Treatment for invasive bladder cancer

Saturday 1 March, 2014

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On this page: Surgery | Replacing the bladderSystemic chemotherapyRadiotherapyPalliative treatmentKey points


The most common treatment for muscle-invasive bladder cancer is surgery. Other treatments, such as chemotherapy and radiotherapy, may be combined with surgery. Some bladder cancers may be treated only with a combination of chemotherapy and radiotherapy.

Surgery

Surgery is the preferred treatment for muscle-invasive disease, or cancer that has invaded the lamina propria and has not responded to BCG. The main surgery for invasive bladder cancer is the removal of the bladder (cystectomy). This can be done in different ways.

Removing the whole bladder (radical cystectomy)

A radical cystectomy is the most common operation for invasive bladder cancer. In this operation, the whole bladder and nearby lymph nodes are removed. In most cases, the appendix is also taken out. In men, the prostate, urethra and seminal vesicles may be removed. In women, the uterus, ovaries, a small portion of the vagina, and the Fallopian tubes are often removed.

Surgical techniques

It may be possible to remove the bladder using laparoscopic (keyhole) surgery. The surgeon makes a few small cuts in the abdomen to insert the instruments needed during surgery. Recovery is usually faster following keyhole surgery, but it has not been shown to be more effective than standard surgery. Some surgeons use robotic-assisted keyhole surgery, but this is usually available only in some large hospitals.

Removing part of the bladder (partial cystectomy)

This type of operation is less common, as it is not suitable for most types of bladder cancer. In a partial cystectomy, only the bladder tumour and a border of healthy tissue around it is removed.

Cystectomy side effects

After a radical cystectomy, you will probably stay in hospital for 1–2 weeks. You will have tubes in your body to give you fluids and to drain the operation area. You may have pain after the surgery and need pain relief for a few days.

After a partial cystectomy, your bladder will be smaller and hold less urine, so you may need to pass urine more often.

If you have a radical cystectomy, removing the bladder and surrounding organs will change the way your body functions. In men, the nerves needed to get an erection may be affected. Women who have their reproductive organs removed will go through menopause if they have not already. This may affect how you feel about your appearance, sex life and fertility. For more information, see sexuality & intimacy.

Replacing the bladder

With the bladder removed, you will need to store urine in another way. This is called a urinary diversion. Before any operation, your urologist will discuss the risks and possible complications, and what is suitable for you. There are several options for surgically reconstructing the bladder:

IIeal conduit (urostomy)

This is the most common procedure. It means that urine will drain into a bag attached to the outside of the abdomen.

The doctor will use a piece of your small bowel (ileum) to create a passageway (conduit) that connects the ureters to an opening (hole) on the outside of your body. The hole created on the surface of the abdomen is called a stoma.

A watertight bag is placed over the stoma to collect urine. This small bag, worn under clothing, fills continuously and needs to be emptied throughout the day through the tap on the bag. The small bag will be connected to a larger drainage bag at night. For information see living with a urostomy.

Illeal conduit - a common procedure for bowel cancer

Continent urinary diversion

In this procedure, the doctor uses a piece of small bowel to create a pouch with a valve to hold urine. This allows urine to be stored inside the pouch for a period of time before being removed through a stoma (opening).

The surgeon connects the pouch to the ureters, which drain urine into it from the kidneys. The pouch valve is joined to the surface of the abdomen, where the stoma is created.

Several times a day, you will need to insert a drainage tube (catheter) through the stoma into the pouch, to collect and drain the urine. Once the pouch is empty, the catheter is removed. You do not need to wear a bag over the stoma.

Continent urinary diversion - a procedure for bowel cancer

New bladder (neobladder)

Another way of making a storage place for urine is to create a pouch. This new bladder is called a neobladder.

The neobladder is made from about 45–75cm of your small bowel. The surgeon will stitch your ureters into the top area of the neobladder (chimney). Urine will drain into the ureters from the kidneys.

After the operation you will need to learn different methods for emptying your neobladder. A continence nurse will help you do this.

Neobladder - a procedure for bowel cancer

Caring for a neobladder

Following surgery you will be given support, education and information from specialist nursing staff such as continence nurse.

  • The neobladder will not have the nerves that tell you when your bladder is full.
  • A continence nurse will help you retrain your bladder by using a toilet schedule.
  • At first the capacity of the new bladder will be small, but over the next 6–12 months it will gradually increase from 120–200mls to the normal range of 400–500mls.
  • This may mean that you experience some leakage when the neobladder is full. You may have to get up during the night to empty the neobladder.
  • The continence nurse will teach you how to drain your bladder with a catheter in case you are not able to empty it completely using your abdominal muscles. This is called intermittent self-catheterisation.
  • If you need a long term supply of continence aids, including catheters for intermittent self-catheterisation, ask the continence nurse if you’re eligible for the Medicare operated Continence Aids Payment Scheme (CAPS). See www.bladderbowel.gov.au or call Medicare on 13 20 11 for more information.
  • Discuss any concerns with your nurse, local doctor and urologist, and organise follow-up visits with them.
The continence nurse

A continence nurse can talk to you about having a neobladder. The role of the nurse is to:

  • reinforce a toileting schedule
  • teach self-catheterisation
  • tell you about continence products
  • help you apply for assistance through Medicare
  • answer related questions.
Reconstructive surgery side effects

The side effects of a bladder reconstruction may include:

Your doctor or continence nurse can give you information about the aids available to help you cope with side effects, such as urine leakage. A physiotherapist can show you how to exercise the muscles in your pelvis to stop or reduce leakage.

