Knowing you have cancer can be scary. Still, your doctor and health care team are there to help you. Your health care team will discuss what you must know about all the treatment choices. They will tell you about possible risks and the side effects of treatment on your quality of life.
Choices for Treatment
Treatments for muscle invasive bladder cancer include:
- Bladder removal (cystectomy) with chemotherapy or without chemotherapy
- Chemotherapy with radiation, in addition to TURBT
Chemotherapy
Chemotherapy uses drugs to kill cancer cells. For MIBC, chemotherapy will most likely be given before radical (total) cystectomy. Bladder removal with chemotherapy raises survival rates for bladder cancer patients. Neoadjuvant chemotherapy (given before cystectomy) should include the drug cisplatin. Adjuvant chemotherapy means the drug is given after surgery. Your doctor may offer this treatment if it is right for you.
Chemotherapy drugs are mostly given by vein (intravenous). The drugs enter the bloodstream and travel throughout your body.
Most often, doctors offer chemotherapy before bladder removal for best survival rates. But not all people are able to have chemotherapy. You may not get chemotherapy if you have poor kidney function, hearing loss, heart problems or other health issues. Some patients may choose not to get chemotherapy before surgery. But some may still need to have it after surgery based on the tumor stage. You will likely have your bladder surgery about six to eight weeks after you have finished chemotherapy.
You may have your chemotherapy treatment in an outpatient part of the hospital, at the doctor's office or at home. Rarely, you will need to stay overnight in the hospital. Chemotherapy is sometimes given in cycles. Each cycle often has a treatment period followed by a rest period.
There are side effects to chemotherapy. The side effects depend on which drugs are given and how much is given. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells, such as:
- Blood cells: If chemotherapy drugs lower the levels of healthy blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. If your levels are low, you may need to stop the chemotherapy or reduce the dose of the drug. There are also medicines that can help your body make new blood cells.
- Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back after treatment. But your hair color and texture may be different.
- Cells that line the digestive system: Chemotherapy can cause a poor appetite, upset belly and vomiting, loose stools, or mouth and lip sores. Your health care team can give you medicines and suggest other ways to help with these problems. Symptoms most often go away when treatment ends.
- Nerve cells: Some drugs used for bladder cancer may cause tingling or numbness in your hands and feet. Your healthcare team can suggest ways to control these side effects.
Surgery to Remove the Bladder (Cystectomy)
FFor MIBC, because the cancer has grown into the muscle, in most cases the whole bladder is removed (in some cases only part of the bladder is removed). As mentioned, before your bladder is removed, you will most likely be given neoadjuvant cisplatin-based chemotherapy. Bladder cancer can spread to the lymph nodes. When the bladder is removed, a pelvic lymph node dissection is also done to remove the fatty tissue surrounding the pelvic blood vessels. A pelvic lymph node dissection is thought of as standard of care. Standard of care means that this is the usual treatment.
What happens during surgery?
Your bladder can be removed by an open or a robotic approach. In the open approach, the doctor makes one larger cut in the middle of the belly to remove the bladder. Open surgery may have a shorter operative time.
In a "robotic" procedure, a few smaller cuts are made in the belly. Your surgeon puts small tools through the openings to reach the bladder. Often people have less pain and less blood loss with robotic surgery.
There are many things to think about before choosing open or robotic bladder removal:
- Your body weight
- History of prior surgery
- History of prior radiation
- Where to go for surgery. There is some evidence that complex surgery (such as bladder removal) has better outcomes when performed at Centers of Excellence facilities rather than hospitals, etc.
- Surgeon's experience: ask your surgeon about their familiarity with this type of surgery. If you have concerns, get a second point of view.
For more information on bladder removal, view our Bladder Removal Surgery video.
