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) is most common. For this operation, a type of rigid cystoscope called a resectoscope is placed into the bladder through the urethra. Because the resectoscope has a wire loop at its end to remove tissue, the urologist can see into the bladder and remove the tumor, . The removed tissue is sent to a pathologist for examination. Since about 70% to 80% of patients have superficial cancer when they are first diagnosed, this is usually the first treatment they receive. This procedure is done while you are under general or regional anesthesia. It does not involve cutting into the abdomen.

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

The side effects of transurethral bladder surgery are generally mild and do not usually last long. There may be some bleeding and discomfort right after surgery. After transurethral surgery, you can usually return home the same day or the next day and can resume your usual activities in less than 2 weeks. Long-term side effects can be more disturbing. If the procedure needs to be repeated many times, the bladder can become scarred and lose its capacity to hold much urine. This means frequent urination and the chance of not being able to control urination (incontinence).

Cystectomy

When bladder cancer is invasive, all or part of the bladder may need to be removed. This operation is called a cystectomy.

If the cancer is not very large, it can sometimes be removed without removing the whole bladder. This operation is called a partial cystectomy.

If the cancer is larger or if the bladder contains more than one area of cancer, a radical cystectomy is done. 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 with the bladder.

General anesthesia is used for either type of cystectomy. These surgeries are done through a cut (incision) into the abdomen. You will need to stay in the hospital for about 7 to 10 days. You can usually go back to your usual activities in 4 to 6 weeks.

The complications and side effects of a radical cystectomy (removing the bladder and nearby organs) can be serious. There is a risk of excessive bleeding, urinary tract infections, urine leakage (incontinence), and blockage of urine flow. It is important that this operation be done by a surgeon with experience in treating bladder cancer. Studies have shown there is a wide variation in quality. If the surgery is not done well, the cancer is more likely to come back.

Several types of reconstructive surgery can be done, depending on your medical situation and personal preferences (this is discussed below). Removing the bladder and creating another system for draining urine can also have a major psychological impact. You should feel free to discuss your feelings and concerns with your health care team. Many of these problems can be overcome by medical treatments.

Bladder preservation: Some urologists have strongly supported bladder preservation, using transurethral resection of the bladder cancer, along with radiation therapy and chemotherapy. Others disagree, and feel that cystectomy is the best treatment for patients with early bladder cancer.

Some studies support the use of this more conservative approach for locally advanced bladder cancer. In these studies, patients who did not respond to treatment with radiation and chemotherapy could safely have their bladders removed with a radical cystectomy at a later date.

It is very important to carefully evaluate patients who choose this treatment for bladder cancer

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 possibility is to remove a short piece of the intestine and use it as a passageway for urine to pass from the kidneys to the outside of the body. Urine flows from the kidneys through the ureters into a small sac (pouch) made from the intestine. This sac is connected to the skin of the abdomen by an opening called a stoma. In some cases, urine empties continuously into a small bag placed over the stoma. An example of this is called an ileal conduit, which is made from a piece of small intestine.

Another way for urine to drain is called a continent diversion. For this, a valve is created in the 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 close to normal 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 allows the patient to urinate normally.

If the cancer has spread or can't be removed with surgery, a diversion may be made without removing the bladder. This would relieve blockage of urine flow.

The possible side effects of urinary diversion and urostomy may include wound infections, urine leaks (incontinence), pouch stones, and blockage of urine flow.

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

Sexual Effects of Radical Cystectomy and Urostomy

In men, radical bladder surgery removes the prostate gland. Since this gland produces most of the seminal fluid, removing it 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" - without semen.

After surgery, many men have nerve damage that prevents them from having an erection. 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.

It is normal to be concerned about your sex life after having a urostomy. With some simple planning, sex can be pleasurable and less stressful. Having your appliance fit correctly and emptying it before sexual activity, reduces the chances of a major leak. A pouch cover or small ostomy pouch can be worn during intercourse. Even a sash can keep the pouch out of the way. Wearing a T-shirt may be even more comfortable. To reduce rubbing against the appliance, choose positions for sexual activity that keep your partner's weight off the appliance.

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

Last Medical Review: 01/27/2009
Last Revised: 5/13/2009