Bladder cancer surgery

Overview

Bladder cancer surgery includes procedures to remove cancer from the bladder. Depending on where the cancer is in the bladder, surgery may remove a tumor, part of the bladder or the whole bladder.

The main types of bladder cancer surgery are transurethral resection of bladder tumor (TURBT), partial cystectomy and radical cystectomy. If the entire bladder is removed, the surgeon creates a new way for urine to leave the body, called a urinary diversion.

It is possible to live without a bladder. After bladder removal, a urinary diversion allows urine to either drain outside the body or collect in a holding area inside the body. The holding area is called a reservoir. Some reservoirs are more like bladders. They are called neobladders.

Bladder cancer surgery isn't the same for everyone. Your healthcare team can help you understand which options may be right for you and what each could mean for your treatment and daily life.

Types

There are three main types of bladder cancer surgery.

Transurethral resection of bladder tumor

Transurethral resection of bladder tumor (TURBT) is a surgery that removes bladder tumors through the urethra. The urethra is the tube that carries urine out of the body. The surgeon passes an instrument through the urethra into the bladder to see and remove a tumor. Tissue from a tumor is studied to find out how deeply it has grown into the bladder wall.

Sometimes a second TURBT is needed. Your care team may recommend this if the first procedure did not completely remove the tumor. TURBT also may be recommended if more tissue is needed to look at the depth of tumor growth, even if the entire tumor was removed the first time.

Laser technology also may be used to remove some non-muscle-invasive bladder tumors. One technique, called en bloc resection, removes the tumor in one piece.

Partial cystectomy

Partial cystectomy, also called segmental cystectomy, removes the part of the bladder that contains the cancer while leaving the rest of the bladder in place. In rare cases, it may be an option for people who meet very strict criteria.

Radical cystectomy

Radical cystectomy removes the entire bladder. Pelvic lymph nodes also are removed as part of the surgery.

Other nearby organs also may be removed. For men, surgery typically includes removal of the prostate and seminal vesicles. For women, surgery may include removal of the uterus, ovaries, fallopian tubes and part of the vagina. In certain people, surgeons may be able to avoid removing some reproductive organs.

Radical cystectomy can be performed through an open incision or with robot-assisted surgery. Complication rates and cancer outcomes are about the same for each method.

After the bladder is removed, the surgeon creates another way for urine to leave the body. This is called a urinary diversion.

Types of urinary diversion include:

• Ileal conduit. A section of intestine carries urine to an opening in the belly, called a stoma. Urine drains into a collection bag worn outside the body.
• Neobladder. A reservoir made from intestine is connected to the urethra, so urine can leave the body through the urethra. Some people need to use a catheter to completely empty the neobladder.
• Continent cutaneous reservoir. An internal pouch stores urine. The pouch is emptied with a catheter through an opening in the belly.

Why it's done

Bladder cancer surgery may be used for different reasons.

• Diagnosing or treating non-muscle-invasive bladder cancer. TURBT is used to diagnose and treat non-muscle-invasive bladder cancer. Tissue removed during TURBT helps determine whether cancer has grown into the muscle of the bladder wall. These findings help guide decisions about additional treatment. Radical cystectomy may be recommended for some people with high-risk non-muscle-invasive bladder cancer. This includes cancer that remains or returns after treatment with bacillus Calmette-Guerin (BCG).
• Treating muscle-invasive bladder cancer. Radical cystectomy is the standard and most common treatment for muscle-invasive bladder cancer that hasn't spread to distant parts of the body. A combination of immunotherapy, antibody drug conjugates and sometimes chemotherapy also may be given before surgery to improve survival.
• Keeping the bladder. Some people with muscle-invasive bladder cancer may not need bladder removal. Partial cystectomy may be an option for some people who meet very strict criteria. However, it is not an option for most people with bladder cancer. Another bladder-preserving approach combines TURBT with chemotherapy and radiation therapy.

Risks

The risks and complications of bladder cancer surgery depend on the type of surgery, your overall health and other factors.

