Bladder Cancer Surgery

Bladder cancer (tumor) is a malignant disease of the urinary bladder. Treatment of bladder cancer depends on the stage of the disease. Bladder cancer surgery depends on the stage of the disease. If the disease is at an early stage and has not spread to the bladder muscle, only endoscopic resection of the tumor (TUR-T) and administration of chemotherapy drugs into the bladder according to the pathology result is sufficient. In the advanced stage, larger surgery is required. These are radical cystectomy and surgeries such as ileal loop or ileal bladder (artificial bladder). In this article, I will give general information about bladder cancer surgery with our own experiences and literature.

What are the causes of bladder cancer?

Bladder cancer is one of the most common cancers among urological cancers. It is most common in men aged 65 and over. Due to the prevalence of smoking nowadays, it can also be seen at an earlier age. The causes of bladder cancer are:

• Smoking: It is one of the most important causes of bladder cancer. More than 1/3 of all bladder cancers are associated with smoking. Bladder cancer is 4 times more common in smokers. It is more common in men.
• Chemicals: Chemicals such as aniline dyes, 2-naphthylamine, 4-naphthylamine, benziidine, o-toludine, xenylamine cause bladder cancer.
• Occupational carcinogens: Paints, textile products, rubber products, plastic products, leather products and those who work for a long time in these sectors are at high risk.
• Radiotherapy: Bladder cancer may be seen in people who have undergone radiotherapy to the bladder area due to bowel and gynecological cancers.
• Chemotherapy drugs: Drugs used in other cancer treatment such as cyclophosphamide and cisplatin.
• Diabetics: The incidence of bladder cancer is high in long-term Type-2 diabetics.
• Long-term catheter use: The risk of bladder cancer is high in patients who use catheters for a long time due to stroke.
• Infections: Prolonged and frequently recurring urinary tract infections are a risk factor for bladder cancer.
• Bladder stones: Long-term bladder stones cause irritation and irritation in the bladder, which leads to cancer.
• Schistosomiasis (bilharsiasis): Squamous cell bladder cancer is common in bladder infections caused by the Schistosoma parasite.

What are the symptoms (signs) of bladder cancer?

Common symptoms (symptoms) that may aid diagnosis in patients with bladder cancer include:

• Blood in the urine (hematuria): The most common symptom of bladder cancer is painless blood in the urine. It is especially seen in smokers and is more common in men. If a man who has been smoking for a long time has painless blood in the urine, he should definitely consult a urologist. Pain does not always occur, it can be seen as intermittent bleeding. There may be occasional clots.
• Urgency: Sudden urination and the need to urinate may be seen. This condition can be confused with BPH (benign prostatic enlargement).
• Dysuria: There may be burning during urination. Dysuria is common, especially in cases of carcinoma in situ (CIS).

If you have advanced (metastatic) cancer;

• Bone pain
• Weight loss
• Swelling in the legs

How is bladder cancer diagnosed?

The steps to be followed in order to diagnose bladder cancer are as follows;

• examinations, the tumor in the bladder and whether it has spread to the surrounding organs can be shown.
• Anamnesis: Patients are questioned in detail. Especially in men who complain of painless blood in the urine and smoke for a long time, bladder cancer should be considered and research should be done accordingly. In addition, it is questioned whether the patients are exposed to the work area and chemicals, the drugs they use, chemotherapy and radiotherapy for other diseases.
• Urine microscopy: In patients with bladder cancer, blood may be seen in the urine (microscopic hematuria).
• Urine cytology: It is investigated whether there are cancer cells in the urine of patients who are thought to have bladder cancer in cytological examination.
• Cystoscopy: It is the examination of the bladder by entering the endoscopic (light device) method. On cystoscopy, the location of the cancer, its size, and how many can be seen.
• Ultrasonography (USG): Tumor in the bladder can be shown in the urinary system USG examination.
• CT, MRI: In advanced • Scintigraphy: Bone scintigraphy can show whether there is spread to the bones. In addition, spread to distant organs can be demonstrated with advanced examinations such as CT and MRI.

What methods are used for bladder cancer surgery?

Different surgical methods are used for bladder cancer surgery. Today, with the advancement of technology, surgical techniques have also advanced. Bladder cancer can be performed openly, as well as by laparoscopic and robotic methods. Although technological possibilities are used, the processes are similar to each other. Bladder cancer surgery methods are as follows;

• Open surgical methods
• Laparoscopic methods
• Robotic methods

Pre-operative preparation

Bladder cancer is performed under spinal anesthesia or general anesthesia. Endoscopic (TUR-T) surgery is usually performed under spinal anesthesia. General anesthesia is applied to patients with muscle invasion and who will undergo radical cystectomy and artificial bladder (ileal neobladder) or ileal ileal loop.

