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Bladder cancer


Treatment for muscle-invasive bladder cancer

Page last updated: May 2024

The information on this webpage was adapted from Understanding Bladder Cancer - A guide for people with cancer, their families and friends (2024 edition). This webpage was last updated in May 2024.

Expert content reviewers:

This information was developed based on international clinical practice guidelines, and with the help of a range of health professionals and people affected by bladder cancer:

  • Dr Prassannah Satasivam, Urologist and Robotic Surgeon, Epworth Hospitals and Cabrini Hospitals, VIC
  • Donna Clifford, Urology Nurse Practitioner, Royal Adelaide Hospital, SA
  • Marc Diocera, Genitourinary Nurse Consultant, Peter MacCallum Cancer Centre, VIC
  • Dr Renee Finnigan, Radiation Oncologist, Gold Coast University Hospital, QLD
  • Lisa Hann, 13 11 20 Consultant, Cancer Council SA
  • Dr Andrew Hirschhorn, Director of Allied Health and MQ Health Academy, MQ Health, Macquarie University, NSW
  • Anne Marie Lyons, Stomal Therapy Nurse, Concord Hospital and NSW Stoma Limited, NSW
  • John McDonald, Consumer
  • Prof Manish Patel, Urological Cancer and Robotic Surgeon, Westmead Hospital, Macquarie University Hospital, and The University of Sydney, NSW
  • Dr Jason Paterdis, Urological Surgeon, Brisbane Urology Clinic, QLD
  • Graeme Sissing, Consumer
  • Prof Martin Stockler, Medical Oncologist, The University of Sydney, Concord Cancer Centre, and Chris O’Brien Lifehouse RPA, NSW


When bladder cancer has invaded the muscle layer (muscularis propria), the main treatment options are:

  • surgery to remove the whole bladder (cystectomy), sometimes with chemotherapy given before or after the surgery
  • bladder-conserving surgery (TURBT), followed by radiation therapy with or without chemotherapy (trimodal therapy). 

 

What to do before and after treatment

Talk with your doctors about whether you need to do anything to prepare for treatment and help your recovery. Some things they may suggest are to:

  • Stop smoking if you smoke, aim to quit before starting treatment. If you keep smoking, you may not respond as well to treatment and you may have more treatment-related side effects. 
  • Begin or continue an exercise program exercise will help build up your strength for treatment and recovery. It can also help you deal with side effects of treatment.
  • Improve diet aim to eat a balanced diet with a variety of fruit, vegetables, wholegrains and protein. Eating well can improve your strength and you may respond better to treatment.
  • See a physiotherapist – they can teach you exercises to strengthen your pelvic floor muscles, which help control how your bladder and bowel work. It's important to do these exercises after some types of treatment and if you have a neobladder.
  • Talk to someone – you may find it useful to talk to a psychologist or counsellor about how you are feeling. This can help you deal with any anxiety about having surgery and any longer term changes after treatment.

Speak to a cancer nurse

Surgery (cystectomy)

Some people with muscle-invasive disease have surgery to remove the bladder (cystectomy). This may also be recommended for high-risk superficial bladder cancer that has not responded to BCG.

The surgeon usually needs to remove the whole bladder and nearby lymph nodes (radical cystectomy). 

Surgery to remove the bladder

The most common operation for muscle-invasive bladder cancer is a radical cystectomy. The surgeon removes the whole bladder and nearby lymph nodes. Other organs may also be removed:

  • In males, the prostate and seminal vesicles are often removed, and the urethra may also be removed
  • In females, the fallopian tubes, uterus, part of the vagina, and the urethra are often removed. The ovaries are usually removed in females who have been through menopause.

Because a radical cystectomy removes the whole bladder, the surgeon needs to create a new way for your body to collect and store urine.

This is called urinary diversion and there are different options, including urostomy, neobladder and continent urinary diversion.

How the surgery is done

Surgery to remove the bladder (cystectomy) and create a urinary diversion is a major and complicated operation. It is important to have this surgery in a specialised centre with a surgeon who does a lot of cystectomies.

Different surgical methods may be used for removing the bladder:

  • Open surgery makes one long cut (incision) in the abdomen. A cut is usually made from the area below the bellybutton to the pubic area.
  • Keyhole surgery, also known as minimally invasive or laparoscopic surgery, makes several smaller cuts in the abdomen. Instruments are inserted through the cuts, sometimes with help from a robotic system. 

