Bladder cancer is a rare, but serious type of cancer that most commonly affects older adults. Fortunately, bladder cancer is usually caught early and is highly treatable, however, recurrence is common, so followup testing is generally recommended. Symptoms generally include blood in the urine, sometimes accompained by pain during urination.
Transurethral Resection (TUS) With Fulguration
Transurethral resection (TUS) with fulguration is an outpatient procedure that diagnoses and removes tumors in the bladder. After an initial bladder cancer diagnosis, a urologist may recommend a transurethral resection to fully examine the bladder while the patient is under general or spinal anesthesia. This procedure helps physicians determine whether or not a patient’s cancer has invaded the bladder wall.
During the procedure, a urologist inserts a cystoscope, also called a resectoscope, through the urethra into the bladder. This surgical instrument has a wire loop at the end of it, which is used to remove abnormal tissues or tumors. This process prevents cutting into vital muscles and tissues in the abdomen. If abnormal or diseased tissue needs to be removed from the bladder, it will be sent to a lab to be reviewed by a pathologist. If the patient has already been diagnosed with an early stage, non-muscle invasive bladder cancer, this procedure may be performed in conjunction with fulguration to remove and completely destroy any remaining tumors.
Fulguration is a procedure that burns tissue using a high-frequency electrical current. This technique can be performed a number of ways, but the most common is a high energy laser that’s inserted through the cystoscope. Because TUS with fulguration is an outpatient procedure, patients typically return home the same day or the following day. Side effects after surgery include slight bleeding and some pain during urination Patients can typically resume their normal, daily activities a week or two after the procedure.
Partial Cystectomy (Robotic and Open)
Partial cystectomy is a surgical procedure that removes a portion of the bladder after a cancerous tumor has invaded the bladder’s muscular wall. There are many advantages to partial cystectomy, but the most notable advantage is that the bladder is preserved, which means the patient will not need to undergo reconstructive surgery. During the procedure, a urologist makes several small incisions in the abdomen before inserting a laparoscope. This long and thin surgical instrument has a camera attached to one end to help the surgeon see inside the pelvis and bladder.
Once the laparoscope has located the cancerous tumors, the urologist will remove part of the bladder wall and nearby lymph nodes. These tissue samples may be sent to a lab for further examination. After the diseased area of the bladder has been removed, the urologist will close the missing portion with sutures and close the incision. Although this surgical procedure (i.e. robotic partial cystectomy) can result in less pain and downtime, patients will need to spend one to three days in the hospital to recover.
Surgical complications are not common, but they can still happen. Risks and side effects associated with cystectomy include allergic reactions to anesthesia, damage to nearby organs, surgical infections, and blood clots in the legs or lungs. Only a small number of patients with less invasive bladder cancers can undergo this surgery. That being said, patients may need to have a radical cystectomy if the cancer is larger in size or is in more than one region of the bladder.
Radical Cystectomy
Radical cystectomy is a surgical procedure that removes the entire bladder, and occasionally, nearby lymph nodes due to invasive bladder cancer. In some instances, the prostate may be removed in men, and for women, the ovaries, fallopian tubes, uterus, cervix, and a small part of the vagina may also be removed. Although this procedure is extensive, it can help prevent the spread of cancerous cells, reducing the likelihood of bladder cancer recurrence.
During the procedure, a urologist makes small incisions in the abdomen before inserting a laparoscope into the pelvis. This surgical instrument is used by the surgeon for a number of reasons: it helps provide a clear view of the bladder; it minimizes blood loss during surgery; it can reduce pain; and it generally results in a shorter recovery time for the patient. Once the bladder is in clear view, the surgeon will use special tools to make small cuts into the organ to slowly remove it from the pelvic region. After the bladder has been removed completely, the surgeon will begin reconstructing a conduit for urine.
There are different types of conduits that can be created based on the patient’s medical needs and personal preferences. An incontinent diversion is a procedure that removes a short piece of the intestine and connects it to the ureters to create a passageway for urine. For this particular procedure, a stoma is created, which requires an ostomy bag for urine collection. A continent diversion is another way to store and remove urine. It creates a small pouch from a piece of intestine and attaches it to the ureters. Patients will need to use a catheter to drain their urine for this option. A neobladder is a newer treatment option that routes urine back into the urethra. After several months, patients may regain the ability to urinate normally.
