder is still present.

After segmental cystectomy, patients may not be able to hold as much urine in their bladder. In most cases, this problem is temporary; however, some patients may have long-lasting changes in bladder capacity.

Creation of Alternative Bladders or Neobladders

Because surgical treatment of bladder cancer removes the bladder, doctors must design an alternate way for the body to store and pass urine. This is often referred to as a urinary diversion technique. Sometimes, this involves using part of the intestine to construct a tube that carries urine from the ureters to an opening (called a stoma) to the outside of the body. The procedure to construct this stoma is called an ostomy or urostomy. Many researchers have also been studying more permanent ways to allow urine to be stored and passed to help improve urinary function and quality of life. This often involves creating a substitute bladder, sometimes called a neobladder.

The construction of a neobladder involves the use of a segment of the intestine between the ileum (last part of the small intestine) or colon (part of the large intestine) to form a new bladder, referred to as an ileocolonic neobladder. The ureters, which deliver urine from the kidneys to the bladder, are attached to one end of the neobladder. Urine collects in the storage pouch and empties into a stoma (opening in the abdominal wall) through the abdomen to a collection bag. Whenever possible, the neobladder is connected to the urethra and voiding can be more natural.

The use of an intestinal neobladder is an extremely effective form of continent diversion. Complete day and night continence can be achieved in approximately 80% patients. Mild to moderate stress incontinence occurs in 10% of patients and severe stress incontinence in 5%. Patients older than 70 years are more likely to have trouble with continence than younger patients. However, in one retrospective analysis from a single institution, elderly patients (70 years of age or older) in good general health were found to have similar clinical and functional results following radical cystectomy as younger patients. This is an important observation because it suggests that medical condition is more important than age for outcome of surgery.

Strategies to Improve Treatment

The progress that has been made in the treatment of bladder cancer has resulted from improved treatment developed in clinical trials. Future progress in the treatment of bladder cancer will result from patients and doctors continuing to participate in appropriate studies. Currently there are several areas of active exploration aimed at improving the treatment of bladder cancer.