Surgery for bladder cancer

Surgery is part of the treatment for most bladder cancers. The type of surgery done for bladder cancer will depend on its stage.

Transurethral surgery

For early stage or superficial bladder cancers, a transurethral resection (TUR), also known as a transurethral resection of the bladder tumor (TURBT), is the most common treatment. This surgery is done through an instrument passed up the urethra, so it does not require cutting into the abdomen. You will get either general anesthesia (where you are asleep) or regional anesthesia (where the lower part of your body is numbed).

For this operation, a type of rigid cystoscope called a resectoscope is placed into the bladder through the urethra. The resectoscope has a wire loop at its end to remove any abnormal tissues or tumors. The removed tissue is sent to a lab to be looked at by a pathologist. Most patients have superficial cancer when they are first diagnosed, so this is usually the first treatment they receive.

After surgery, more steps may be taken to try to ensure that the tumor has been completely destroyed. Any remaining cancer may be treated by fulguration (burning the base of the tumor) while looking at it with the cystoscope. Cancer can also be destroyed using a high-energy laser through the cystoscope.

The side effects of transurethral bladder surgery are generally mild and do not usually last long. You might have some bleeding and pain during urination right after surgery. You can usually return home the same day or the next day and can resume your usual activities in less than 2 weeks.

Unfortunately, even with successful treatment, bladder cancer often recurs (comes back) in other parts of the bladder. If transurethral resection needs to be repeated many times, the bladder can become scarred and lose its capacity to hold much urine. Some people may have side effects such as frequent urination, or even incontinence (loss of control of urination).

In patients with a long history of recurrent, non-invasive low-grade tumors, the surgeon may sometimes 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 is 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.

Partial cystectomy: If the cancer has invaded the muscle but is not very large and 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. Nearby lymph nodes are also removed and examined 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 a person keeps their bladder and does not need reconstructive surgery (see below). But the remaining bladder may not hold as much urine, requiring more frequent urination. The main concern with this type of surgery is that bladder cancer can still recur in another part of the bladder wall, which is not a concern after radical cystectomy.

Radical cystectomy: If the cancer is larger or is in more than one part of the bladder, a radical cystectomy is needed. This operation removes the entire bladder and nearby lymph nodes. In men, the prostate is also removed. In women, the ovaries, fallopian tubes (tubes that connect the ovaries and uterus), the uterus (womb) and a small portion of the vagina are often removed along with the bladder.

General anesthesia (where you are in a deep sleep) is used for either type of cystectomy.

These surgeries are typically done through a cut (incision) into the abdomen. You will need to stay in the hospital for about a week after the surgery. You can usually go back to your normal activities in 4 to 6 weeks.

In some cases, the surgeon may operate through several smaller incisions using special long, thin instruments, one of which has a tiny video camera on the end to see inside the pelvis. This is known as laparoscopic, or “keyhole” surgery. The surgeon may either hold the instruments directly or may sit at a control panel in the operating room and maneuver robotic arms to do the surgery. If it can be done, laparoscopic surgery may result in less pain and quicker recovery after the operation (due to the smaller incisions). But it has not been around as long as the standard type of surgery and it’s not yet clear if it is equally as effective.

It is 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: If your whole bladder is removed, you will need another way to store and remove urine. Several types of reconstructive surgery can be done depending on your medical situation and personal preferences.

One option may be to remove a short piece of the intestine and connect it to the ureters. 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. The conduit is connected to the skin on the front of the abdomen by an opening called a stoma (also known as a urostomy).

After this procedure, a small bag is placed over the stoma to collect the urine, which comes out continuously in small amounts. The bag then needs to be emptied once it is full.

Another way for urine to drain is called a continent diversion. For this, a valve is created in a pouch made from the piece of intestine. The valve allows urine to be stored in the pouch. It is emptied several times each day by placing a drainage tube (catheter) into the stoma through the valve. Some patients prefer this method because there is no bag on the outside.

A newer method routes the urine back into the urethra, restoring urination. One way to do this is to create a neobladder – a urinary reservoir made of a piece of intestine. As with the ileal conduit and continent diversion, the ureters are connected to the neobladder. The difference is that the neobladder is also sewn to the urethra. This lets the patient urinate normally.

If the cancer has spread or can’t be removed with surgery, a diversion may be made without removing 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.

Side effects of cystectomy

Cystectomy is a major operation, and the complications and side effects can be serious. Short-term risks include reactions to anesthesia, excess bleeding, blood clots, and infections. Most people will have at least some pain after the operation, which is usually helped with pain medicines, if needed.

Aside from changes in how urine leaves the body, the possible side effects of urinary diversion and urostomy may include wound infections, incontinence (urine leaks), pouch stones, and blockage of urine flow. Radical cystectomy can also have sexual side effects, as described in the next section. The physical changes that result from removing the bladder and having a urostomy can have a major emotional and psychological impact as well. You should feel free to discuss your feelings and concerns with your health care team.

More about urostomies can be found in our document, Urostomy: A Guide.

Sexual effects of radical cystectomy in men: In men, radical bladder surgery 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 produce semen. The testicles still make sperm, but instead of exiting the body in semen, it is simply reabsorbed. After radical bladder surgery, orgasm can still occur, but it will be “dry,” that is, without semen.

After surgery, many men have nerve damage that prevents them from having an erection. In some men this may improve over time. Generally, the younger a man is, the more likely he is to regain the ability to have full erections. Men younger than 60 (and especially those under 50) have higher recovery rates than older men. If this issue is important to you, you should discuss it with your doctor before surgery. Newer surgical techniques may lower the chance of impotence.

To read more about ways to cope with sexual issues, see our document, Sexuality for the Man With Cancer.

Sexual effects of radical cystectomy in women: This surgery often removes half of the vagina, which can make sex less comfortable for some women. Orgasms and lubrication may also be affected. You will want to talk with your surgeon to learn how surgery is likely to affect your sex life.

Most of the time intercourse is still possible. One option is to have the vagina rebuilt, which is known as vaginal reconstruction. There is more than one way to do this, so talk with your surgeon about the pros and cons of each.

If the vagina is not reconstructed, it will be shorter than before, but you may still enjoy intercourse. Certain sexual positions, such as those where the partners are side-by-side or with you on top, limit the depth of penetration. 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. During a cystectomy, the 2 nerve bundles that run along each side of the vagina can be damaged when the front of the vagina is removed. Women who have surgery that preserves these nerve bundles may have better sexual function after surgery than those whose nerve bundles are removed or cut. 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 a good deal of its blood supply, which might affect some parts of sexual arousal. Talk with your surgeon about whether the end of the urethra can be spared, and how that may affect your chances of normal clitoris function.

To read more about ways to cope with these and other sexual issues, see our document, Sexuality for the Woman With Cancer.

Sexual effects of urostomy: For both men and women, it is normal to be concerned about your 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 even more comfortable. To reduce rubbing against the pouch, choose positions for sexual activity that keep your partner’s weight off of it.