Bladder Cancer Surgery: Everything You Need to Know

Bladder cancer is the most common type of urinary tract cancer. Approximately 83,000 new cases are diagnosed annually in the United States.

Surgery is the preferred first-line treatment for this type of cancer, especially when it is caught early and has not yet spread. Surgery is used to remove a cancerous (malignant) tumor of the bladder and, when needed, restore the function of the bladder.

There are several different procedures that may be used depending on the specific stage of the cancer, including transurethral resection for small tumors and removal of the bladder (cystectomy) for larger tumors.

This article will explain the reasons why these different procedures are done, the potential risks, and what to expect with your general as well as sexual health during recovery.

Surgeons working

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What Is Bladder Cancer Surgery?

Bladder cancer surgery involves the removal of part or all of the bladder (and sometimes surrounding tissues and nearby lymph nodes) to eliminate a cancerous tumor. If the bladder is removed, surgery will also be done to provide a method for urine to be transported from the kidneys to outside the body.

The surgery is used primarily in adults (bladder cancer in children is rare) and usually performed as a scheduled surgery after a number of other tests are done to look for any spread of the cancer.

Types of Surgical Techniques

  • Endoscopic surgery: A thin, flexible tube equipped with a camera and surgical tools (an endoscope) is inserted into a natural opening (in this case, the urethra) so no incision is made in the skin.
  • Keyhole surgery: This minimally invasive procedure involves several small incisions in the skin to access the bladder, and the cancer is removed through these holes using special instruments.
  • Robotic surgery: Similar to keyhole surgery, robotic surgery differs in that the actual surgery is done via mechanized instruments instead of a surgeon's hands controlling the instruments.
  • Open surgery: With an open approach, a traditional large incision is made in the abdomen to access the bladder.

3 Bladder Cancer Surgery Approaches

There are three different surgical approaches to treating bladder cancer. What type of procedure your healthcare team recommends will depend on the size and location of the tumor, the stage of the cancer and other considerations. The types of surgery include:

Transurethral resection of bladder tumor (TURBT): Used as the initial diagnostic procedure in most people with bladder cancer, this procedure is also used as a treatment method for some early-stage small or superficial cancers that have not invaded the muscle of the bladder.

During the surgery, a thin, rigid tube equipped with a light and camera (cystoscope) is inserted through the urethra (the opening from the bladder to the outside of the body) and fed up into the bladder. Other instruments can also be passed through the cystoscope to help remove a tumor and control bleeding.

Partial cystectomy: Also called "bladder preservation surgery," this procedure involves removing only part of the bladder. It is done infrequently and only in a few special situations, such as when the tumor is small or easy to access, if the tumor has not spread, or if the tumor invaded the muscular layer of the bladder, but in only one place. Since much of the bladder remains, reconstructive surgery is not required, though follow-up surgery may be needed to fully restore function.

Radical cystectomy: Used for most tumors that have spread to the muscle layer of the bladder (stage 2 and stage 3 cancers), this procedure includes removing the entire bladder, regional lymph nodes, as well as some other tissues, such as the layer of fat surrounding the bladder.

In people with female anatomy, the uterus, fallopian tubes, and sometimes the ovaries and part of the vagina may also be removed. In people with male anatomy, the prostate, seminal vesicles, and part of the urethra may be removed.

Urinary Diversion Surgery Options

When the entire bladder is removed, an alternative way to remove urine from the body is needed. The three different procedure options are:

  • Urinary conduit: This is the least complex (both in technique and complications) procedure. A small piece of the intestine is removed and the ureters (the tubes that carry urine from the kidneys to the bladder) are inserted into this piece. The piece is then tacked on to the front of the abdomen with an opening made to the outside of the body called a stoma or urostomy. A bag is then attached to the stoma into which urine can drain continuously. The bag is drained every few hours and must be kept in place to catch urine at all times.
  • Cutaneous urinary diversion (Indiana pouch): In this procedure, a piece of large intestine is removed, the ureters are inserted, and the pouch is attached to the inside wall of the abdomen, usually near the belly button. A stoma is created between the pouch and the outside of the body to allow for drainage of the pouch. A catheter must then be inserted through the stoma to drain the pouch several times per day. Unlike a urinary conduit, a person does not have a bag on the outside of their body.
  • Neobladder: With this procedure, a new bladder or "neobladder" is made from apart the large intestine, then attached to the ureters. The urethra is attached to the neobladder, and urine leaves the body through the urethra. This allows people to urinate as much as they had prior to their cystectomy, though the urge to urinate is not present as it was before. Training is required (and a regular schedule kept) to empty the bladder properly. Leakage can occur, especially at night. People also need to know how to insert a catheter to remove urine if needed.

Complications are not uncommon with any of these procedures, and a careful discussion with your healthcare team is needed to make the right choice for you alone.

Risks and Contraindications

There are settings in which the above procedures for bladder cancer are not recommended (known as contraindications). Some of these based on procedure types include:

TURBT: TURBT should not be done for people with Tis tumors (carcinoma-in situ) as these tumors are often diffuse and hard to visualize. It's also not considered for people who have higher stages of bladder cancer, or for those who have poor bladder function prior to the surgery.

