Bladder Cancer Surgery

Surgery is part of the treatment for most bladder cancers . The type of surgery done depends on the stage (extent) of the cancer. It also depends on your choices based on the long-term side effects of some kinds of surgery.

Transurethral resection of bladder tumor (TURBT)

A transurethral resection of bladder tumor (TURBT) or a transurethral resection (TUR) is often used to find out if someone has bladder cancer and, if so, whether the cancer has spread into (invaded) the muscle layer of the bladder wall.

TURBT is also the most common treatment for early-stage or superficial (non-muscle invasive) bladder cancers. Most patients have superficial cancer when they're first diagnosed, so this is usually their first treatment. Sometimes, a second, more extensive TURBT is done to better ensure that all the cancer has been removed. The goal is to take out the cancer cells and nearby tissues down to the muscle layer of the bladder wall.

How TURBT is done

This surgery is done using an instrument put in through your urethra, so there's no cutting into the abdomen (belly). You'll get either general anesthesia (drugs are used to make you sleep) or regional anesthesia (the lower part of your body is numbed).

A type of thin, rigid cystoscope called a resectoscope is put into your bladder through your urethra. The resectoscope has a wire loop at the end that's used to remove any abnormal tissues or tumors. The removed tissue is sent to a lab for testing.

After the tumor is removed, more steps may be taken to try to ensure that the cancer has been completely destroyed. For instance, the tissue in the area where the tumor was may be burned while looking at it with the resectoscope. This is called fulguration. Cancer cells can also be destroyed using a high-energy laser through the resectoscope.

Possible side effects

The side effects of TURBT are generally mild and don't usually last long. Right after TURBT you might have some bleeding and pain when you urinate. You can usually go home the same day or the next day and can return to your usual activities within a week or two.

Even if the TURBT removes the tumor completely, bladder cancer often comes back (recurs) in other parts of the bladder. This might be treated with another TURBT. But if TURBT needs to be repeated many times, the bladder can become scarred and not be able to hold much urine. This can lead to side effects like frequent urination, or even incontinence (loss of control of urine).

In patients with a long history of recurrent, non-invasive low-grade tumors (slow-growing tumors that keep coming back), the surgeon may just use fulguration to burn small tumors that are seen during cystoscopy (rather than removing them). This can often be done using local anesthesia (numbing medicine) in the doctor’s office. It's safe but can be mildly uncomfortable.

Cystectomy

When bladder cancer is invasive, all or part of the bladder may need to be removed. This operation is called a cystectomy. Most of the time, chemotherapy is given before cystectomy is done. General anesthesia (where you are in a deep sleep) is used for either type of cystectomy.

Partial cystectomy

If the cancer has invaded the muscle layer of the bladder wall but is not very large and is only in one place, it can sometimes be removed along with part of the bladder wall without taking out the whole bladder. The hole in the bladder wall is then closed with stitches. Nearby lymph nodes are also removed and tested for cancer spread. Only a small portion of people with cancer that has invaded the muscle can have this surgery. The main advantage of this surgery is that the person keeps their bladder and doesn’t need reconstructive surgery (see below). But the remaining bladder may not hold as much urine, which means they'll have to urinate more often. With this type of surgery, the main concern is that bladder cancer can still come back (recur) in another part of the bladder wall.

Radical cystectomy

If the cancer is larger or is in more than one part of the bladder, a radical cystectomy will be needed. This operation removes the entire bladder and nearby lymph nodes. In men, the prostate and seminal vesicles are also removed. In women, the ovaries, fallopian tubes (tubes that connect the ovaries and uterus), the uterus (womb), cervix, and a small part of the vagina are removed too.

Most of the time, cystectomy is done through a cut (incision) in the belly (abdomen). You'll need to stay in the hospital for about a week after the surgery. You can usually go back to your normal activities after several weeks.

In some cases, the surgeon may operate through many smaller incisions using special long, thin instruments, one of which has a tiny video camera on the end to see inside your body. This is called laparoscopic, or “keyhole” surgery. The surgeon may either hold the instruments directly or may sit at a control panel in the operating room and use robotic arms to do the surgery (sometimes known as a robotic cystectomy). This type of surgery may result in less pain and quicker recovery because of the smaller cuts. But it hasn’t been around as long as the standard type of surgery, so it’s not yet clear if it works as well.

It's important that any type of cystectomy be done by a surgeon with experience in treating bladder cancer. If the surgery is not done well, the cancer is more likely to come back.

Reconstructive surgery after radical cystectomy

If your whole bladder is removed, you'll need another way to store urine and pass it out of your body. Several types of reconstructive surgery can be done.

