Surgery
Surgery is the removal of the tumor and some surrounding healthy tissue during an operation. There are different types of surgery for bladder cancer. The most beneficial option usually depends on the stage and grade of the disease. Surgical options to treat bladder cancer include:
Transurethral bladder tumor resection (TURBT). This procedure is used for diagnosis and staging, as well as treatment. During TURBT, a surgeon inserts a cystoscope through the urethra into the bladder. The surgeon then removes the tumor using a tool with a small wire loop, a laser, or fulguration (high-energy electricity). The patient is given an anesthetic, medication to block the awareness of pain, before the procedure begins.
For people with non-muscle-invasive bladder cancer, TURBT may be able to eliminate the cancer. However, the doctor may recommend additional treatments to lower the risk of the cancer returning, such as intravesical chemotherapy or immunotherapy (see below). For people with muscle-invasive bladder cancer, additional treatments involving surgery to remove the bladder or, less commonly, radiation therapy are usually recommended.
Cystectomy. A radical cystectomy is the removal of the whole bladder and possibly nearby tissues and organs. For men, the prostate and urethra also may be removed. For women, the uterus, fallopian tubes, ovaries, and part of the vagina may be removed. In addition, lymph nodes in the pelvis are removed for both men and women. This is called a pelvic lymph node dissection. An extended pelvic lymph node dissection is the most accurate way to find cancer that has spread to the lymph nodes. Rarely, for some specific cancers, it may appropriate to remove only part of the bladder, which is called partial cystectomy.
During a laparoscopic or robotic cystectomy, the surgeon makes several small incisions (cuts) instead of the 1 larger incision used for traditional surgery. The surgeon then uses telescoping equipment with or without robotic assistance to remove the bladder. The surgeon must make an incision to remove the bladder and surrounding tissue. This type of operation requires a surgeon who is very experienced in minimally invasive surgery. Several studies are still in progress to determine whether laparoscopic or robotic cystectomy is as safe as the standard surgery and whether it is able to eliminate bladder cancer as successfully as standard surgery.
Urinary diversion. If the bladder is removed, the doctor will create a new way to pass urine out of the body. One way to do this is to use a section of the small intestine or colon to divert urine to a stoma or ostomy (an opening) on the outside of the body. The patient then must wear a bag attached to the stoma to collect and drain urine.
Increasingly, surgeons can use part of the small or large intestine to make a urinary reservoir, which is a storage pouch that sits inside the body. With these procedures, the patient does not need a urinary bag. For some patients, the surgeon is able to connect the pouch to the urethra, creating what is called a neobladder, so the patient can pass urine out of the body normally. However, the patient may need to insert a thin tube called a catheter if urine does not empty through the neobladder. Also, patients with a neobladder will no longer have the urge to urinate and will need to learn to urinate on a consistent schedule.
For other patients, an internal (inside the abdomen) pouch made of small intestine is created and connected to the skin on the abdomen or umbilicus (belly button) through a small stoma. With this approach, patients do not need to wear a bag. Patients drain the internal pouch multiple times a day by inserting a catheter through the small stoma and immediately removing the catheter.
Chemotherapy
Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. A chemotherapy regimen typically consists of a specific number of cycles given over a set period of time. A patient may receive 1 drug at a time or combinations of different drugs at the same time.
There are 2 types of chemotherapy that may be used to treat bladder cancer. The type the doctor recommends and when it is given depends on the stage of the cancer. Patients should talk with their doctor about chemotherapy before surgery.
Intravesical chemotherapy. Intravesical (local) chemotherapy is usually given by a urologist. During this type of therapy, drugs are delivered into the bladder through a catheter that has been inserted through the urethra. Local treatment only destroys superficial tumor cells that come in contact with the chemotherapy solution. It cannot reach tumor cells in the bladder wall or tumor cells that have spread to other organs. Mitomycin (Mitozytrex, Mutamycin) and thiotepa (multiple brand names) are the drugs used most often for intravesical chemotherapy. Other drugs that are used include cisplatin (Platinol), doxorubicin (Adriamycin), gemcitabine (Gemzar), and valrubicin (Valstar).
Systemic chemotherapy. Systemic (whole body) chemotherapy is usually prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication. Systemic chemotherapy gets into the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).
The most common chemotherapy regimens for bladder cancer are:
Cisplatin and gemcitabine
Carboplatin (Paraplatin) and gemcitabine
MVAC, which combines 4 drugs: methotrexate (multiple brand names), vinblastine (Velban, Velsar), doxorubicin, and cisplatin
Dose dense (DD)-MVAC
Which chemotherapy regimen is selected depends on the treatment goals and the stage of the bladder cancer.
Many systemic chemotherapies continue to be tested in clinical trials to help find out which drugs or combinations or drugs work best to treat bladder cancer. Usually a combination works better than 1 drug alone. Researchers are also studying when it is best to use chemotherapy, either before or after surgery.
Radiation therapy
Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. When radiation therapy is given using implants, it is called internal radiation therapy or brachytherapy. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time.
Radiation therapy is usually not used by itself as a primary treatment for bladder cancer, but it may be given in combination with chemotherapy. Some people who cannot receive chemotherapy might receive radiation therapy alone. The following reasons describe why a combination of radiation therapy and chemotherapy may be used to treat cancer that is located only in the bladder:
To destroy any cancer cells that may remain after TURBT so all or part of the bladder does not have to be removed
To relieve symptoms caused by a tumor, such as pain, bleeding, or blockage
To treat a metastasis located in 1 area, such as the brain or bone
Side effects from radiation therapy may include fatigue, mild skin reactions, and loose bowel movements. For bladder cancer, side effects most commonly occur in the pelvic or abdominal area and may include bladder irritation, with the need to pass urine frequently during the treatment period, and bleeding from the bladder or rectum. Most side effects go away soon after treatment is finished.