Get answers to the most frequently asked questions about bladder cancer from urologist Mark Tyson, M.D., M.P.H.
Hi. I'm Dr. Mark Tyson, a urologist at Mayo Clinic, and I'm here to answer some of the important questions you might have about bladder cancer.
What type of bladder cancer do I have?
The type of bladder cancer that most patients are diagnosed with is urothelial carcinoma. There are other types of cancers of the bladder, like adenocarcinomas and small cell carcinomas, but urothelial carcinoma is the most common. Some urothelial carcinomas have what's called variant histology, and these can be plasmacytoid, micropapillary, microcystic. These are tumors that generally increase the aggressiveness of the urothelial carcinoma. But in addition to the cell type, you'd also need to know the grade and the stage of your tumor. These tumors are generally graded as low grade and high grade, with high-grade cancers being more aggressive. The grade, the stage, and the type of cancer are all used to determine the type of treatment that you will receive.
What are my treatment options?
The treatment options depend on the grade and stage of your tumor. If you have a high-grade, non-muscle-invasive bladder cancer, we generally treat that with a transurethral resection of the bladder tumor, followed by intravesicle therapy, either with chemotherapy or immunotherapy, like BCG. If you have an invasive carcinoma, such as a muscle-invasive cancer, we generally treat that with upfront cisplatin-based combination chemotherapy, followed by removal of the bladder or radiation. There are quality of life and toxicity considerations with each of those options, and it's up to the individual to decide which is right for them. Adjuvant immunotherapy is a type of treatment that's given after surgery to help mitigate the risk of cancer recurrence down the road. Patients who have stage 4 bladder cancer are generally treated with first-line cisplatin-based combination chemotherapy.
Should I have my surgery done robotically?
The short answer is it really doesn't matter. Whether you had the surgery done open or whether you have it done robotically, the outcomes are about the same. This is a big operation and patients are going to be in the hospital for a few days after surgery and require a few weeks to recover, no matter how the surgery is done. With a robotic approach, though, there are tiny laparoscopic incisions. And in general, there's a little bit less blood loss and perhaps a few fewer wound complications. With the open approach, the surgery is faster, but associated with a little bit more blood loss. And I encourage patients to go with the surgery that feels right for themselves.
What is a neobladder?
A neobladder is a type of urinary diversion that's performed during the surgery to remove the bladder. So, when we remove the bladder, we have to reroute the urine somewhere. And what we do is we take about a foot of small intestines, called ileum, and we detubularize it, or fillet it, open. We create it into a sphere. And then we connect that down to the urethra and then we connect the kidneys into that. And it's nice because all of the hardware, so to speak, is on the inside of the body. There's no external drainage bag for urine, like there is with an ileal conduit. But there are some downsides to a neobladder. They don't work perfectly. For example, about 25% of men will have some degree of long-term incontinence, and about 30% of women. About 10% of men will need to catheterize to empty their neobladder and about 25% of women will, as well. And these are important considerations as one is deciding between a neobladder and a conduit.
What is an ileal conduit?
An ileal conduit is a form of urinary diversion where there's an external bag used for drainage. Unlike a neobladder where we build a new bladder and connect the kidneys to the urethra and everything's on the inside of the body, an ileal conduit diverts the urine outside of the body. So just to the right of your belly button there'll be a stoma, like an ostomy, that drains into a bag. For lots of patients, this is the best option. It's simple and it's easy to learn how to use. There's no getting up at night to use the restroom. There's no stopping when you're driving. And anything that you were doing before surgery, you can do after. This includes scuba diving, skydiving, water skiing, golfing, hiking, biking. Lots of patients ask the question of what's the right diversion for me? And it just really depends upon the individual. For individuals who are looking for simplicity, the ileal conduit is the right choice.
How will treatment affect my quality of life?
Quality of life is a very important consideration when deciding what treatment options are best for you. For non-muscle-invasive bladder cancer, we generally treat with intravesicle therapy. But there are side effects of treatment: Burning pain with urination, frequency, urgency, blood in the urine. They also involve catheterizations and can be painful during administrations. For patients who have muscle-invasive disease, and they're trying to decide between whether to do a cystectomy, which is complete removal of the bladder, or radiation therapy, there are a number of quality of life implications there as well.
How can I be the best partner to my medical team?
Patients who are invested in their care are the easiest to take care of. Learn as much as you can. And remember, we're all on the same team. Never hesitate to ask your medical team any questions or concerns you have. Being informed makes all the difference. Thanks for your time and we wish you well.