Treatment

Treatment options for bladder cancer depend on a number of factors, including the type of cancer, grade of the cancer and stage of the cancer, which are taken into consideration along with your overall health and your treatment preferences.

Bladder cancer treatment may include:

  • Surgery, to remove cancerous tissue
  • Chemotherapy in the bladder (intravesical chemotherapy), to treat tumors that are confined to the lining of the bladder but have a high risk of recurrence or progression to a higher stage
  • Reconstruction, to create a new way for urine to exit the body after bladder removal
  • Chemotherapy for the whole body (systemic chemotherapy), to increase the chance for a cure in a person having surgery to remove the bladder, or as a primary treatment in cases where surgery isn't an option
  • Radiation therapy, to destroy cancer cells, often as a primary treatment in cases where surgery isn't an option or isn't desired
  • Immunotherapy, to trigger the body's immune system to fight cancer cells, either in the bladder or throughout the body

A combination of treatment approaches may be recommended by your doctor and members of your care team.

Bladder cancer surgery

Approaches to bladder cancer surgery might include:

  • Transurethral resection of bladder tumor (TURBT). TURBT is a procedure to remove bladder cancers confined to the inner layers of the bladder, those which aren't yet muscle-invasive cancers. During the procedure, a surgeon passes a small wire loop through a cystoscope and into the bladder. The wire loop burns away cancer cells using an electric current. Alternatively, a high-energy laser may be used to destroy the cancer cells.

    TURBT is performed under regional anesthesia — where medication given numbs only the lower part of your body — or general anesthesia — where medication puts you to sleep during the surgery. Because doctors perform the procedure through the urethra, you won't have any cuts (incisions) in your abdomen.

    As part of the TURBT procedure, your doctor may recommend a one-time injection of cancer-killing medication (chemotherapy) into your bladder to destroy any remaining cancer cells and to prevent a tumor from coming back. The medication remains in your bladder for up to an hour and then is drained.

  • Cystectomy. Cystectomy is surgery to remove all or part of the bladder. During a partial cystectomy, your surgeon removes only the portion of the bladder that contains a single cancerous tumor. Partial cystectomy may only be an option if cancer is limited to one area of the bladder that can easily be removed without harming bladder function.

    A radical cystectomy is an operation to remove the entire bladder, part of the ureters and surrounding lymph nodes. In men, radical cystectomy typically includes removal of the prostate and seminal vesicles. In women, radical cystectomy also involves removal of the uterus, ovaries and part of the vagina.

    Radical cystectomy can be performed through a single incision on the lower portion of the belly or with multiple small incisions using robotic surgery. During robotic surgery, the surgeon sits at a nearby console and uses hand controls to precisely move robotic surgical instruments.

    Cystectomy carries a risk of infection and bleeding. In men, removal of the prostate and seminal vesicles may cause erectile dysfunction. But, your surgeon may be able to spare the nerves necessary for an erection. In women, removal of the ovaries causes infertility and premature menopause.

  • Neobladder reconstruction. After a radical cystectomy, your surgeon must create a new way for urine to leave your body (urinary diversion). One option for urinary diversion is neobladder reconstruction. Your surgeon creates a sphere-shaped reservoir out of a piece of your intestine. This reservoir, often called a neobladder, sits inside your body and is attached to your urethra. In most cases, the neobladder allows you to urinate normally. A small number of people with a neobladder have difficulty emptying the neobladder and may need to use a catheter periodically to drain all the urine from the neobladder.
  • Ileal conduit. For this type of urinary diversion, your surgeon creates a tube (ileal conduit) using a piece of your intestine. The tube runs from your ureters, which drain your kidneys, to the outside of your body, where urine empties into a pouch (urostomy bag) you wear on your abdomen.
  • Continent urinary reservoir. During this type of urinary diversion procedure, your surgeon uses a section of intestine to create a small pouch (reservoir) to hold urine, located inside your body. You drain urine from the reservoir through an opening in your abdomen using a catheter a few times each day.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. Chemotherapy treatment for bladder cancer usually involves two or more chemotherapy drugs used in combination.

