for Bladder Cancer
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.
Robotic Bladder Cancer Surgery Safe and Effective
Minimally invasive surgical procedures have become an alternative to several types of open surgery. Robotic-assisted radical cystectomy (RARC) is a type of laparoscopic procedure that allows for removal of the cancer without the invasiveness of an open procedure. Robotic surgery is a major surgical procedure performed in a minimally invasive fashion. It involves sophisticated medical devices that allow surgeons to operate through tiny incisions, using enhanced imagery and incredibly precise movements. Robotic-assisted surgery offers improved, magnified visualization in high-definition 3D. Surgeons are able to precisely control the surgical instruments because they offer seven degrees of free motion.
Some studies have demonstrated that when performed by an experienced surgeon robotic-assisted surgery for invasive bladder cancer is effective and results in less bleeding and shorter hospital stays when compared to the traditional open procedure.1 Although these retrospective clinical studies have suggested that RARC leads to fewer complications and a shorter hospital stay compared with open surgery, supporting data from randomized comparative trials has been lacking.
Investigators at Sloan Kettering have now reported that RARC may offer no advantages to a traditional open cystectomy. They performed a clinical trial that directly compared open and RARC in patients with newly diagnosed invasive bladder cancer. All surgeries were performed by the same seven surgeons, each of whom had at least 10 years of experience. The 90-day complication rate was 62% with robotic surgery and 66% with open surgical resection of the bladder. The robotic procedure failed to shorten hospital stays, with a mean duration of 8 days in both groups. Severe complications also occurred in a similar proportion of patients in the two groups. Robot-assisted laparoscopic cystectomy was associated with less intraoperative blood loss but required significantly more time to complete, averaging 456 minutes versus 329 minutes with open cystectomy.2
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 eliminate the need for an external urinary appliance.
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.
Supportive Care: Supportive care refers to treatments designed to prevent and control the side effects of cancer and its treatment. Side effects not only cause patients discomfort, but also may prevent the optimal delivery of therapy at its planned dose and schedule. In order to achieve optimal outcomes from treatment and improve quality of life, it is imperative that side effects resulting from cancer and its treatment are appropriately managed. For more information, go to Managing Side Effects.
1 Parekh DJ, Messer J, Fitzgerald J, et al. Perioperative outcomes and oncologic efficacy from a pilot prospective randomized clinical trial of open versus robotic assisted radical cystectomy. Journal of Urology. 2013; 189(2): 474-479.
2 Bochner BH et al. A randomized trial of robot-assisted laparoscopic radical cystectomy. N Engl J Med 2014; 371: 389-390.