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Stephan L. Werner, M.D., F.A.C.S. Transurethral resection: Treatment of bladder cancer is dependant upon the stage of the disease. However most bladder cancers are initially treated with trans urethral resection of the tumor, known as TURB or TURBT. Under anesthesia a cystoscope, a telescopic instrument is inserted through the urethra into the bladder to inspect the bladder. If the tumor is tiny it may be removed with a biopsy forceps and the base and surrounding area cauterized or fulgurated. If the tumor is larger, a resectoscope, a similar instrument with an electric "knife", is inserted into the bladder and the tumor cut away. The pieces are washed out of the bladder, and the base of the tumor and the surrounding area is fulgurated to control bleeding and kill invisible cancer cells that may have been left behind. A catheter or tube is frequently left in the bladder, especially if the resection has been wide or deep, to allow the bladder to heal. Depending on the extent of the resection, postoperative bleeding or other conditions, the patient may go home postoperatively, or stay in the hospital for up to a few days. Bladder cancer is frequently multicentric so at the time of TURB, tiny biopsies may taken from other areas in the bladder, (bladder mapping), to help plan further therapy. Some urologists will instill chemotherapy into the bladder immediately after the TURB to decrease the incidence of recurrence. Further treatment of Superficial, Ta-T1 bladder cancer: For small, primary, superficial, solitary bladder cancers resection may be adequate treatment, requiring repeat cystoscopies every 3 months for 2 years, then every 6 months for 3 years, and after 5 years, annual examination. If no tumor is found at the first repeat cystoscopy the chance of later recurrence is about 20% whereas if repeat rumor is found, further recurrences are likely in 80% of patients. For multiple superficial tumors, recurrent tumors, tumors invading the lamia propria or in the presence of carcinoma in situ further therapy is indicated. Bacillus Calmette-Guerin, (BCG), mitomycin, adriamycin and thio-tepa have all been used to prevent recurrence. BCG has proven to be the most effective in decreasing recurrence and progression. BCG or Bacillus Calmette-Guerin is a bacteria related to the tuberculosis bacteria. When placed in the bladder it induces a strong immune response to bladder cancer cells in many patients, killing many of the visible and hidden cancer cells. It is usually given through a catheter and the patient asked to retain the solution for 2 hours. Six weekly treatments is the standard course. Irritable bladder symptoms such as bleeding, frequency and burning on urination ore common and are positive signs of a reaction. Fever is less common and rarely a major systemic infection occurs requiring several months of antibiotics. Rarely a patient has died from overwhelming infection. Another rare complication is a shrunken bladder. Many urologists will put patients on a maintenance regimen of 3 BCG treatments every three months for 1 to 2 years. If a patient fails to respond to the primary course of BCG, frequently a second course of 6 weeks is given. If the tumor then recurs there are several treatment regimens possible including reduced BCG dose plus interferon, switching to other drugs or more aggressive surgery. Further treatment of Invasive, T2-T4, Bladder Cancer: If the cancer has invaded into the muscle standard therapy is removal of the bladder. For a few patients with very superficial muscle invasion, T2 disease, TURB may be adequate treatment . For a few others, bladder sparing surgery may be possible. A solitary tumor that is located on the dome of the bladder may be treated with a partial cystectomy, removal of part of the bladder, Occasionally TURB + chemotherapy + radiation has been used, but as long term survival is less than 50%, it should be reserved for patients with other major conditions and those who are willing to gamble on results. Patients who have deep muscle invasion without sing of metastases are best treated with radical cystectomy, or removal of the bladder and regional lymph nodes. In men the prostate and seminal vesicles are usually removed as well, and if the cancer invades the prostate, the urethra is also removed. In women, the urethra, uterus, ovaries and part of the vagina are frequently removed as well. Urinary Diversion: When the bladder is removed, some other drainage for urine is requires. The classic and most common solution is the formation of a urinary conduit, an ileal loop or Bricker procedure where a segment of small intestine is taken out of continuity with the bowel and connected to the ureters and brought out through the abdominal wall as a stoma. A urostomy appliance must then be worn to collect the urine. Modern urostomy appliance design allows for one to continue an essentially normal life style. A second type of diversion is a continent stoma, where a reservoir is constructed from intestine, and a valved stoma is constructed that requires catheterization several times a day. These do not require an appliance, but have a higher long term complication rate.. A third approach is to construct a neo-bladder, (new bladder), from intestine and hook it up to the urethra, so that voiding is done through the urethra. This technique requires a highly motivated and cooperative patient, as many complications are possible, such as blockage or metabolic imbalance or not infrequently incontinence. It is not the "easy way out" as there is a significant reoperation rate. Treatment of Recurrent or Metastasic Disease: When the disease has spread beyond the bladder to the lymph nodes or further, chemotherapy may slow down or rarely eliminate the cancer. Historically MVAC: methotrexate, vinblastine, doxyrubicin and cisplatinum has induced responses in 60 to 80% of patients, but unfortunately recurrences are common. Newer less toxic combinations of drugs are now achieving similar results, but long term solutions are yet to be found for most patients. Rev: 02/02
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[Home] Werner - Francis Urology Associates llc - Mid Atlantic Urology Associates llc Greenbelt - Bowie - Laurel Maryland (301) 441-8900 Fax (301) 982 0453 7500 Hanover Parkway Suite 206 Greenbelt, MD 20770
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