Invasive Bladder Cancer

Bladder cancer either affects the superficial lining of the bladder or the muscle wall. A third of new patients have cancer invading the muscle wall, and a third of patients with superficial tumours will develop muscle-invading cancer over time. Invasive cancers are therefore quite common. Superficial tumours tend to remain superficial within the bladder and are a nuisance, whereas invasive cancers extend into neighbouring organs within the pelvis and metastasise to elsewhere in the body, ultimately causing death if untreated. Whilst most superficial cancer can be treated telescopically, invasive cancers require more aggressive management.

Radical therapy aims to cure cancer and the most proven and accepted radical treatment is surgical removal of the whole bladder. Some form of reconstruction is then required to drain the urine from the kidneys: several options are available, but only some may be appropriate to an individual patient.

Cystectomy is the name given to bladder removal. It is a major operation with potential problems and can only be performed in relatively fit patients. The likelihood of cure depends on the extent of the cancer, smaller cancers having a better prognosis than more extensive lesions. Thus, 80% of patients with tumour confined to the bladder wall can be cured and 40% of patients with cancer extending outside the bladder can be cured.

Wakefield Hospital
Florence Street
Newtown
Wellington
New Zealand

Postal Address:
Wakefield Urology & Urodynamics
Private Bag 7909
Wellington South 6021
New Zealand

The reconstruction is performed simultaneously:
Ileal conduit: This is the simplest form of diversion, via a stoma into a bag. This works well long-term, most patients get used to it and most are happy with it.
Neo-bladder: The continence structures and urethra are preserved and a new bladder is created out of a bowel segment. Whilst more complicated to perform, this avoids a bag and is preferred where the bladder base is free of tumour. The bowel-bladder does not function quite as well as the natural bladder, most patients needing to wake at night to void, many having to self-catheterise. However, overall satisfaction is higher with neo-bladder than with conduit.

Important early complications that occur with either of the above, include:

• Bleeding requiring transfusion – 20%
• Infection – chest, urine, wound
• DVT, pulmonary embolism and other cardiovascular events
• Death in 3%

Late complications:

• Kidney infections
• Problems with mucus, stones and with the stoma and bags
• Bowel disturbance
• Impotence and sexual disturbance
• Need for revision surgery

Bladder preserving treatment (chemoradiotherapy) for invasive cancer involves a combination of telescopic surgery, chemotherapy and radiotherapy, with cystectomy reserved for patients in whom the cancer continues to grow. Not all patients and not all cancers are suitable for this treatment. In those that are suitable, the cancer-cure rates are similar to the outcomes from cystectomy.

There are different protocols, but most will involve daily treatment over 8 weeks. In half of these patients, the cancers will not respond to chemoradiotherapy. In those that do respond, half will develop tumour recurrence in the preserved bladder. Most responders however end up with a well-functioning bladder.

Important early side-effects include:

• Cystitis
• Diarrhoea and nausea
• Bone marrow toxicity
• Kidney toxicity

And long-term side-effects:

• Radiation damage to bowel and rectum, causing diarrhoea, bleeding and bowel obstruction
• Radiation damage to bladder, requiring cystectomy for symptom control in 2% of patients
• Sexual disturbance
• Non-bladder cancers secondary to the radiation treatment

Where cystectomy is subsequently required after chemoradiotherapy, the procedure is more difficult, neo-bladder is not feasible and the only reconstruction option is ileal conduit.

Wherever possible, prior to radical therapy, we try to identify cancer that has spread to the lymphatics or to other organs. Neither radical surgery nor chemoradiotherapy can cure cancer that has metastasised although some patients will have good responses to and remissions from chemotherapy. CT scan and examination under anaesthetic are the best guides to curability, and help to direct treatment towards cystectomy or chemoradiotherapy.

This fact sheet complements the discussion during your consultation, which will apply your individual circumstances to the above facts.