Radical Cystectomy (removal of the whole bladder)
For MIBC, the most common type of surgery is radical cystectomy. The surgeon removes the whole bladder, nearby lymph nodes and part of the urethra. In men, the surgeon also may remove the prostate. In females, the surgeon may remove the uterus, fallopian tubes, ovaries and vagin*l wall. Other nearby tissues may also be removed.
When the whole bladder is removed, the surgeon makes another way for urine to be collected from the kidneys and stored before passing from your body. This is called urinary diversion. Your doctor will talk over the risks of cystectomy and the different methods of urinary diversion.
Partial Cystectomy (removal of part of the bladder)
For MIBC, partial cystectomy is a less likely choice as the cancer may be more advanced. Partial cystectomy may be thought about in select cases of bladder cancer in which the tumor is found in a specific part of the bladder and does not involve more than one spot in the bladder. Ask your surgeon whether you are a candidate for this type of surgery.
Urinary Diversion after Bladder Removal
When your bladder is removed or partly removed, your urine will be stored and made to leave your body by a different route (urinary diversion). If you have a radical cystectomy, you will need to know about urinary diversion options.
Because the surgeon uses tissue from your intestines for bladder reconstruction, you must have enough bowel tissue for a urinary diversion. Before surgery, your surgeon will go over the procedure and the changes you will need to make.
Here are some of the urinary diversion choices your surgeon may offer:
- Ileal conduit: To make an ileal conduit, the surgeon will take a piece of your upper intestine and use it to make an opening (stoma) on the surface of your stomach. The ureters are joined so that the urine leaves your body by the opening. A bag will be attached to collect the urine and you will "dump" the bag many times a day. This is the most simple and most often used diversion after bladder surgery.
- Continent cutaneous reservoir: Your surgeon makes a pouch inside your body and you will learn to use a catheter to remove your urine.
- Orthotopic neobladder: Your surgeon makes an internal pouch, much like your bladder, to store urine. Your ureters are joined to this new "bladder" and you are able to empty through your urethra the same way you did before surgery. In some instances, you may need to use a catheter to remove the urine.
Talk with your doctor about your choices for a urinary diversion. Having a urinary diversion will greatly impact your quality of life.
For more information on urinary diversion, visit our Urinary Diversion article or view our Urinary Diversion video.
Chemotherapy with radiation
Bladder Preservation
Chemotherapy with radiation may be used for bladder preservation (keeping the bladder or parts of it). Bladder preservation may be suggested for select patients where radical cystectomy is not an option or is undesired. The right health circ*mstances must be present for bladder preservation.
Your surgeon (urologist) will repeat a TURBT as described above to remove all visible tumor. Chemotherapy and radiation will then be given by medical oncologists and radiation oncologists (doctors that specialize in giving chemotherapy and radiation). This is called a multi-modal (many methods) approach. Radiation alone for MIBC is not a choice to control the spread of bladder tumors. Some chemotherapy drugs that may be used along with radiation are cisplatin, 5-FU and Mitomycin-C. Once treatment is complete, follow up includes ongoing cystoscopy exams, cross-sectional imaging (e.g. CT scan) and other procedures to check to make sure the cancer has not come back.
For patients who use the multi-modal approach to bladder preservation, 30% of the time MIBC will return. Thus it is very important for you to be watched closely by your health care team in case the tumor progresses and cystectomy becomes needed.
For more information on bladder preservation, view our Bladder Preservation Therapy video.
Radiation therapy
Radiation as a single form of treatment is not given for MIBC. It is most often done along with chemotherapy and rarely after surgery. Radiation therapy uses high-energy rays to kill cancer cells.
The radiation comes from a large machine that aims beams of radiation at the bladder area in the abdomen. You may go to a hospital or clinic five days a week for many weeks to get radiation therapy. Each treatment session takes about 30 minutes.
Radiation therapy is painless, but it may cause other side effects. Problems with radiation include upset belly, vomiting or loose stools. Also, you may feel very tired during radiation therapy. Your health care team can suggest ways to treat or control these side effects.
