Bladder cancer

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Surgery for bladder cancer

Most people with bladder cancer will have surgery. The type of surgery you have depends mainly on the stage of the cancer. When planning surgery, your healthcare team will also consider other factors, such as your age and overall heath.

Surgery may be done for different reasons. You may have surgery to:

  • diagnose bladder cancer and find out the stage
  • completely remove the cancer
  • remove as much of the cancer as possible before other treatments
  • reduce pain or ease symptoms (called palliative surgery)

The following types of surgery are used to treat bladder cancer. You may also have other treatments before or after surgery.

Transurethral resection of bladder tumour (TURBT)

A transurethral resection of bladder tumour (TURBT) removes tumours from the bladder through the urethra. It is used to diagnose, stage and treat bladder cancer. It is usually the first surgery done for bladder cancer because it’s the most common way to biopsy bladder tumours. A TURBT may also be called a transurethral resection (TUR).

A TURBT may be the only treatment needed for early stages of bladder cancer that haven’t grown into the muscle layer of the bladder wall. Sometimes a second TURBT is done to make sure all the cancer is removed. For bladder cancer that has grown deeper into the bladder wall, a TURBT may be done to remove as much of the cancer as possible before other treatments. This is called bladder-preserving surgery because the bladder is kept in place so you can continue to urinate (pee) normally.

A local, spinal or general anesthetic is given before a TURBT. The surgeon inserts a thin tube with a light and lens on the end (called a cystoscope) through the urethra and into the bladder. Then the surgeon passes a special tool with a wire cutting loop through the cystoscope to remove the tumour along with a margin of normal tissue around it. Some muscle from the bladder wall is also removed to see if the cancer has grown into the muscle layer of the bladder wall.

The surgeon burns the area where the tumour was removed with a high-energy electric current (called fulguration) or a laser. This procedure seals off blood vessels and helps destroy any remaining cancer.

A tube (catheter) may be inserted and left in place for a few days after surgery. This helps urine leave the body while the bladder heals.

You may be able to go home on same day as your surgery or you might have to stay in the hospital longer.

Cystectomy

A cystectomy removes all or part of the bladder. It is most commonly done for bladder cancer that has grown into the muscle layer of the bladder wall. Lymph nodes in the pelvis are usually removed (called a pelvic lymph node dissection) following a cystectomy.

Radical cystectomy

A radical cystectomy removes the whole bladder along with surrounding fat and organs. In men, usually the prostate, seminal vesicles and ends of the ureters are removed and sometimes part of the urethra (called a radical cystoprostatectomy). In women, the uterus, cervix, fallopian tubes, ovaries, front wall of the vagina and urethra may be removed (called an anterior pelvic exenteration).

A radical cystectomy is done when the:

  • tumour has grown into the muscle layer of the bladder wall
  • cancer has spread to nearby lymph nodes in the pelvis (lymph node metastases)
  • cancer keeps coming back (recurring) after a TURBT and other local treatments, especially when it is high grade
  • cancer is in a large part of the bladder
  • tumour has grown into nearby tissues or organs outside of the bladder
  • cancer is a rare type, such as squamous cell carcinoma or adenocarcinoma of the bladder

A radical cystectomy is done using a general anesthetic (you will be unconscious). The surgeon can do open surgery, making a cut (incision) in the abdomen to remove the bladder. Or in some cases, the surgeon can do laparoscopic surgery. For this type of surgery, the surgeon makes several small cuts and then inserts an endoscope and special tools to remove the bladder.

Once the bladder is removed, the surgeon makes a new way to hold urine and pass it out of the body (called urinary diversion).

Partial cystectomy

A partial cystectomy (also called segmental cystectomy) removes only part of the bladder (with the tumour). It is called bladder-preserving surgery because the bladder is kept in place so you can continue to urinate normally. A partial cystectomy is not commonly done for bladder cancer.

A partial cystectomy may be done when:

  • invasive bladder cancer is only in one area of the bladder and the surgeon can get clean surgical margins
  • the tumour is in an abnormal pouch of the bladder wall (called a bladder diverticulum)
  • you have urachal cancer (a rare type of bladder cancer)

A partial cystectomy is done using a general anesthetic. The surgeon makes a cut in the abdomen above the bladder. The section of bladder with the tumour is removed along with a margin of healthy bladder tissue around it.

Pelvic lymph node dissection (PLND)

A pelvic lymph node dissection (PLND) is surgery to remove lymph nodes from the pelvis. It is done following a radical cystectomy (or partial cystectomy), usually during the same surgery.

A PLND for bladder cancer is done to:

  • remove lymph nodes that contain cancer
  • remove lymph nodes that are at high risk of having cancer
  • reduce the risk of cancer coming back or spreading
  • help your doctor plan treatments after surgery

Find out more about a pelvic lymph node dissection (PLND).

Urinary diversion

A urinary diversion is reconstructive surgery to make a new way for urine to leave the body. It is done after the whole bladder is removed (radical cystectomy). In rare cases, a urinary diversion may be done without removing the bladder to relieve blocked urine flow if the cancer has spread or cannot be removed by surgery.

The type of urinary diversion done depends on many factors, including:

  • your age
  • how well you can move around
  • how well the intestine, liver and kidneys are working
  • other medical problems you have
  • if you have had radiation therapy
  • how close the cancer was to the urethra
  • how long you are expected to live (life expectancy)

Urinary diversions can be either incontinent or continent.