Chemotherapy drugs can be given:

  • Through a vein in your arm (intravenously)
  • Via a tube passed through your urethra directly to your bladder (intravesical therapy)

Chemotherapy is frequently used before bladder removal surgery to increase the chances of curing the cancer. Chemotherapy may also be used to kill cancer cells that might remain after surgery. Chemotherapy is sometimes combined with radiation therapy in very select cases as an alternative to surgery.

Intravesical chemotherapy may be the primary treatment for superficial bladder cancer, where the cancer cells affect only the lining of the bladder and not the deeper muscle tissue. Or sometimes immunotherapy may be administered as intravesical therapy for superficial bladder cancer.

Radiation therapy

Radiation therapy uses high-energy beams aimed at your cancer to destroy the cancer cells. Radiation therapy for bladder cancer usually is delivered from a machine that moves around your body, directing the energy beams to precise points.

In select cases, radiation therapy is sometimes combined with chemotherapy as an alternative to surgery or when surgery isn't an option.

Immunotherapy

Immunotherapy, also called biological therapy, works by signaling your body's immune system to help fight cancer cells.

Immunotherapy for bladder cancer often is administered through the urethra and directly into the bladder (intravesical therapy). One such immunotherapy drug used to treat bladder cancer is Bacillus Calmette-Guerin (BCG), which is a vaccine used to protect against tuberculosis. Another immunotherapy drug is a synthetic version of interferon, which is a protein your immune system makes to help fight infections. The synthetic version, called interferon alfa-2b (Intron A), is sometimes used in combination with BCG.

Atezolizumab (Tecentriq) is a new immunotherapy option for locally advanced or metastatic bladder cancer that didn't respond to or got worse after chemotherapy. An intravenous (IV) medication, the drug works by triggering the body's immune system to attack the cancerous tumor. Atezolizumab is also being studied as a possible first line therapy for people with bladder cancer who aren't eligible for chemotherapy.

Bladder preservation

Using a three-prong treatment approach may preserve the bladder in certain cases of muscle-invasive disease. Known as trimodality therapy, the treatment approach includes TURBT, chemotherapy and radiation therapy.

First, your surgeon performs a TURBT procedure to remove as much cancerous tissue as possible from your bladder, while maintaining bladder function. After TURBT, you undergo a regimen of chemotherapy along with radiation therapy, which both take place during the first several weeks after surgery.

If, after trying trimodality therapy, not all of the cancer is gone or you have a recurrence of muscle-invasive cancer, your surgeon may recommend a radical cystectomy.

Upper urinary tract disease

The same kind of cancer (urothelial cancer) that causes the majority of bladder cancers can also occur in the upper urinary tract, affecting:

  • The thin tubes that drain urine from your kidneys to your bladder (ureters)
  • The area within your kidney where urine collects before emptying into a ureter (renal pelvis)
  • Other urinary tract structures deep within the kidney where the process of producing urine begins

Similar to treatment for bladder cancer, treatment of upper urinary tract cancer depends on a lot of factors, such as tumor size, tumor location, your overall health and your preferences.

Upper urinary tract cancer generally involves surgery to remove the cancer, along with chemotherapy or radiation therapy as follow-up treatments to kill any remaining cancer cells and to prevent recurrence.

Surgery might leave you with only one functioning kidney, if one of your kidneys needs to be removed. If that happens, your doctor will likely recommend regular testing of your kidney function to monitor how well your remaining kidney is doing.

After bladder cancer treatment

Bladder cancer may recur. Because of this, people with bladder cancer need follow-up testing for years after successful treatment. What tests you'll have and how often depends on your type of bladder cancer and how it was treated, among other factors.

Ask your doctor to create a follow-up plan for you. In general, doctors recommend a test to examine the inside of your urethra and bladder (cystoscopy) every three to six months for the first few years after bladder cancer treatment. After a few years of surveillance without detecting cancer recurrence, you may need a cystoscopy exam only once a year. Your doctor may recommend other tests at regular intervals as well.

People with aggressive cancers may undergo more-frequent testing. Those with less aggressive cancers may undergo testing less often.

