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The treatment for bladder cancer is dependant on the tumor grade and stage. Low grade tumors can usually be treated endoscopically, through removal of the tumor using a telescope in the operating room. If the tumor is more aggressive or higher grade but limited to the mucosa or lamina propria, we recommend treating the patient with immunotherapy (BCG) or chemotherapy placed in the bladder. This is usually done in the office on a set schedule. Cancer that is higher stage or progressed through the inner lining of the bladder requires more invasive treatment.
Radical cystectomy with an extended and thorough pelvic lymph node dissection is the gold-standard treatment for high-grade, invasive bladder cancer. Most comparative studies have indicated that local recurrence and survival outcomes using bladder-sparing protocols (transurethral resection, chemotherapy and/or radiation) for muscle-invasive disease are inferior to those from radical cystectomy to control muscle-invasive bladder cancer. Continuous improvement in surgical techniques and post-operative care has greatly reduced morbidity and late effects of surgery, including sexual dysfunction in select cases. At USC, we offer patients the option of minimally invasive techniques, including robotic assisted laparoscopy, or the traditional open approach. Our surgeons are world renowned for both techniques and depending on the patient’s preferences and clinical findings, we work with the patient to develop a plan that put the patient in charge of his or her care without compromising quality or expertise.
In men, radical cystectomy involves complete removal of the bladder, prostate, seminal vesicles and pelvic lymph nodes. At USC we have experience in performing nerve sparing cystectomies, and some cystectomies that spare the male reproductive organs for those who are still seeking to father children.
In female patients, a radical cystectomy (referred to as anterior exenteration), traditionally involves removal of the bladder, uterus, fallopian tubes, ovaries, and the anterior vaginal wall. While this is still necessary in some patients, the pelvic organs and the vagina can sometimes be spared in certain female patients without compromising cancer control. At USC, we have been able to perform uterine sparing cystectomies in women of child bearing age, without compromising the cancer surgery.
Cystectomy provides the best survival outcomes and the lowest local recurrence rates for muscle-invasive disease. The recurrence-free and overall survival is significantly related to the pathological stage with overall survival rates of about 50% at 5 years. Patients who have lymph node negative, organ confined cancer have a 5 year survival of about 80%, whereas patients with disease extending outside the bladder into the perivesical fat or patients with lymph node involvement have 5 year survival of 35-58%. Remarkably, patients with lymph node involvement still have an approximately 35% chance of long term survival with a radical cystectomy and extended pelvic lymph node dissection.
Pelvic lymph nodes are one of the first sites to which bladder cancer spreads. Although the extent or absolute limits of the lymph node dissection remain to be better defined, a growing body of data supports a more extended lymphadenectomy at the time of cystectomy in all patients who are appropriate surgical candidates. An extended lymph node dissection should include the distal para-aortic and paracaval lymph nodes as well as the pre-sacral nodes, known anatomic sites of lymph node drainage from the bladder and potential sites of lymph node metastases in patients with bladder cancer. An extended dissection may provide a survival advantage in patients with node-positive as well as node-negative tumors without significantly increasing the morbidity or mortality of the surgery. The extent of the primary bladder tumor (p stage), the number of lymph nodes removed, and the lymph node tumor burden are important prognostic variables in patients undergoing cystectomy with pathologic evidence of lymph node metastases. At USC, we not only believe in this principle, we were some of the pioneers in this field. We have been performing an extended lymph node dissection as routine practice for years, and we have published the survival advantage in many academic journals.
Types of Urinary Diversion
Once the native bladder is removed, the kidneys will need to drain the urine into another space. There are several options for bladder cancer patients in terms of urinary diversion. At USC, we offer world class expertise amongst our surgeons to work with the patient to determine the optimal choice in urinary diversion that would cater best to the patients lifestyle and needs.
Ileal Conduit (Urostomy)
The ileal conduit is constructed from a small segment of the intestine and brought out to the skin as a stoma. The ureters are anastamosed directly into the bowel segment used and urine passes freely from the conduit into an external collection device (stoma bag), which is emptied periodically. This is the least technically demanding method of urinary reconstruction and is what is performed at a majority of institutions. Patients who have impaired kidney function or are otherwise not a candidate for an orthotopic neobladder are offered this form of urinary diversion.
The orthotopic neobladder offers the advantages of a superior cosmetic appearance (without the need for a cutaneous stoma or urostomy appliance), and allows for a more natural voiding pattern via the native urethra. The sense of body image however is very personal and subjective and varies considerably from patient to patient. In fact, most patients are quite content with their choice of urinary diversion whether it is continent or incontinent. All patients undergoing cystectomy should be properly informed of the various urinary diversion options. There are established contraindications to a continent urinary diversion and certain clinical indications that may favor a conduit diversion but the majority of patients today undergoing cystectomies are candidates for a continent urinary diversion, and should be counseled accordingly. We believe that each patient facing urinary diversion should have a long discussion with their surgeon to discuss the risks and benefits of all forms of diversion.