Possible risks include:

• Bleeding or infection.
• Blood clots.
• Injury to the bladder or nearby organs.

More extensive surgery, particularly radical cystectomy, can have additional risks, including:

• Bowel problems, including ileus, which is a short-term slowing or stopping of bowel function.
• Urinary tract or kidney concerns.
• Issues with the urinary diversion, such as infection, urine leakage or narrowing where the ureters connect to the diversion.
• Changes in urinary or sexual function or fertility.

Your care team takes steps before, during and after surgery to lower the risk of complications and help you recover.

How you prepare

How you prepare depends on the type of bladder cancer surgery you're having. You may need tests before surgery. Your care team will give you instructions about medicines, eating and drinking.

If you're having radical cystectomy, your care team will discuss the type of urinary diversion you'll have. The team may recommend steps such as physical activity and nutrition to help prepare for recovery. If you need a stoma, you also may meet with an ostomy nurse to help plan for it.

What you can expect

What you can expect depends on whether you're having TURBT, partial cystectomy or radical cystectomy.

Before the procedure

Before surgery, your care team reviews the planned procedure with you. You may be awake or asleep during TURBT. Partial and radical cystectomy are done with general anesthesia, which is medicine that puts you in a sleeplike state during surgery.

During the procedure

What happens during surgery depends on the surgery.

TURBT. The surgeon passes an instrument called a resectoscope through the urethra and into the bladder. The surgeon looks at the bladder and removes visible tumor tissue. The tissue is sent to a laboratory for examination. A urinary catheter may be placed to drain the bladder after TURBT.

Partial cystectomy. The surgeon removes the part of the bladder containing cancer. Pelvic lymph nodes also may be removed.

Radical cystectomy. The surgeon removes the bladder and pelvic lymph nodes. Other nearby organs may be removed or left in place depending on the cancer. The surgeon then creates a urinary diversion so urine can leave the body. Small tubes called urinary stents may be placed to help urine drain while the urinary tract heals.

Radical cystectomy can be done with open surgery or robot-assisted surgery. Open surgery uses an incision in the belly. Robot-assisted surgery uses several smaller incisions and instruments controlled by the surgeon. Robot-assisted surgery may take longer than open surgery.

After the procedure

Recovery depends on the type of surgery. Ask your care team whether you'll need someone to drive you home and how much time you may need time off from work or other activities.

TURBT. TURBT is often an outpatient procedure, which means you can go home the same day. Some people may need to stay in the hospital overnight. You may have a urinary catheter temporarily to drain the bladder.

Partial or radical cystectomy. You'll stay in the hospital while you recover. After radical cystectomy, your care team monitors you for complications and helps you slowly return to eating and physical activity. Your care team may use a recovery program that includes nutrition, pain management, and getting up and moving soon after surgery.

If you have a urinary diversion, you'll learn how to manage it. This may include learning how to care for a stoma and collection pouch or how to empty a neobladder. Some people with a neobladder need to use a catheter to empty it completely.

Recovery time. Recovery after TURBT is generally shorter than recovery after partial or radical cystectomy. Radical cystectomy is major surgery, and recovery continues after you leave the hospital.

The timing of drain and urinary stent removal depends on the surgery and how you're healing. A urinary stent is a thin tube that may be used to help urine drain while the urinary tract heals. Your surgical team can tell you when these devices can safely be removed.

Results

Tissue removed during bladder cancer surgery is looked at in a laboratory. The results can show the type, how deeply it has grown into the bladder wall and whether cancer is in nearby lymph nodes. After partial or radical cystectomy, the results also show whether cancer is present at the edges of the removed tissue. The edges are called the surgical margins.

Your care team uses these results to determine whether you need additional treatment and to plan follow-up care.

Bladder cancer can come back after surgery. Ongoing follow-up is needed to check for cancer in the remaining bladder. After TURBT or partial cystectomy, cancer can come back in the bladder. After radical cystectomy, cancer can return elsewhere in the urinary tract, lymph nodes or other parts of the body.

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