In general, having an experienced surgeon is more important than the type of surgery. Talk to your surgeon about the pros and cons of each surgical method, and check what you’ll have to pay.

Unless you are treated as a public patient in a public hospital, there are likely to be substantial costs not covered by Medicare or your health fund.

What to expect after surgery

When you wake up after the operation, you will be in a recovery room near the operating theatre. Once you are fully conscious, you will be moved to intensive care or to the ward.

  • Tubes and drips – you may have an intravenous (IV) drip to give you fluid and medicine, and a tube in your abdomen to drain fluid from the operation area. These will be removed as you recover.
  • Pain and discomfort – after a major operation, it is common to feel some pain. You will be given pain medicine as a tablet (orally), through a drip (intravenously) or through a catheter inserted in the spaces in the spine (epidural) or along the wound (wound catheters). Your doctor or nurse can change your medicine as needed.
  • Recovery time – you will probably be in hospital for 1–2 weeks, but it can take 6–8 weeks to fully recover from a cystectomy. The recovery time will depend on the type of surgery, your fitness and whether you have any complications.
  • Passing urination – because a radical cystectomy removes the whole bladder, the surgeon needs to create a new way for your body to store and pass urine.

 

Sexuality and fertility after cystectomy

A cystectomy can affect sexuality and fertility in many ways. You may find these changes upsetting and worry about how they’ll affect your relationships. Ask your treatment team for information about ways to manage these changes.

It may be helpful to talk about how you’re feeling with your partner, family members or a counsellor. You can also listen to  The Thing About Cancer podcast episode on sex and cancer .

Learn more about fertility

Learn more about sexuality and intimacy

Changes for males

Nerve damage to the penis

A cystectomy can often damage nerves to the penis, but the surgeon will try to prevent or minimise this. Nerve damage can make it difficult to get an erection.

Options for improving erections include:

  • oral medicines prescribed by a doctor that increase blood flow to the penis
  • injections of medicine into the penis
  • vacuum devices that use suction to draw blood into the penis and make it firm
  • an implant called a penile prosthesis – under general anaesthetic, flexible rods or thin inflatable cylinders are inserted into the penis and a pump is placed in the scrotum. You can then turn on or squeeze the pump when you need an erection.
Orgasm changes

You will not be able to ejaculate after a radical cystectomy if the prostate and seminal vesicles were removed along with the bladder.

You can still feel the muscular spasms and pleasure of an orgasm even if you cannot ejaculate or get an erection, but it will be a dry orgasm because you no longer produce semen.

Fertility changes

If the prostate and seminal vesicles are removed, you will no longer produce semen. This means you won’t be able to have children naturally.

If you may want to have children in the future, talk to your treatment team about whether you can store sperm at a fertility clinic before treatment. The sperm could then be used when you are ready to start a family.

Changes for females

Vaginal changes

Sometimes, the vagina may be shortened or narrowed during a cystectomy. Nerves that help keep the vagina moist can also be affected, making the vagina dry.

These changes can make penetrative sex difficult or uncomfortable at first. Ways to manage these changes include:

  • using a hormone cream (available on prescription) or vaginal moisturiser (available at pharmacies) to keep your vagina moist
  • asking a physiotherapist how to use vaginal dilators to help stretch the vagina – vaginal dilators are plastic or rubber tube-shaped devices that come in different sizes
  • when you feel ready, trying to have sex regularly and gently to gradually stretch the vagina
  • using a water-based or silicone-based lubricant (available from pharmacies and supermarkets) to make sex more comfortable.
Arousal changes

A cystectomy can damage the nerves in the vagina or reduce the blood supply to the clitoris, which can affect how you become aroused and your ability to orgasm.

Talk to your surgeon or nurse about ways to minimise potential side effects. You can also try exploring other areas of your body that feel pleasurable when touched, such as the breasts, inner thighs, feet or buttocks. 

Menopause and fertility

Sometimes, the uterus and other reproductive organs are removed during a radical cystectomy. This will cause menopause if you have not already been through it.

Your periods will stop, you will no longer be able to become pregnant, and you may have menopausal symptoms such as hot flushes and vaginal dryness.

Talk to your doctors about ways to deal with the symptoms of menopause.

Systemic chemotherapy

Chemotherapy uses drugs to kill or slow the growth of cancer cells. For muscle-invasive bladder cancer, drugs are injected into a vein (intravenously). As the drugs circulate in the blood, they travel throughout the body.

