Surgical Procedures: Surgery and Staging for Bladder Cancer

Cancerous cells in the bladder are called bladder cancer. The bladder is in the pelvis and is a hollow muscular organ. The job of the bladder is to store urine. Once the body is ready to eliminate (get rid of) urine, it passes from the bladder through the urethra (tube connected to the bladder) and out of the body.

Often, bladder cancers start in the inner lining of the bladder. This is called transitional or urothelial cell cancer. The other types of bladder cancer are:

• Squamous cell carcinoma.
• Adenocarcinoma.
• Small cell carcinoma.

Bladder cancer be either:

• Superficial: cancer is only in the lining of the bladder.
• Invasive: cancer has spread to other parts of the body.

What is staging and how is it performed?

Staging looks at the size of the tumor and where it is, and if it has spread to other organs. It also helps figure out what treatment is best. Bladder cancer can spread to other parts of the body through the tissue, lymph, and blood systems. Your provider will have you get a few tests to figure out the stage of your cancer and if it has spread. For bladder cancers, these tests may be:

Physical Exam: This is a general exam to look at your body and to talk about past health issues. This may include an internal pelvic exam to evaluate the vagina and/or rectum.

Imaging: Radiology tests can look inside your body to look at the cancer and determine if it has spread. These tests can include: 

• Chest X-ray.
• CAT scan (CT scan).
• Magnetic resonance imaging (MRI).
• Bone scan.

Laboratory Tests: Often, your urine will be tested for any abnormalities.

Procedures: These may include:

• Intravenous pyelogram (IVP): Dye is injected into a vein. This makes the kidneys, ureters, and bladder visible on an x-ray. The x-ray can show abnormal areas and blockages. 
• Cystoscopy: A thin, lighted tube (cystoscope) is passed through the urethra and into the bladder. A biopsy can be done during this procedure.
• Transurethral Resection of Bladder Tumor (TURPT): This is a cystoscopy with biopsy or tumor removal. It can be used to both treat and diagnose bladder cancer. 

Bladder cancer is described as stage 0 (Papillary carcinoma and Carcinoma in Situ) through stage IV (4) disease (most advanced).

Surgical Procedures Used for Bladder Cancer

Surgery is often used to treat bladder cancer. The procedure used will depend on many things, including the size and location of the cancer. Your provider will talk to you about your specific procedure. 

Surgical procedures used to treat bladder cancer include:

Transurethral Resection of Bladder Tumor (TURBT) or Transurethral Resection with fulguration: A cystoscopy is done. An electrically charged loop or laser is used to take out the cancer on the inner layer of the bladder. 

Partial Cystectomy (Segmental Cystectomy): The cancer and a small area around the cancer are taken out. Some lymph nodes may be taken out. This is used for cancer that has invaded the bladder wall but is low-grade in nature.

Radical Cystectomy: The whole bladder and any organs or lymph nodes affected are taken out. Men may need their prostate and seminal vesicles taken out. Women may need their uterus, cervix, ovaries, fallopian tubes, and a portion of the vagina taken out. This will require a urinary diversion (alternate route for urine to leave the body). A radical cystectomy can be done with one large incision (called an open procedure) or laparoscopically, in which several small incisions are used. Robotic surgery may also be used.

Urinary Diversion: This surgery makes a new way for urine to be stored and to leave the body. Methods include a urinary conduit, cutaneous urinary diversion, or the creation of a neobladder.

• Urinary Conduit (Incontinent Diversion): The intestine is used as a tube (called ileal conduit) connecting the ureters to an external collection bag called a urostomy bag.
• Cutaneous Urinary Diversion (Continent Diversion): The intestine can be used as a urine reservoir to collect urine, which can then be drained with a catheter inserted into a surgically placed opening in the abdomen.
• Neobladder: A neobladder (reservoir) can be made with the intestine and attached to the urethra. This will allow a patient to urinate as if the bladder were still there. It may require catheterization for full neobladder emptying.

What are the risks associated with bladder cancer surgery?

As with any surgery, there are risks and possible side effects. These can be:

• Infection.
• Reaction to anesthesia (anesthesia is the medication you are given to help you sleep through the surgery, not remember it and manage pain). Reactions can include wheezing, rash, swelling, and low blood pressure.
• Blood clots.
• Bleeding.
• Damage to nearby organs.
• Erectile dysfunction and/or dry orgasm in men.
• Infertility, premature menopause, painful intercourse, difficulty with orgasm, and effects on sexual arousal in women.
• Urinary frequency and incontinence (changes in how often you urinate or not being able to hold your urine).
• Urine leaks, pouch stones, and urine flow blockages with urinary diversion and urostomy.

What is recovery like?

Recovery from bladder cancer surgery will depend on the extent of the procedure you had. At times, a week long hospital stay is needed.

You will be told how to care for your incisions, stoma, tubes, and any dietary changes before leaving the hospital.

Your medical team will discuss with you the medications you will be taking, such as those for pain, blood clot, infection, and constipation prevention and/or other conditions.

If you had had a TURBT:

• Your urinary catheter may remain in place for 1-2 days or longer.
• Do not lift anything heavy.
• Do not drive while taking narcotic pain medications. 

If you had a radical cystectomy:

• Walk as tolerated and rest when you need to.
• Do not lift or bend until told by your team that you can. 
• Do not drive until you are told that you can. 
• Drink lots of fluids to flush mucous from the urine and avoid plugging of the stoma.
• Do not lift anything heavy.
• Do not play contact sports. 
• Wear loose clothing around the stoma.

Contact your healthcare provider if you experience:

• Fever. Your team will tell you at what temperature you should call. 
• Chills, incisional redness/swelling, warmth, and/or drainage.
• Concerns with the stoma include surrounding skin redness, itching, and/or a darkening of the stoma.
• Decreased (less) urine output and/or a feeling of fullness.
• Nausea, vomiting, and/or pain unrelieved with medication.

How can I care for myself?

You may need a family member or friend to help you with your daily tasks until you are feeling better. It may take some time before your team tells you that it is ok to go back to your normal activity.

Be sure to take your prescribed medications as directed to prevent pain, infection, and/or constipation. Call your team with any new or worsening symptoms.

There are ways to manage constipation after your surgery. You can change your diet, drink more fluids, and take over-the-counter medications. Talk with your care team before taking any medications for constipation. 

Taking deep breaths and resting can help manage pain, keep your lungs healthy after anesthesia, and promote good drainage of lymphatic fluid. Try to do deep breathing and relaxation exercises a few times a day in the first week, or when you notice you are extra tense.

• Example of a relaxation exercise: While sitting, close your eyes and take 5-10 slow deep breaths. Relax your muscles. Slowly roll your head and shoulders.

This article contains general information. Please be sure to talk to your care team about your specific plan and recovery.,