For more information, call the National Continence Helpline on 1800 33 00 66.

"My continence has improved steadily. The only problem I have is at night, so I set an alarm and wake up to drain the neobladder and avoid accidents."
Patricia

Systemic chemotherapy

Chemotherapy is the treatment of cancer with anti-cancer drugs. The aim is to kill cancer cells while doing the least possible damage to normal cells.

For invasive bladder cancer, drugs are given by injection into a vein (intravenously). As the drugs circulate in the blood they travel throughout the body. This type of chemotherapy is often called systemic chemotherapy.

You may have systemic chemotherapy:

  • before surgery, to shrink the cancer and make it easier to remove
  • after surgery, if there is a high risk of the cancer coming back
  • with radiotherapy, if the cancer has already spread to other parts of the body or if surgery is not an option.

Systemic chemotherapy is given as a course of drugs over a few days. The drugs are given every few weeks for several months.

Side effects

Systemic chemotherapy drugs circulate in the body and can affect normal, healthy cells as well as cancer cells.

Chemotherapy can cause temporary side effects, including:

  • nausea and vomiting
  • fatigue
  • skin itchiness
  • mouth sores
  • hair loss.

Generally, side effects are temporary. However, sometimes the effects are long-term or permanent. Some side effects can be eased with prescription drugs; talk to your doctor about this.

Radiotherapy

Radiotherapy uses high energy x-rays to kill cancer cells or injure them so they cannot multiply. It may be used instead of surgery to treat invasive bladder cancer without removing the bladder. However, radiotherapy alone is not likely to cure the cancer. Chemotherapy can be given with radiotherapy to make the cells more sensitive to the radiation.

You will lie on an examination table and a machine will direct the radiotherapy towards your body. The treatment is painless and can’t be seen or felt. Radiotherapy is usually given from Monday to Friday for several weeks. You will meet with the radiation oncology team to plan your treatment.

Side effects

Radiotherapy for bladder cancer can cause temporary side effects, including:

  • skin redness and soreness
  • burning when you pass urine and feeling that you need to go frequently
  • fatigue
  • loss of appetite
  • diarrhoea
  • soreness around the anus.

Less commonly, radiotherapy may permanently affect the bowel or bladder. More frequent and looser bowel motions may occur. You may also have bladder irritation and blood in the urine.

Your medical team can give you more information about coping with temporary and permanent side effects. You can also call Cancer Council 13 11 20 for a free copy of the booklets Understanding Chemotherapy or Understanding Radiotherapy.

Palliative treatment

If the bladder cancer spreads or returns after treatment, your doctor will discuss palliative treatment for problems caused by the cancer, such as pain.

Palliative treatment helps to improve quality of life by reducing symptoms of cancer without trying to cure the disease. However, it is not just for end-of-life care and it can be used at different stages of cancer. Treatment may include radiotherapy, chemotherapy or other medication.

For more information or resources about palliative treatment, call Cancer Council on 13 11 20 for a copy of Understanding Palliative Care or Living with Advanced Cancer.

Key points

  • Muscle-invasive bladder cancer is usually treated with surgery, which may be used with other treatments.
  • The most common surgery is a radical cystectomy. The whole bladder is removed (sometimes with other organs).
  • A partial cystectomy (removing the tumour only) is a less common operation.
  • If the whole bladder is removed, you will need reconstructive surgery to store urine in another way. This is called a urinary diversion. Several options are available, including ileal conduit, continent urinary diversion or a neobladder. Talk to your medical team about the most suitable method for you.
  • In an ileal conduit, a portion of the small bowel is used to connect the ureters to a surgically-created hole (a stoma). A bag is worn over the stoma to collect urine.
  • In a continent urinary diversion, the bowel portion is used to form a pouch. Urine is stored in the body for a while until it is removed through a stoma.
  • The small bowel can be used to make a neobladder, which is stitched to your urethra. You will urinate as usual without the need for a stoma.
  • Radiotherapy uses high-energy x-rays to kill the cancer cells or injure them.
  • In systemic chemotherapy drugs are injected into your body to treat the cancer. Chemotherapy is usually given Monday to Friday over several weeks.
  • Palliative treatment may be used to treat symptoms and improve your quality of life.

Reviewed by: Dr Mohan Arianayagam, FRACS (Urol), Urologic Oncologist, Nepean Hospital, Penrith, NSW; Donna Clifford, Urology Nurse Practitioner Candidate, Royal Adelaide Hospital, SA and David Connah, Cancer Council Connect Consumer Volunteer.
Updated: 01 Mar, 2014