This type of chemotherapy is called systemic chemotherapy. It is different to the intravesical chemotherapy used for superficial bladder cancer, which is delivered directly into the bladder.

Systemic chemotherapy for non-muscle-invasive bladder cancer is used:

  • before surgery (neoadjuvant chemotherapy) – to shrink the cancer and make it easier to remove. It can also reduce the risk of the cancer coming back.
  • after surgery (adjuvant chemotherapy) – if there is a high risk of the cancer coming back.

Chemotherapy is commonly given as a period of treatment followed by a break (a cycle). In most cases, you will have several cycles of treatment over a few months.

Usually a combination of drugs works better than one drug alone. The drugs you are offered will depend on your age, fitness, kidney function and personal preference.

Systemic chemotherapy can sometimes be combined with radiation therapy (chemoradiation) as part of trimodal therapy.

Systemic chemotherapy may also be used for bladder cancer that has spread to other parts of the body. The side effects of chemotherapy vary, and in most cases last for only a few weeks or months. Sometimes, they are permanent.

Radiation therapy

Radiation therapy uses a controlled dose of radiation to kill or damage cancer cells. The radiation is usually in the form of x-ray beams.

Radiation therapy to treat bladder cancer is used as part of trimodal therapy, either on its own or combined with chemotherapy.

It is common to have more imaging scans to help pinpoint the exact area to receive the radiation. During a radiation therapy session, you will lie on an examination table and a machine will direct the radiation towards your bladder. The treatment is painless and can’t be seen or felt. 

Side effects of radiation therapy

Radiation therapy for bladder cancer can cause temporary side effects, including:

  • needing to urinate more often and more urgently
  • burning when you pass urine
  • fatigue
  • loss of appetite
  • diarrhoea
  • soreness around the anus.

Symptoms tend to build up during treatment and usually start improving over a few weeks after treatment ends.

Less commonly, radiation therapy may permanently affect the bowel or bladder. Bowel motions may be more frequent and looser, and damage to the bladder lining (radiation cystitis) can cause blood in the urine.

Radiation therapy for males may cause poor erections and make ejaculation uncomfortable for some months after treatment. For females, radiation therapy can cause the vagina to become drier, narrower and shorter.

Radiation therapy may also lead to premature menopause. In addition, if the therapy affects the lymph nodes, there may be an increased risk of lymphoedema (swelling in the legs caused by a build-up of lymph fluid).

 

Trimodal therapy

Instead of cystectomy, you may have trimodal therapy as the main treatment for muscle-invasive tumours.

Trimodal therapy may be used if a person is unable to have surgery to remove the bladder or would prefer to keep their bladder. It is most suited for people whose bladder is working well and smaller tumours that haven’t spread.

Trimodal therapy involves:

  • a shorter surgery to remove the tumour from the bladder (TURBT), followed by
  • radiation therapy combined with chemotherapy (chemoradiation). Some people who are not fit enough for chemotherapy will have radiation therapy on its own.

Studies have shown that trimodal therapy has similar outcomes to radical cystectomy. However, there is a chance the cancer may come back in the bladder and cystectomy may still be required.

Talk to your medical team to discuss whether trimodal therapy may be an option in your situation.

Having trimodal therapy

If you have trimodal therapy, chemotherapy or other medicines are given to make the cancer cells more sensitive to radiation and can increase the success of the treatment.

You will usually have radiation therapy as daily treatments, Monday to Friday, over 4–7 weeks as an outpatient.

There are different options for receiving chemotherapy. Some people will have it once a week a few hours before or after a radiation therapy session. Other people may take a tablet or have an infusion over several days.

During and after chemoradiation, you may experience side effects from both the chemotherapy and the radiation therapy. Talk to your treatment team about management strategies. Trimodal therapy has the advantage of not removing the bladder, so you can still urinate in the usual way.

You will need to have regular cystoscopies after treatment to check that the cancer has not come back.

 

Advanced bladder cancer treatment

If bladder cancer has spread to other parts of the body, it is known as advanced or metastatic bladder cancer. Treatment will focus on controlling the cancer and relieving symptoms without trying to cure the disease.

This is called palliative treatment and it can include systemic chemotherapy, immunotherapy, surgery and radiation therapy. 

Many people think that palliative treatment is only for people at the end of their life, but it may help people at any stage of advanced bladder cancer.

It is one aspect of palliative care, in which a team of health professionals aims to meet your physical, emotional, practical, cultural, social and spiritual needs.

Learn more about advanced cancer

 

Understanding Bladder Cancer

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