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).
When deciding on treatment for muscle-invasive bladder cancer, you may want to discuss your options with a urologist, radiation oncologist and medical oncologist. Ask your GP for referrals.
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. Continuing to smoke also increases your risk of cancer returning.
- 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. These exercises are useful if you have a neobladder, a partial cystectomy, or radiation therapy.
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Most people with muscle-invasive disease have surgery to remove the bladder (cystectomy). This may also be recommended for high-risk non-muscle-invasive bladder cancer that has not responded to BCG.
The surgeon usually needs to remove the whole bladder (radical cystectomy). Less commonly, it may be possible to do a partial cystectomy. This removes only the tumour and a border of healthy tissue. The bladder will be smaller afterward, so you may need to pass urine more often.
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.
Learn more about urinary diversions
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. Recovery may be faster and the hospital stay may be shorter with keyhole surgery, but the surgery may be more difficult and take longer.
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
- 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). 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 recovery from a cystectomy. The recovery time will depend on the type of surgery, your fitness and whether you have any complications. Depending on the type of work you do, you will probably need around 4–6 weeks leave from your job.
- Urination – a cystectomy will affect how you store urine and urinate.
Sexuality and fertility after a 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 if you have one, 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.
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.
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
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.
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.
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.
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 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
- loss of appetite
- 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.
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. Talk to your medical team to discuss whether trimodal therapy may be an option in your situation.
Having trimodal therapy
If you have chemoradiation, the chemotherapy makes 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 receive an infusion over several days through a small plastic tube and pump.
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. Some people who have had trimodal therapy for muscle-invasive bladder cancer will later need their bladder removed because the cancer has come back (radical cystectomy).
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 palliative care
Learn more about advanced cancer
Understanding Bladder Cancer
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Expert content reviewers:
Prof Dickon Hayne, Professor of Urology, UWA Medical School, The University of Western Australia, Chair of the Bladder, Urothelial and Penile Cancer Subcommittee, ANZUP Cancer Trials Group, and Head of Urology, South Metropolitan Health Service, WA; A/Prof Tom Shakespeare, Director, Radiation Oncology, Coffs Harbour, Port Macquarie and Lismore Public Hospitals, NSW; Helen Anderson, Genitourinary Cancer Nurse Navigator (CNS), Gold Coast University Hospital, QLD; BEAT Bladder Cancer Australia; Mark Jenkin, Consumer; Dr Ganessan Kichenadasse, Lead, SA Cancer Clinical Network, Commission of Excellence and Innovation in Health, and Medical Oncologist, Flinders Centre for Innovation in Cancer, SA; A/Prof James Lynam, Medical Oncology Staff Specialist, Calvary Mater Newcastle, NSW; Jack McDonald, Consumer; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council WA; Tara Redemski, Senior Physiotherapist – Cancer and Blood Disorders, Gold Coast University Hospital, QLD; Prof Shomik Sengupta, Consultant Urologist, Eastern Health and Professor of Surgery, Eastern Health Clinical School, Monash University, VIC.
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The information on this webpage was adapted from Understanding Bladder Cancer - A guide for people with cancer, their families and friends (2022 edition). This webpage was last updated in February 2022.