Incontinent diversion

With an incontinent diversion, you don’t control urination. A urostomy is used to continuously drain urine from the body. The urine is collected in a small bag worn outside of the body (urostomy bag, appliance or pouching system). This type of diversion is used more often for people who are older or in poor health.

An ileal conduit (also called a loop diversion) is the most common type of urinary diversion done. The surgeon removes a piece of the small intestine (ileum) and uses it as a passageway (conduit) for urine. The ureters are placed into the piece of intestine and then each ureter is surgically attached to it. An open end of the intestine is attached to an opening (called a stoma) made in the abdominal wall and skin. Urine travels from the kidneys, through the ureters, into the piece of intestine and then out through the stoma. The urine is collected in a small bag outside of the body.

Diagram of an ileal conduit

Continent diversion

With a continent diversion, you control urination. The surgeon makes a pouch to hold the urine. You drain the urine from this new pouch either with a tube or through the ureter (as you would normally).

A continent cutaneous reservoir (Indiana pouch) is also called a continent diversion with catheterizable cutaneous stoma. The surgeon creates a pouch using the right side of the colon (cecum and ascending colon) and a piece of the small intestine (ileum). The pouch is attached to an opening (stoma) made in the abdominal wall and skin. You drain urine from the pouch by inserting a tube into the opening several times throughout the day.

Diagram of a continent cutaneous reservoir (Indiana pouch)

An orthotopic neobladder is when the surgeon makes a pouch (called a neobladder, or new bladder) usually from part of the small intestine. (Part of the colon may be used in some cases.) The ureters are attached to the pouch, which is then attached to the urethra. You empty the pouch by urinating normally. An orthotopic neobladder is a more difficult type of surgery than other urinary diversions and there is more chance of problems (complications). So it is usually done in younger people without serious medical problems.

Diagram of an orthotopic neobladder

Find out more about urinary diversions.

Side effects

Side effects can happen with any type of treatment for bladder cancer, but everyone’s experience is different. Some people have many side effects. Other people have only a few side effects.

If you develop side effects, they can happen any time during, immediately after or a few days or weeks after surgery. Sometimes late side effects develop months or years after surgery. Most side effects will go away on their own or can be treated, but some may last a long time or become permanent.

Side effects of surgery will depend mainly on the type of surgery and your overall health.

A TURBT may cause these side effects:

  • bladder spasms, which tend to come and go
  • having to urinate often (frequent urination)
  • burning when you urinate
  • bleeding when you urinate
  • urinary incontinence

A cystectomy may cause these side effects:

Tell your healthcare team if you have these side effects or others you think might be from surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Questions to ask about surgery

Find out more about surgery and side effects of surgery. To make the decisions that are right for you, ask your healthcare team questions about surgery.

stage

A description of the extent of cancer in the body, including the size of the tumour, whether there are cancer cells in the lymph nodes and whether the disease has spread from its original site to other parts of the body.

Stages are based on specific criteria for each type of cancer.

The process of determining the extent of cancer in the body based on exams and tests is called staging.

biopsy

The removal of cells or tissues for examination under a microscope.

Different types of biopsies include incisional biopsy, excisional biopsy and needle biopsy. Sometimes imaging techniques are used to guide the biopsy, as in ultrasound-guided biopsy and computed tomography (CT)–guided biopsy.

anesthetic

A drug that causes anesthesia (the loss of some or all feeling or awareness).

General anesthetics put a person to sleep. Regional anesthetics cause a loss of feeling in a part of the body, such as an arm or leg, but the person does not lose awareness. Local anesthetics numb only a small area of the body.

catheter

A flexible tube used to carry fluids into or out of the body.

For example, an intravenous catheter delivers fluid into the body through a vein and a urinary catheter carries urine from the bladder out of the body.

endoscope

A thin, tube-like instrument with a light and lens used to examine or treat organs or structures in the body.

An endoscope can be flexible or rigid. It may have a tool to remove tissue for examination. Specialized endoscopes may have tools designed to examine or treat specific organs or structures in the body.

Specialized endoscopes are named for the organ or structure they are used to examine or treat.

margin

The area of normal tissue surrounding a tumour that is removed along with the tumour during surgery.

The margin may be described as negative or clean if no cancer cells are found at the edge of the tissue. It may be described as positive or involved if cancer cells are found at the edge of the tissue, which suggests that not all of the cancer was removed.

urostomy

A surgical procedure to create a stoma (artificial opening) so that urine can pass out of the body through the abdominal wall.

A urostomy may be done if the bladder or urethra (the tube that carries urine from the bladder to the outside of the body) need to be bypassed or removed. A special bag (urostomy bag) is attached to the stoma to collect urine.

ileum

The last part of the small intestine that receives almost completely digested food from the jejunum, absorbs more nutrients and fat, then passes digested food to the large intestine.  

colon

The longest part of the large intestine that receives almost completely digested food from the cecum (the first part of the large intestine), absorbs water and nutrients and passes waste (stool or feces) to the rectum.

The colon is made up of 4 parts. The ascending colon starts at the cecum and goes up the right side of the abdomen. The transverse colon goes across the upper abdomen. The descending colon goes down the left side of the abdomen. The sigmoid colon is the last part of the colon that connects the descending colon to the rectum.

Sometimes called the lower intestine or large bowel.

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