Bladder Cancer: Surgery
You have to be healthy for surgery to be an option for you. Before surgery, you'll meet with a surgeon who's a urologist. This is a doctor who specializes in problems with the urinary tract, including the bladder. In this meeting, you’ll talk about the details of the type of surgery to be done, what, if any, other organs may need to be removed, and how you’ll pass urine after surgery. You'll also be able to ask questions and address concerns you may have. You may want to ask about the risks and possible short- and long-term side effects of the surgery. You may also want to ask when you can expect to return to your normal activities. You may want to know where the scars will be and what they’ll look like.
The surgeon will need to know if you’re taking any medicines. This is to make sure you're not taking anything that could affect the surgery. After you’ve talked about all the details with the surgeon, you’ll sign a consent form that says you understand what will be done. It gives permission to the surgeon to do the surgery.
To help deal with the information you'll get and remember all of your questions, it helps to bring a family member or close friend with you. You should also bring a written list of concerns. This will make it easier for you to remember your questions. You may also find it helps to take notes.
You may also want to consider getting a second opinion before deciding what kind of treatment you'll get. This might help you feel better about the choices you're making. The peace of mind a second opinion gives you may be well worth the effort.
Types of bladder cancer surgery
Your healthcare provider will use the stage of the cancer to help decide the type of surgery you should have. The stage is the size of the cancer and where it is. Your provider will also consider your personal choices. There are several types of surgery for bladder cancer.
Transurethral resection (TUR)
This may also be called transurethral resection of bladder tumor (TURBT). In this surgery, all of the cancer in your bladder is taken out. But your whole bladder isn't removed. This type of surgery may be done if the cancer is only in the lining of your bladder. This may be called superficial cancer. TUR can also be done to diagnose bladder cancer and find out how deep it has spread into the bladder wall.
You stay in the hospital for this surgery. After you get to the operating room, you'll be given anesthesia medicine to prevent pain. You may get a local anesthesia. This keeps you from feeling what's going on, but you’re still awake. Or you may get general anesthesia. This puts you to sleep and keeps you from feeling pain. You won't need to have any cuts (incisions) made in your skin to get this treatment. It's done using a special tool called a cystoscope.
The cystoscope is a thin, lighted tube. The urologist puts it in through your urethra and moves it up into your bladder. Using the cystoscope, he or she looks at the inside of your bladder, usually on a computer screen. If bladder cancer is seen, he or she will use a special tiny attachment at the end of the cystoscope to cut out the tumor. After the cancer has been taken out, the area may be burned. Or your healthcare provider may use a laser to kill any cancer cells that may be left behind at that spot. All of this is done through the cystoscope.
You may be able to go home the same day. Or you may stay in the hospital a day or so after TUR. A soft tube (catheter) is left in your urethra after the procedure. The tube drains the urine from your bladder. It prevents blockage of your urethra. It also helps stop bleeding and gives your bladder time to heal. It will be taken out when the bleeding stops. Your bladder will then work the way it did before surgery.
You may feel the need to urinate more often when the catheter is first removed. You may feel a little pain when you urinate. There may also be blood or even clots in your urine. These problems are normal and go away after a day or two. Call your urologist if you have a lot of pain or bleeding, or if the pain or bleeding doesn't get better within a few days.
There's a good chance that you won't have any cancer left after TUR. But you'll still need to see your urologist every 3 to 6 months. Superficial bladder cancer often comes back. In some cases, TUR may be followed by some type of intravesical therapy. For this treatment, a medicine such as chemotherapy or immunotherapy is put right into your bladder for a certain amount of time.
In follow-up visits, your urologist will look at the inside of your bladder with a cystoscope. This is called a cystoscopy. It uses a thin, lighted tube that's like the one that was used for the TUR. It's put into your bladder through your urethra. You’ll also give urine samples for testing. These tests are done to make sure the cancer hasn't come back or to find it early if it does.
This surgery may be done if the cancer has spread to deeper tissue under the lining of the bladder, but is small and only in one place. In this case, only the part of the bladder with the cancer is removed.
