Surgery is by far the most widely used treatment for bladder cancer. It is used for all types and stages of bladder cancer. Several different types of surgery are used. Which type is used in any situation depends largely on the stage of the tumor. Many surgical procedures are available today that have not gained widespread acceptance. They can be difficult to perform, and good outcomes are best achieved by those who perform many of these surgeries per year. The types of surgery are as follows:
- Transurethral resection with fulguration: In this operation, an instrument (resectoscope) is inserted through the urethra and into the bladder. A small wire loop on the end of the instrument then removes the tumor by cutting it or burning it with electrical current (fulguration). This is usually performed for the initial diagnosis of bladder cancer and for the treatment of stages Ta and T1 cancers. Your surgeon may administer a dose of intravesical mitomycin after the TURBT to prevent cancer cells that are floating in the bladder after the resection from attaching the bladder and causing a recurrence of the bladder cancer. Often, after transurethral resection, additional treatment is given (for example, intravesical therapy) to help treat the bladder cancer, depending on the grade and stage of the bladder cancer.
- Radical cystectomy: In this operation, the entire bladder is removed, as well as its surrounding lymph nodes and other structures adjacent to the bladder that may contain cancer. This is usually performed for cancers that have at least invaded into the muscular layer of the bladder wall or for more superficial cancers that extend over much of the bladder or that have failed to respond to more conservative treatments. Occasionally, the bladder is removed to relieve severe urinary symptoms.
- If the urethra, the tube that connects the bladder to the perineum, is involved with cancer, the urethra may need to be removed along with the bladder, known as radical cystectomy plus urethrectomy (cystourethrectomy).
- Segmental or partial cystectomy: In this operation, part of the bladder is removed. This is usually performed for solitary low-grade tumors that have invaded the bladder wall but are limited to a small area of the bladder and have not spread outside of the bladder.
As the name implies, radical cystectomy is major surgery. Not only the entire bladder but also other structures are removed.
- In men, the prostate and seminal vesicles are removed. (The seminal vesicles are small structures that contain fluid that is part of the ejaculate.) This operation stops prevents sperm and semen from coming out when you ejaculate, called dry ejaculate. The nerves that go to the penis to cause erections may also be affected by the surgery, causing erectile dysfunction.
- In women, the womb (uterus), ovaries, and part of the vagina are removed. This permanently stops menstruation, and you can no longer become pregnant. The operation may also interfere with sexual and urinary functions.
- Removal of the bladder is complicated because it requires creation of a new pathway for urine to be stored and to leave the body. There are a variety of different surgical procedures that can be performed. Some people wear a bag outside the body to collect urine, called noncontinent urinary diversion. Others have a small pouch made inside the body to collect urine, known as continent urinary diversion. The pouch is usually made by a surgeon from a small piece of the intestine. A connection between the pouch and the skin can be catheterized with a small catheter (hollow tube) to empty the pouch. In others, a new bladder can be made of intestine that is sewn to the urethra (neobladder), and one can void either by increasing abdominal pressure or catheterizing per urethra to empty the bladder,
- Historically, the ureters, the tubes that drained the kidneys, were attached to the colon, and one would empty both urine and stool together. This procedure was associated with a risk of developing cancer near the area where the ureter was sewn into the colon, so it is rarely used today in the U.S. but may still be used in some underdeveloped countries.
- Surgeons and medical oncologists are working together to find ways to avoid radical cystectomy. A combination of chemotherapy and radiation therapy may allow some patients to preserve their bladder; however, the toxicity of the therapy is significant, with many patients requiring surgery to remove the bladder at a later date, due to severe voiding symptoms, frequency, urgency, pain and blood in the urine.
If your urologist recommends surgery as treatment for your bladder cancer, be sure you understand the type of surgery you will have and what effects the surgery will have on your life.
Even if the surgeon believes that the entire cancer is removed by the operation, many people who undergo surgery for bladder cancer receive chemotherapy after the surgery. This “adjuvant” (or “in addition”) chemotherapy is designed to kill any cancer cells remaining after surgery and to increase the chance of a cure.
Some patients may receive chemotherapy before radical cystectomy. This is called “neoadjuvant” chemotherapy and may be recommended by your surgeon and oncologist. Neoadjuvant chemotherapy can kill any microscopic cancer cells that may have spread to other parts of the body and can also shrink the tumor in your bladder before surgery.