Bladder cancer is considered to be invasive if cancer cells have gone through the bladder lining and are present in the muscle. This poses the possibility of the spread of the cancer into additional areas of the body and, therefore, treatment is essential.

The most common treatment plan for muscle invasive bladder cancer is “radical cystectomy.” During a radical cystectomy the entire bladder is removed and an alternative route for removal of urine from the body is provided. In addition to the bladder, adjacent lymph nodes are removed for analysis. In men, the prostate and adjacent structures are usually removed. In women, the cervix, the uterus, the ovaries, the fallopian tubes, and part of the vagina are also often removed.

In many cases chemotherapy is administered prior to and/or after radical cystectomy. This has been shown in some instances to reduce the chance of the cancer spreading.

There are three general types of urinary diversions used with radical cystectomy:

Ileal Conduit

Urinary diversion that allows urine to drain through a stoma into an external bag affixed to the abdomen. This is the most common of the diversions used by many general urologists. It is the simplest surgically.

Continent Reservoir

The “continent reservoir” (sometimes called an Indiana Pouch) uses the patient’s own intestine to form an internal pouch to collect urine. A small stoma is formed and located on the abdomen or in the navel. A catheter is used to drain the pouch several times a day.

Neobladder

The third diversion is the “Neobladder.” Again, part of the patient’s intestine is used to form an internal pouch. This is attached to the kidneys and ureter allowing the possibility for the patient to void normally.

Each diversion type has its pros/cons and not all patients are candidates for every type. The good news is that there are thousands of people with any of these urinary diversions who live full lives, including marathon runners and mountain climbers. The success rates for any of these diversions have been shown to be the highest when the surgery is done by a surgeon and at a center that does a large number of these very specialized surgeries.

Partial Cystectomy

This is a procedure where only a part of the urinary bladder is removed. The most common use for partial cystectomy is used for a type of bladder cancer called adenocarcinoma. Partial Cystectomy is rarely used in the treatment of Transitional Cell Carcinoma as the likelihood of recurrence in the remaining bladder is high.

Nerve-sparing radical cystectomy

Nerve sparing radical cystectomy is an option dependent on each individual’s situation. In this procedure the nerve bundles that control erection in men and orgasm in woman are spared. You will need to talk to your medical team to ascertain the possibility of using this procedure in your personal case. If this is an important part of your life a frank discussion between you and your medical team about your sexuality and what can be done to preserve your function should happen prior to your radical cystectomy.

Bladder Preservation?

Bladder preservation is sometimes offered by some major cancer centers. It is only offered to patients that fit strict selection criteria; often this involves transurethral resection of the tumor, radiation, and a chemotherapy regime. Bladder preservation is still in the investigational stage and is considered controversial by some in the medical field.

Should I get a second opinion?

Radical cystectomy is a complicated surgery with many options and ramifications. It is essential that the surgeon has extensive experience with the procedure. Should a patient be facing a radical cystectomy, one of the questions to ask is how many diversion does this physician and this medical center perform each year. (You would not take your car to a mechanic who has never worked on that particular problem/model before!)

It is highly recommended that a patient facing a major medical procedure always get a second opinion from a major center that deals with a high volume of bladder cancer. Statistics show a distinct advantage to dealing with a doctor and hospital that see a lot of bladder cancer patients.

Never feel too embarrassed or intimidated to ask for a second opinion! Most doctors welcome a second opinion, and, if they do not, you do not want them for a doctor. The very best result will be to confirm that the treatment plan proposed by your doctor is “right on.” And, if it isn’t, you will be able to find a more appropriate one.

Suggested Reading

From the Cleveland Clinic

From the National Institute of Diabetes and Digestive and Kidney Diseases