Potential side effects and complications of this procedure include temporary pain with urination (as well as frequency and urgency of urination), bleeding, obstruction of the ureters, especially if a tumor is near the area where the ureters enter the bladder, infection, bladder perforation, or recurrence of the cancer.

Cystectomy: Since a cystectomy is a major surgical procedure, there are some in which it is not recommended, including:

  • Advanced metastatic bladder cancer, unless it is done to alleviate symptoms
  • Bleeding disorders that are not controlled or current use of some anticoagulation medications
  • Very poor lung function
  • Generalized poor health such that a person would not tolerate general surgery

Other potential risks and complications of this surgery include general risks related to anesthesia, bleeding, infection, blood clots, erectile dysfunction in men, sexual dysfunction in women, and damage to organs near the bladder.

Urinary diversion procedures: Most of the contraindications for urinary diversion procedures are related to the need to remove a section of the intestine, such as in those who have inflammatory bowel disease (IBD, which includes the conditions Crohn's disease or ulcerative colitis), or have had radiation to their bowel.

There are also settings in which Indiana pouch and neobladder versions of urinary diversion are contraindicated, including:

  • Poor kidney function
  • The presence of proteinuria (passing protein in your urine)
  • Poor eye-hand coordination for any reason (such as in people who have had a stroke or spinal cord injury), which could make the ability to insert a catheter challenging (needed with both continent procedures)
  • Dementia: Since urine needs to be removed either through the stoma or urethra several times a day and forgetting to do so could be problematic

Potential complications of these procedures include urine leakage, pouch stones, blockages, urinoma (a pocket of trapped urine), and intestinal absorption problems such as vitamin B12 deficiency depending on the location of the piece of intestine removed.

How to Prepare

Before you have surgery (especially a cystectomy and urinary diversion), your healthcare provider will want to make sure you are healthy enough to tolerate surgery and an anesthetic. This may include:

  • Reviewing your medications (Blood thinners or aspirin, for instance, may need to be stopped for a period of time.)
  • Blood tests to check on your kidney function as well as electrolytes
  • Pulmonary function tests if you have lung disease
  • An ECG, echocardiogram, or stress test if you have heart disease (and ECG is often done routinely for people over the age of 50)

A urinalysis will be done prior to a TURBT since urine needs to be clear of white blood cells prior to surgery (no signs of infection).

Most of the time you will be advised not to eat or drink after a certain amount of time, usually six to eight hours. Routine medications can often be taken with a few sips of water the day of surgery, but talk to your healthcare provider about whether you should take these the day of surgery.

If you will be having urinary diversion surgery, you will be asked to do a bowel prep as well beginning at least a day before surgery. This is similar to the procedure done prior to having a colonoscopy.

What to Expect on the Day of Surgery

Before surgery: When you arrive at the hospital on the day of your surgery, you will meet with your surgical nurse as well as your doctor and anesthesiologist (specialist in anesthesia). They will ask if you have any questions before proceeding with the surgery and ask you to sign a consent form

Your nurse will then check your weight, temperature, breathing rate, and pulse. You may also have blood tests or an ECG on the day of surgery. You will be given a hospital gown and socks to wear and given a bag for your clothing. It's best to leave all valuables at home and have a friend or family member take care of any articles you bring with you.

During surgery: You will then be taken to the operating room and your anesthesiologist will talk to you about the anesthetic. An intravenous (IV) line will be inserted to put you to sleep, and a dose of antibiotics is given.

Next, the surgical team will clean and prepare the site of surgery, and place sterile surgical drapes over your body. The full preparation and surgical steps will depend upon the exact type of procedure being completed.

After surgery: You will be taken to recovery until you begin to wake up, then you'll be moved to your hospital room, where you will be reunited with any friend or family member present. You will likely have a PCA (patient-controlled anesthesia) device so that you can self-administer intravenous medication to manage your pain.

The time you will be in the hospital varies for everyone. With a TURBT, you may be released that day or stay overnight, while with a radical cystectomy and urinary diversion, a stay of five to seven days is common.

With many bladder cancer procedures, you will be able to eat and drink a regular diet when you are fully awake and comfortable after the surgery. It's important to drink a lot of water both while at the hospital and when you return home. This can help reduce your chance of developing an infection.

Before you go home, your nurse will also discuss any dietary recommendations and restrictions and help you learn to manage your stoma. With a continent cutaneous diversion, this will be setting up a regular schedule to using the catheter to drain the pouch. With a neobladder, this will include setting up a training schedule to urinate, as well as knowing how to catheterize yourself in case this is ineffective.

Recovery

Bladder cancer surgery is a major procedure, and recovery can take some time. It's common to have blood in your urine for the first two to three days. You may still have some light bleeding for up to two weeks.