After you get to the operating room, you'll be given anesthesia to prevent pain. This puts you to sleep and keeps you from feeling pain. A cut (incision) is made in the skin of your lower belly (abdomen). The urologist takes out the cancer and some of the healthy bladder wall around it. Nearby lymph nodes may be removed, too.
In some cases, this surgery is done through many small cuts on your abdomen instead of one big one. A long, thin tube with camera (called a laparoscope) is put in one cut. Long, thin tools are put in the other cuts to do the surgery. This is called laparoscopic surgery.
After the cancer is removed, your healthcare provider will close the hole in your bladder wall with stitches. A soft tube (catheter) is left in your urethra after the procedure. It drains the urine from your bladder and gives your bladder time to heal. It will be taken out when the bleeding stops. You stay in the hospital for about a week after this surgery. After you heal and the catheter is removed, your bladder works like it did before surgery. But it's smaller, so it may not hold as much urine. A concern with this surgery is that the cancer may come back in another part of your bladder.
You will have regular follow-up visits with your urologist. He or she will look at the inside of your bladder with a thin, lighted tube called a cystoscope. This is called a cystoscopy. You’ll also give urine samples for testing and X-rays and/or scans will be done. These tests are done to make sure the cancer hasn't come back or to find it early if it does.
This means your whole bladder is taken out during surgery. Nearby tissues, organs, and lymph nodes are also removed. This may be needed if the cancer has spread deeply into the bladder wall and/or is large or in more than one part of the bladder. When all the bladder is removed, you’ll need reconstructive surgery to create a new way for urine to leave your body. All of this is done in one surgery.
In men, the prostate gland and seminal vesicles are also removed. This is because the cancer can come back in these areas. In women, the uterus, fallopian tubes, ovaries, cervix, and the top of the vagina may need to be removed. Your healthcare provider will talk to you about which organs may need to be taken out. He or she will also talk to you about side effects. Your provider will also tell you how this surgery will change your body and how it works.
In the operating room, you’ll be given general anesthesia. This puts you to sleep and keeps you from feeling pain. A cut will be made in your lower belly (abdomen) to do this surgery. In some cases, the surgery may be done with a laparoscope. This means it's done through many small cuts instead of one big one. A long, thin tube with camera (laparoscope) is put in one cut. Special tools are then put in the other cuts to do the surgery.
Your surgeon must create a new way for urine to leave your body. So, right after your bladder is removed, bladder reconstruction is done. This is covered in the next section. You’ll stay in the hospital for about a week after surgery.
You will have regular follow-up visits with your urologist after surgery. For the first few years these visits may be every 3 months or so. You will have blood and urine tests, and imaging scans. These tests are used to make sure the cancer hasn't come back or to find it early if it does.
Reconstructive bladder surgery
There are many ways to rebuild a "bladder" after it’s been removed to treat cancer. Urine made by your kidneys will need to be stored and moved out of your body in a new way. This is called reconstructive surgery. Your surgeon does reconstructive surgery at the same time that you have your bladder removed. There are 2 main types of reconstructive surgery.
Incontinent urinary diversion
This is also called an urostomy. After this type of surgery, you no longer urinate the way you once did. You’ll wear a bag on the outside of your body to collect urine.
This procedure is also called an ileal conduit. To do it, your healthcare provider makes a pouch out of a small piece of your intestine. Then, he or she connects it to your ureters. These are the tubes carrying urine out of your kidneys. The opening of the pouch is connected with your skin to direct urine through an opening (stoma). Urine passes out of the opening into a plastic bag that’s attached to your skin. You then empty urine from the bag several times a day.
After the operation, urine will constantly flow through the ileal conduit into the external pouch. Right after surgery, a drainage tube from the ileal conduit will come out through stoma. This tube may be in place for 2 to 3 weeks after surgery. Your surgeon may take X-rays to check how well your bladder has healed. He or she will also make sure there isn't leakage before taking out the drainage tube.