Incontinent diversion

One option may be to remove and clean a short piece of your intestine and then connect it to the ureters (the tubes that carry urine out of the kidneys). This creates a passageway, known as an ileal conduit, for urine to pass from the kidneys to the outside of the body. Urine flows from the kidneys through the ureters into the ileal conduit. One end of the conduit is connected to the skin on the front of the belly (abdomen) by an opening called a stoma. (This is also called a urostomy. )

After this procedure, a small bag sticks to the skin of your belly around the stoma to collect the urine. Urine slowly drains out non-stop, so the bag must be on all the time. It's emptied whenever it's full. This is called an incontinent diversion, because you cannot control the flow of urine out of your body.

Continent diversion

Another way for urine to drain is a continent diversion. A pouch is made from a piece of intestine that's attached to the ureters. One end of the pouch is connected to an opening (stoma) in your skin on the front of your belly. A one-way valve is created at this opening. This allows urine to be stored in the pouch. You then empty it several times a day by putting a thin drainage tube (catheter) into the stoma through the valve. Some people prefer this method because there's no bag on the outside.

Neobladder

This method routes the urine back into the urethra, so you pass urine the same way. To do this, the surgeon creates a new bladder (neobladder) from a piece of intestine. As with the incontinent and continent diversions, the ureters are connected to the neobladder. The difference is that the neobladder is also sewn to the urethra. This lets you urinate normally on a schedule. (You won't have the urge to urinate, so a schedule is needed.) Over time, most people regain the ability to urinate normally during the day, but incontinence at night may be a problem.

If the cancer has spread or can’t be removed with surgery, a diversion may be made without taking out the bladder. In this case, the purpose of the surgery is to prevent or relieve blockage of urine flow, rather than try to cure the cancer.

Risks and side effects of cystectomy

The risks with any type of cystectomy are much like those with any major surgery. Problems during or shortly after surgery can include:

• Reactions to anesthesia
• Bleeding
• Blood clots in the legs or lungs
• Damage to nearby organs
• Infection

Most people will have at least some pain after the operation, which can be controlled with pain medicines.

Effects of cystectomy on urination

Bladder surgery can affect how you pass urine. If you have had a partial cystectomy, this might be limited to having to go more often (because your bladder can’t hold as much urine).

If you have a radical cystectomy, you'll need reconstructive surgery (described above) to create a new way for urine to leave your body. Depending on the type of reconstruction, you might need to learn how to empty your urostomy bag or put a catheter into your stoma. Aside from these changes, urinary diversion and urostomy can also lead to:

• Infections
• Urine leaks
• Incontinence
• Pouch stones
• Blockage of urine flow
• Absorption problems (depends on the amount of intestine that was used)

The physical changes that come from removing the bladder and having a urostomy can affect your quality of life, too. Discuss your feelings and concerns with your health care team.

To learn a lot more about urostomies, see Urostomy Guide.

Sexual effects of radical cystectomy in men

Radical cystectomy removes the prostate gland and seminal vesicles. Since these glands make most of the seminal fluid, removing them means that a man will no longer make semen. He can still have an orgasm, but it will be “dry.”

After surgery, many men have nerve damage that affects their ability to have erections. In some men this may improve over time. For the most part, the younger a man is, the more likely he is to regain the ability to have full erections. If this issue is important to you, discuss it with your doctor before surgery. Newer surgical techniques may help lower the chance of erection problems.

For more on sexual issues and ways to cope with them, see Sex and the Man With Cancer.

Sexual effects of radical cystectomy in women

This surgery often removes the front part of the vagina. This can make sex less comfortable for some women, though most of the time it's still possible. One option is to have the vagina rebuilt (called vaginal reconstruction). There's more than one way to do this, so talk with your surgeon about the pros and cons of each method. Whether or not you have reconstruction, there are many ways to make sex more comfortable.

Radical cystectomy can also affect a woman’s ability to have an orgasm if the nerve bundles that run along each side of the vagina are damaged. Talk with your doctor about whether these nerves can be left in place during surgery.

If the surgeon takes out the end of the urethra where it opens outside the body, the clitoris can lose some of its blood supply, which might affect sexual arousal. Talk with your surgeon about whether the end of the urethra can be spared.

For more on ways to cope with these and other sexual issues, see Sex and the Woman With Cancer.

Sexual effects of urostomy

It’s normal people to be concerned about having a sex life with a urostomy. Having your ostomy pouch fit correctly and emptying it before sex reduces the chances of a major leak. A pouch cover or small ostomy pouch can be worn with a sash to keep the pouch out of the way. Wearing a snug fitting shirt may be more comfortable. Choose sexual positions that keep your partner’s weight from rubbing against the pouch. For more tips, see Urostomy Guide.