Bladder Cancer

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Treating Bladder Cancer TOPICS

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 (non-muscle invasive) bladder cancers, a transurethral resection (TUR), also known as a transurethral resection of the bladder tumor (TURBT), is the most common treatment. Most patients have superficial cancer when they are first diagnosed, so this is usually the first treatment they receive.

This surgery is done using 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.

After the tumor is removed, more steps may be taken to try to ensure that it has been destroyed completely. 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 when you urinate 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, which means the person will have to urinate more frequently. The main concern with this type of surgery is that bladder cancer can still recur in another part of the bladder wall.

Radical cystectomy with extended lymph node dissection: If the cancer is larger or is in more than one part of the bladder, a radical cystectomy with extended lymph node dissection will be 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.

Typically, these procedures are done through a cut (incision) in 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. Laparoscopic surgery may result in less pain and quicker recovery because of 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 after radical cystectomy

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.

Incontinent diversion: One option may be to remove a short piece of your 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. One end of 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. This approach is sometimes called an incontinent diversion, because you no longer control the flow of urine out of the body.

Continent diversion: Another way for urine to drain is called a continent diversion. A valve is created in a pouch made from the piece of intestine attached to the ureters. The valve allows urine to be stored in the pouch. You then empty the pouch several times each day by placing a drainage tube (catheter) into the stoma through the valve. Some people prefer this method because there is no bag on the outside.

Neobladder: A newer method routes the urine back into the urethra, restoring urination. One way to do this is to create a neobladder – basically a new bladder made of a piece of intestine. As with the incontinent 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. Over several months, most people regain the ability to urinate normally during the day, although many people might still have some incontinence at night.

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 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 come from removing the bladder and having a urostomy can have a major emotional and psychological impact as well. You should 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: 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 produce semen. He can still have an orgasm, but it will be “dry” – that is, without semen.

After surgery, many men have nerve damage that affects their ability to have erections. 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. If this issue is important to you, discuss it with your doctor before surgery. Newer surgical techniques may lower the chance of impotence.

To read more about sexual issues and ways to cope with them, see our document Sexuality for 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, although 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. 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.

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: It is normal for both men and women 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 even more comfortable. Choose sexual positions that keep your partner’s weight from rubbing against the pouch. For more information, see our document Urostomy: A Guide.

For more general information about surgery as a treatment for cancer, see our document Understanding Cancer Surgery: A Guide for Patients and Families.


Last Medical Review: 02/26/2014
Last Revised: 02/26/2014