If cancer cells are found only in the inner layers of the bladder (non-muscle-invasive bladder cancer or NMIBC), the main treatment is surgery to remove the cancer. Surgery is commonly combined with chemotherapy or immunotherapy, which is delivered directly into the bladder (intravesical).
Most people with non-muscle-invasive bladder cancer have an operation called transurethral resection of bladder tumour (TURBT). This is done under general anaesthetic using a rigid cystoscope. A TURBT takes 15–40 minutes and does not involve any cuts to the outside of the body.
How the surgery is done
The rigid cystoscope is passed through the urethra into the bladder so the surgeon can see the inside of your bladder on a monitor. The surgeon may remove the tumour through the urethra using a wire loop on the end of the cystoscope. Other methods for destroying the cancer cells include burning the base of the tumour with an electrical current (fulguration) or a high-energy laser.
If the cancer has spread to the lamina propria or is high grade, you may need a second TURBT 2–6 weeks after the first procedure to make sure that all cancer cells are removed. If the cancer comes back after initial treatment, your surgeon may do another TURBT or suggest removing the bladder in an operation known as a cystectomy.
What to expect after a TURBT
- Most people who have a TURBT stay in hospital for 1–2 days. Your body needs time to heal after the surgery.
- You may have a thin, flexible tube (catheter) in your bladder to drain your urine into a bag. The catheter may be connected to a system that washes the blood and blood clots out of your bladder (bladder irrigation). When your urine looks clear, the catheter will be removed and you will be able to go home. If the tumour is small, there may be no need for a catheter and you may be discharged from hospital on the same day.
- Side effects may include blood in the urine, needing to pass urine more often and bladder infections. It is normal to see some blood in your urine for up to two weeks. Your doctor may prescribe antibiotics to prevent infection.
- It is important to keep drinking lots of water to flush the bladder and keep the urine clear.
- When you go home, avoid any heavy lifting, vigorous exercise or sexual activity for 3–4 weeks.
- Contact your medical team promptly if you feel cold, shivery, hot or sweaty, have burning or pain when urinating, need to urinate often and urgently, pass blood clots or have difficulty passing urine.
Check-ups after surgery
Cancer can come back even after a TURBT has removed it from the bladder. You will need regular follow-up cystoscopies to help find any new tumours in the bladder as early as possible. This approach is known as surveillance cystoscopy.
How often you need to have a cystoscopy will depend on the stage and grade of the cancer, and how long since it was diagnosed. For more information about follow-up appointments after surgery, ask your treatment team.
More on living well after cancer
Chemotherapy uses drugs to kill or slow the growth of cancer cells. In intravesical chemotherapy the drugs are put directly into the bladder using a catheter (a thin, flexible tube) inserted through the urethra.
Intravesical chemotherapy is used mainly for low- to medium-risk non-muscle-invasive bladder cancer. It helps prevent the cancer coming back (recurrence). This method of giving chemotherapy can’t reach cancer cells outside the bladder lining or in other parts of the body, so it’s not suitable for muscle-invasive bladder cancer.
Each treatment is called an instillation. People with a low risk of recurrence usually have one instillation straight after TURBT surgery. People with a medium risk of recurrence may have instillations once a week for six weeks. This is usually done as a day procedure in hospital.
Side effects of intravesical chemotherapy
Because intravesical chemotherapy puts the drugs directly into the bladder, it has fewer side effects than systemic chemotherapy (when the drugs reach the whole body).
The main side effect is bladder inflammation (cystitis). Signs of cystitis include wanting to pass urine more often or a burning feeling when urinating. Drinking plenty of fluids can help. If you develop a bladder infection, your doctor can prescribe antibiotics.
In some people, intravesical chemotherapy may cause a rash on the hands or feet. Tell your doctor if this occurs. While you are having a course of intravesical chemotherapy, your doctor may advise you to use contraception.
Intravesical immunotherapy (BCG)
Immunotherapy is treatment that uses the body’s own natural defences (immune system) to fight disease. Bacillus Calmette-Guérin (BCG) is a vaccine that was originally used to prevent tuberculosis. It can also stimulate a person’s immune system to stop or delay bladder cancer coming back or becoming invasive.
The combination of BCG and TURBT is the most effective treatment for high-risk non-muscle-invasive bladder cancer. BCG is given once a week for six weeks, starting 2–4 weeks after TURBT surgery. It is put directly into the bladder through a catheter. This is usually done as a day procedure in hospital, and each treatment session takes up to two hours.
Let your doctor know of any other medicines or complementary therapies you are using, as they may interfere with how well the bladder cancer responds to BCG.
BCG safety at home
Your treatment team will tell you what safety measures to follow after you go home. This is because BCG is a vaccine that contains live bacteria, which can harm healthy people.
- For the first six hours after BCG treatment, sit down on the toilet when urinating to avoid splashing. When finished, pour 2 cups of household bleach (or a sachet of sodium hydrochlorite if provided by your treatment team) into the toilet bowl. Wait 15 minutes before flushing with the toilet lid closed.
- If any clothing is splashed with urine, wash separately in bleach and warm water.
- If you use incontinence pads, for a few days after treatment take care when disposing of them. Pour bleach on the used pad, allow it to soak in, then place the pad in a plastic bag. Tie up the bag and put it in your rubbish bin. You may also be able to take the sealed bag back to the hospital or treatment centre for disposal in a biohazard bin.
- For a few days after each treatment, wash your hands extra well after going to the toilet, and wash or shower with soap and water if your skin comes in contact with urine.
- Drink plenty of liquids for 6–8 hours after treatment.
- For a week after each treatment, use barrier contraception (condoms) to protect your partner from any BCG that may be present in your body fluids and to prevent pregnancy.
- Speak to your medical team if you have any questions.
Ongoing BCG treatment
For most people with high-risk non-muscle invasive bladder cancer, the initial course of six BCG treatments is followed by what is known as maintenance BCG.
Maintenance treatment with BCG reduces the risk of the disease coming back or spreading. Maintenance treatment can last for 1–3 years, but treatment sessions become much less frequent (e.g. one dose a month). Treatment schedules can vary so ask your doctor for further details.
Side effects of BCG
Common side effects of BCG include:
- needing to urinate more often
- burning or pain when urinating
- blood in the urine
- a mild fever
These side effects usually last a couple of days after each BCG treatment session. Less often, the BCG may spread through the body and can affect any organ. If you develop flu-like symptoms, such as fever over 38°C that lasts longer than 72 hours, pain in your joints, a cough, a skin rash, tiredness, or yellow skin (jaundice), contact a nurse or doctor at your treatment centre immediately. A BCG infection can be treated with medicines.
Very rarely, BCG can cause infections in the lungs or other organs in the body months or years after treatment. If you are diagnosed with an infection in the future, it is important to tell the doctor that you had BCG treatment.
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
Immunotherapy for advanced NMIBC
Immunotherapy uses the body’s own immune system to fight cancer. BCG is a type of immunotherapy treatment that has been used for many years to treat non-muscle-invasive bladder cancer.
A newer group of immunotherapy drugs called checkpoint inhibitors work by helping the immune system to recognise and attack the cancer. Some people with advanced bladder cancer may have checkpoint immunotherapy drugs such as pembrolizumab or avelumab after a course of chemotherapy. The drugs are given directly into a vein through a drip (infusion) and the treatment is repeated every 2–6 weeks. How many infusions you receive will depend on how you respond to the drug.
Some drugs may be available through clinical trials for people with bladder cancer that has come back or not responded to treatment. Ask your doctor about recent developments in drugs for bladder cancer and whether a clinical trial may be an option for you.
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.