Related video

June 23, 2017
References
  1. SEER stat fact sheets: Bladder cancer. National Cancer Institute. https://seer.cancer.gov/statfacts/html/urinb.html. Accessed Dec. 27, 2016.
  2. Cancer facts and figures 2016. American Cancer Society. http://www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2016/index. Accessed Dec. 27, 2016.
  3. Niederhuber JE, et al., eds. Bladder cancer. In: Abeloff's Clinical Oncology. 5th ed. Philadelphia, Pa.: Churchill Livingstone Elsevier; 2014. http://www.clinicalkey.com. Accessed Dec. 1, 2016.
  4. Bladder and other urothelial cancers screening (PDQ). National Cancer Institute. http://www.cancer.gov/cancertopics/pdq/screening/bladder/healthprofessional. Accessed Dec. 1, 2016.
  5. Bladder cancer treatment (PDQ). National Cancer Institute. http://www.cancer.gov/cancertopics/pdq/treatment/bladder/healthprofessional. Accessed Dec. 1, 2016.
  6. Lotan Y, et al. Clinical presentation, diagnosis and staging of bladder cancer. http://www.uptodate.com/home. Accessed Dec. 13, 2016.
  7. What is bladder cancer? American Cancer Society. http://www.cancer.org/cancer/bladdercancer/detailedguide/bladder-cancer-what-is-bladder-cancer. Accessed Dec. 1, 2016.
  8. Wein AJ, et al., eds. Tumors of the bladder. In: Campbell-Walsh Urology. 11th ed. Philadelphia, Pa.: Elsevier; 2016. http://www.clinicalkey.com. Accessed Dec. 29, 2016.
  9. Diagnosis and treatment of non-muscle invasive bladder cancer: AUA/SUO guideline. Linthicum, Md.: American Urological Association. https://www.auanet.org/education/guidelines/non-muscle-invasive-bladder-cancer.cfm. Accessed Dec. 29, 2016.
  10. Tumor grade. National Cancer Institute. https://www.cancer.gov/about-cancer/diagnosis-staging/prognosis/tumor-grade-fact-sheet. Accessed March 13, 2017.
  11. Lerner SP, et al. Overview of the initial approach and management of urothelial bladder cancer. http://www.uptodate.com/home. Accessed Dec. 13, 2016.
  12. Wein AJ, et al., eds. Non-muscle-invasive bladder (Ta, T1, and CIS). In: Campbell-Walsh Urology. 11th ed. Philadelphia, Pa.: Elsevier; 2016. http://www.clinicalkey.com. Accessed Dec. 1, 2016.
  13. Wein AJ, et al., eds. Management of metastatic and invasive bladder cancer. In: Campbell-Walsh Urology. 11th ed. Philadelphia, Pa.: Elsevier; 2016. http://www.clinicalkey.com. Accessed Dec. 1, 2016.
  14. Clark PE, et al. NCCN guidelines insights: Bladder cancer, version 2.2016. Journal of the National Comprehensive Cancer Network. 2016;14:1213.
  15. Brown AY. Allscripts EPSi. Mayo Clinic, Rochester, Minn. Oct. 27, 2016.
  16. What are the grades and stages of bladder cancer? Urology Care Foundation. http://www.urologyhealth.org/urologic-conditions/bladder-cancer/grading-and-staging. Accessed March 13, 2017.
  17. Premo C, et al. Trimodality therapy in bladder cancer: Who, what and when? The Urologic Clinics of North America. 2015;42:169.
  18. Efstathiou JA, et al. Bladder preservation treatment options for muscle-invasive urothelial bladder cancer. http://www.uptodate.com/home. Accessed March 14, 2017.
  19. How is upper urinary tract cancer treated? Urology Care Foundation. http://www.urologyhealth.org/urologic-conditions/upper-urinary-tract-cancer/treatment. Accessed March 14, 2017.
  20. Bellmunt J. Treatment of metastatic urothelial cancer of the bladder and urinary tract. http://www.uptodate.com/home. Accessed March 28, 2017.