Intravesical Immunotherapy (BCG) and Chemotherapy (Mitomycin C)
Intravesical immunotherapy (BCG) and chemotherapy (Mitomycin C) are generally effective treatment options for patients suffering from bladder cancer. Intravesical immunotherapy is generally used after transurethral resection (TUS) with fulguration to mitigate non-invasive (stage 0) or minimally invasive (stage 1) bladder cancers. If the cancer has advanced beyond these earlier stages, patients will need to receive more advanced treatment options like chemotherapy. Unfortunately, immunotherapy has little effect on cancer cells that spread outside the bladder lining.
The most common intravesical immunotherapy is called Bacillus Calmette-Guerin (BCG) therapy, and it is placed in the bladder through a catheter every six weeks. On rare occasions, BCG can cause a serious infection to spread throughout the body, so patients should monitor their symptoms and report adverse side effects to their Affiliated Urologists provider. Another treatment option for bladder cancer is chemotherapy. For this treatment, chemotherapy drugs are delivered directly to the bladder through a catheter. Similar to other chemotherapy drugs, these medications help kill growing cancer cells in the body. Mitomycin is the most common drug administered, but other chemotherapy drugs include valrubicin, docetaxel, thiotepa, and gemcitabine.
There are many advantages to delivering chemotherapy drugs directly to the bladder, but for patients with advanced stages of bladder cancer, chemotherapy must be given through a port in a vein. Side effects are common with chemotherapy, and some patients experience irritation and burning pain in the bladder, as well as fatigue, nausea, and vomiting. A urologist may prescribe medication to reduce pain and nausea common with this treatment option.
Urinary Diversion
Urinary diversion is a treatment option for patients who have been diagnosed with advanced stages of bladder cancer. When the patient has lost his or her bladder to cancer, the urine needs to be redirected out of the body. This surgical procedure helps reconstruct the urinary tract in order to achieve this goal.
Urinary diversion can be accomplished in a variety of ways, and ultimately, the procedure that is performed is dependent on the patient’s personal preferences and cancer. One option is called ileal conduit diversion or urostomy. This procedure is among the shortest of urinary diversion surgeries. During this procedure, a small piece of the intestine is removed and attached to the ureters to create the ileal conduit. An opening, which is referred to as a stoma, is then made in the abdomen. Part of the conduit is attached to the stoma so urine can flow directly from the kidneys through the stoma. A bag is connected to the stoma to collect the urine as it flows out. An alternative to this method is a continent diversion, which requires a catheter to be inserted into the stoma throughout the day to relieve urine from an internal pouch, thus eliminating the need for a bag.
Finally, patients can undergo a newer urinary diversion method known as the neobladder procedure. It is similar to the continent diversion method where a small pouch is created with a little part of the small intestine. Urine can pass from the kidneys to the ureters and into the pouch, but in this case, urine will be able to flow out through the urethra – much like normal urination. No bag is needed and patients can urinate in a traditional manner. However, patients may experience incontinence or need to place a catheter into the pouch if normal urination is not occurring.
Some of these procedures may be performed using minimally invasive approaches, but depending on the patient’s condition, open surgery may be required for the urinary diversion.
After each of these surgical procedures, patients wake up in a recovery room. They may be connected to an oxygen machine, various monitors, and an intravenous line. Patients may also be hooked up to a variety of drainage pipes to ensure the safe removal of excess fluid. Hospital staff will teach patients how to care for these drains, as they will need to be worn after the patient arrives home. Patients are expected to stay at the hospital for a few days. At this time, patients may be given antibiotics and pain medication as needed. Pain medication, whether taken at the hospital or at home, may cause constipation, so a physician may recommend liquids, a high-fiber diet, and stool softeners. Surgical dressings should be handled with care to avoid infection. They should only be touched with clean hands and patted dry after showering. Patients should never submerge the dressings in a bath.
Patients must be aware of the risks after their reconstructive surgery. Patients may experience pouch stones, restricted flow of urine, infections, and more following their procedure. Overall, once the patient has made a full recovery in a couple of months, patients can go back to their normal activities. However, external urine pouches and catheters may need to be regularly maintained. Patients should always look for signs of infection and be careful of any leakage from their stoma or bag.