Once the tube is removed, you'll use an adhesive patch to hold a plastic pouch to your skin over the stoma. When the pouch is full, you empty the urine through a valve at the bottom of it. You’ll need to change the pouch every 3 to 5 days. A special nurse (enterostomal nurse) will help watch your care when you've had a urostomy. The nurse will teach you how to keep the urine bag, catheter, or abdominal opening clean. The nurse will also give you advice on lifestyle issues, such as having sex or cleaning your urine bag at work.
Continent urinary diversion
This surgery creates a new bladder for you. This way, you can control when the urine leaves your body and do not have to wear a bag. There are 2 main types of this surgery. One type is cutaneous continent diversion. This requires that urine be drained though a hole in your abdomen. This is called a stoma. This is done with a catheter, several times a day. The other type is orthotopic neobladder. This is the creation of a new bladder that’s emptied through your urethra the same way you did before surgery.
During surgery, your healthcare provider takes a piece of your intestine and connects it to your ureters. This is done to make a new path for your urine to flow. The pouch made from the intestine is directed to a stoma. Your surgeon then creates a one-way valve that allows you to drain the pouch several times a day. You do this by inserting a catheter through the stoma. The catheter drains urine out of the pouch into a container. You can then dispose of the urine in the toilet. Many people prefer this approach because they don't need to wear a urine collection bag on the outside of their body.
After the operation, urine will flow through the ureters into the pouch inside your body. The pouch will hold about a pint of urine a few months after the operation, but will hold more urine as time goes by. You’ll learn to recognize the sensation when the pouch is getting full of urine. Then you’ll pass a catheter into the stoma to let the urine out. For a few weeks after the surgery, you'll likely need to drain the pouch every few hours. As the pouch stretches, you will probably empty it every 4 to 6 hours.
An enterostomal nurse will help teach you how to care for the stoma and use a catheter to get the urine out. The nurse will also give you advice on lifestyle issues, such as having sex or emptying your diversion at work.
This surgery may also be called orthotopic continent urinary reconstruction. You can only have it if your urethra was not removed during the original surgery.
Your surgeon takes out a piece of your intestine and creates a pouch to hold urine. The pouch is called a neobladder or new bladder. It’s attached directly to your ureters and to your urethra. With this approach, you can pass urine through your urethra, just as you did before the surgery. Compared with other reconstructive surgeries, this type is most like your normal urinary system. Many people who have a neobladder say they feel the same urge to urinate as they did before surgery. It may take you awhile, though, to learn the sensations that mean you need to urinate. Right after surgery, you’ll have a catheter to drain out urine as your body heals. Urine control does not come right away after your catheter is taken out. You’ll learn the routine you should follow to help train your new bladder.
The ability to control urination during the day is better than 90% with a neobladder. Your ability to control urine flow at night may not be quite as good, especially in the first 6 to 9 months after surgery. You may be able to manage the problem by drinking less before bedtime. Men may also want to talk with their healthcare providers about a condom catheter. This attaches to the penis like a condom and connects to a tube that collects urine in a bag.
Recovering at home
Make sure you know how to take care of yourself after surgery and are able to manage the way you have to get urine out of your body. Also be sure you have supplies and know where to get more. It may help to have someone learn along with you, so you have a helper and support person at home.
When you get home, you may get back to light activity. But you should avoid strenuous activity for 6 weeks. Your healthcare team will tell you what kinds of activities are safe for you while you heal.
When to call your healthcare provider
Let your healthcare provider know right away if you have any of these problems after surgery:
Redness, swelling, or fluid leaking from the incision site
Irritation, redness, or swelling around the stoma
Damage or injury to the stoma
A blockage of urine flow
The physical and emotional changes from your cancer surgery may be significant. Ask your healthcare team for resources that will help you and your family manage the physical effects of cancer treatment, and also the mental and emotional changes.
Call your healthcare provider or stoma nurse if you have any problems. Know what to do and have a number to call if you have problems or questions after hours or on weekends or holidays.