Things to do before bladder cancer surgery;

• Patients undergo routine tests for anesthesia. Such as blood tests, chest X-ray, EKG.
• If patients are using blood thinners, they should be discontinued 1 week in advance.
• Cardiology consultation is requested from the patients if the anesthesiologist deems it necessary.
• Determination of the patient’s blood group and, if necessary, blood adjustment are useful in radical cystectomy operations.
• If patients are using drugs due to their chronic diseases, they should definitely tell them beforehand. These drugs can be used unless otherwise.
• Before the operation, nothing should be eaten or drunk by mouth for at least 5-6 hours.
• When patients are hospitalized, necessary consent forms are prepared, patients are informed about the surgery and consent forms are signed.

How is the treatment/surgery of bladder cancer done?

Treatment of bladder cancer is based on the stage of the disease. In order to make a correct treatment, first of all, the staging of the disease should be done. Appropriate treatment planning is made when the staging of the disease is done with radiological examinations (CT, MRI, USG).

Treatment of bladder cancer without muscle invasion

In bladder cancers that have not spread to the bladder muscle (stage CIS, Ta, and T1), treatment is based on the risk status (cancers with low or high risk of spreading).

Parameters showing the risk of cancer spreading in bladder cancer;

• Number of cancer in the bladder
• The size of the tumor (the risk is higher if it is 3 cm larger)
• Recurrence or first occurrence of cancer
• Cancer grade

Treatment in low-risk superficial bladder cancers

In low-risk bladder cancer, TUR-T is performed as a complete tumor in the treatment. If the cancer is low grade, smaller than 3 cm, in a single focus and is a primary tumor, a single dose of chemotherapy and drug is given to the bladder after TUR-P. In this way, recurrence of the disease and spread to other normal bladder parts are prevented. The given drug stays in the bladder for up to 1 hour.

Patients are called for control in the 3rd and 9th months. If the cancer recurs within 6 months, it may be sufficient to burn the tumor (fulguration) only in small and unifocal cancers.

Treatment of intermediate-risk superficial bladder cancers

In patients with medium risk superficial bladder cancer, at least 6 doses of intravesical chemotherapy (drug therapy) are required after TUR-T. The drug given each time is kept in the bladder for at least 1 hour. Then they are called for control at regular intervals.

Treatment in high-risk superficial bladder cancer

In superficial bladder cancer without high-risk muscle invasion, it is generally recommended to perform a second TUR-T 4-6 weeks after the first operation. If necessary, advanced radiological examinations such as MRI and CT are also requested for these patients.

These patients are treated with BCG into the bladder after TUR-T. There are different protocols for BCG. The duration of treatment varies from 6 months to 1.5 years. In this period, control is performed with cystoscopy every 3 months for the first 2 years, every 6 months for the next 2 years, and then once a year. There are some complications of BCG therapy applied into the bladder in the treatment of bladder cancer. These complications are;

• Frequent urination
• Painful urination (dysuria)
• Hematuria (bloody urination)
• Urinary tract infection
• Fever, chills, chills

Treatment of bladder cancer with muscle invasion

There are different treatment options for bladder cancer with muscle invasion. These are advanced major surgical procedures. Depending on the pathology result after surgery, additional treatments such as radiotherapy and chemotherapy may be required.

• Cystectomy and ileal neobladder (artificial bladder)
• Cystectomy and ileal loop (connecting the urine to the abdominal wall)
• Chemotherapy
• Radiotherapy

What should be considered after the operation?

Recommendations are made to the patients according to the type and size of the surgery performed after the surgery. The postoperative period is more comfortable in patients who have undergone TUR-T surgery. Postoperative follow-up takes slightly longer time in patients who have undergone radical cystectomy.

• Patients are given antibiotics and painkillers after surgery.
• They do not eat or drink orally for the first 5-6 hours, but patients who have undergone spinal anesthesia can take it orally after surgery.
• Patients who have undergone radical cystectomy do not eat or drink orally for 1-3 days, during this time they are fed intravenously. Then, when bowel movements begin, they first take water and liquid food, then gradually switch to normal food.
• Postoperatively, patients begin to move and walk early. If spinal anesthesia is not performed, they get up and walk slowly 4-5 hours after the operation.
• If TUR-T surgery has been performed, they are discharged the next day.
• Patients who have undergone radical cystectomy stay in the hospital for 5-6 days, depending on the situation.
• Oral antibiotics and pain relievers are given to discharged patients.
• If a catheter is inserted after TUR-T, it can stay for 2-7 days depending on the depth and width of the surgery.
• If TUR-T is applied to the patients after the surgery, they start their normal work 7-10 days later.
• Patients who underwent cystectomy should rest for 1 month.
• Heavy physical activity should be avoided for about a month after the operation.
• Depending on the pathology after TUR-T, patients may be offered additional treatments.
• Chemotherapy and radiotherapy may be recommended to patients according to the pathology and stage of the disease.

In summary; Bladder cancer is one of the most common cancers of the urinary system. Treatment is done according to the stage of the cancer. If the cancer can be completely removed in the bladder, it is completely removed by TUR-T surgery. If there is no progression to the bladder muscle in the pathological examination, chemotherapy drugs are given into the bladder in appropriate cases. If there is bladder muscle involvement, radical cystectomy and ileal loop or artificial bladder surgeries are performed. Cancer patients are included in a regular follow-up program after surgery.

Note: For more information about bladder cancer, you can read the articles on our website.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY

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