With a TURBT, you will have a catheter in your bladder. This may be removed before you are discharged from the hospital, but you may need to wear it at home until your first follow-up appointment. Your nurse will show you how to drain the bag and attach it (often to your leg) so you can move around when you go home.

If you had a cystectomy and urinary diversion, you will also have abdominal incisions to keep clean and dry while you heal. Your healthcare provider will let you know when you can shower or get the areas wet.

Your healthcare provider will also talk about your activity level after discharge. It's often recommended not to lift anything heavier than a gallon of milk for several weeks. You will also be tired after returning home, and this is normal.

It's also important to talk with your medical team about how to prevent constipation due to pain medications and how to watch for signs of blood clots (such as swelling, redness, or pain in your calves).

Long-Term Care

After bladder cancer surgery, regular follow-up is needed, often for life.

Monitoring for recurrence: Bladder cancer tends to recur for many people, so most healthcare providers recommend screenings beginning three months after surgery and then every three to six months for two to four years. If you’re cancer free at that time, reducing visits to annual exams and tests may be sufficient.

It's important to note that physicians vary in the frequency of follow-up they recommend and that there are no "standard" guidelines. This is because there are currently no detailed clinical trials that show the effects of monitoring on survival or quality of life.

Managing urinary diversion: Complications with urinary diversion may occur at any time and have been noted for up to 20 years after surgery. It's important to talk to your healthcare provider both about any special follow-up recommendations and when to call if you suspect you may have a complication.

Navigating sexual side effects: For both men and women, the presence of a pouch on the outside of the body can get in the way during sex as well as alter body image. Bladder cancer treatment can otherwise affect men and women in different ways.

  • Men: Since a radical cystectomy removes both the prostate gland and seminal vesicles (which make the bulk of seminal fluid) when orgasms occur, they will be dry. Erectile dysfunction (due to nerve damage) after surgery is very common but may improve over time.
  • Women: Bladder surgery, especially if part of the vagina has been removed, can cause pain with intercourse (dyspareunia), but it usually improved with time. Nerve damage may result in problems with both arousal and orgasm. Surgical menopause (via removal of the ovaries) can also lead to some of the "normal" sexual problems surrounding menopause.

Fortunately, there are many options for improving sexual health. That said, cancer centers have only recently begun to address these to an adequate degree. Some cancer centers now have sexual medicine programs that are recommended routinely during healing from surgery.

Summary

There are three main types of procedures used to remove bladder cancer:
transurethral resection of bladder tumor (TURBT), partial cystectomy (partial removal of the bladder), and radical cystectomy (total removal of the bladder, nearby lymph nodes, and other tissues).

If your bladder is removed, you will also need a procedure to create a new way to divert urine outside of the body. Options include a urinary conduit (urine is diverted to bag outside the body), cutaneous urinary diversion (a bag to collect urine is tacked inside the stomach, but must be drained regularly), and a neobladder (a new bladder is created that allows for regular urination but without a sense of the need to go).

A Word From Verywell

If you will be having bladder cancer surgery, it's natural to be feeling very anxious. It's not just having to face cancer, and all that entails, but the types of surgery to remove it, and the risk of recurrence. Take heart that the survival rate is very high with early-stage bladder cancers, the stage when it's most diagnosed.

There can be silver linings along the way. Some people find it helpful to learn about post-traumatic growth, or how living with cancer has essentially made many people better people.

Watching for examples of your own personal growth through your journey is one way to help manage the anxiety around bladder cancer, but other strategies, such as meditation, gratitude journaling, or finding a support group, can also be beneficial. Find what works for you.

Frequently Asked Questions

  • Is urinary diversion painful?

    Some discomfort is normal following urinary diversion surgery and can last some time. In the hospital and for four to six weeks after surgery, medication will be used to control your pain. Over the long term, you may notice pain if your pouch isn't emptied often enough, if it ruptures, if you have an obstruction, or if you develop pouch stones or other problems.

  • What does recovery look like after bladder cancer surgery?

    With a TURBT, you may leave the hospital as soon as that day, but you may still have a catheter in place, and your activities will be limited for several days.

    After a radical cystectomy and urinary diversion, you will recover in the hospital for up to a week. Many people continue to require pain control for a few weeks, and it may take four to six weeks to get used to the new process of emptying your bladder and feel like yourself again.

  • How effective is TURBT surgery?

    Effectiveness varies widely depending on the stage of the tumor, whether there was only one tumor or several, and other factors.

    The largest review to date found that one year post-surgery, cancer recurred in 15% to 61% of patients, but progression rates were less than 1% to 17%.

    At five years post-surgery, the risk of recurrence ranged from 31% to 78% and progression from less than 1% to 45%.

  • Can you have sex after bladder cancer surgery?

    Yes, but sex may be different and there may be challenges. For men, medications such as Viagra (sildenafil) and Cialis (tadalafil), can help in dealing with erectile dysfunction. For women, nerve damage and vaginal narrowing can lead to discomfort with intercourse. Vaginal dilators (medical devices used to help expand the vaginal opening) can be used to widen the vagina and alleviate pain.

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