Surgery Surgery is the main treatment modality for bladder cancer with limited stage. Transurethral resection of bladder tumor (TURBT) is preferred for superficial (non-muscle invasive) bladder cancer, and different postoperative intravesical bladder infusion chemotherapy or immunotherapy regimens are used depending on the specific tumor stage and pathological grading. or immunotherapy regimens depending on the specific tumor stage and pathological grade. Radical cystectomy is preferred for muscle-invasive bladder cancer, and systemic chemotherapy can be selectively used preoperatively and postoperatively to improve the outcome. For some patients with invasive bladder cancer who are unable to undergo radical surgery or have the desire to preserve the bladder, a bladder-preserving combination of endoluminal surgery, radiotherapy and systemic chemotherapy can be used. For metastatic bladder cancer (including lymph node metastasis), systemic chemotherapy is the only way to prolong the patient’s survival. Surgery, radiotherapy or arterial interventions only have palliative effects such as hemostasis and pain relief to improve the patient’s quality of life.
TURBT is Transurethral Resection of Bladder Tumor (TURBT). It is a minimally invasive procedure with no incision on the body surface and patients recover quickly after surgery. It requires a special type of cystoscope capable of removing bladder tumors called an electrosurgery. It is inserted through the same route as the cystoscope, through the external urethra. The mirror has an electrosurgical ring that is able to retract back and forth so that when an electric current is passed through it, the ring cuts the tissue and also cauterizes the tissue to stop the bleeding. After the electrodes are removed, the excised pieces of tissue can be flushed out from inside the bladder. This tissue is then sent to a pathologist to determine under a microscope if it is cancerous. It usually takes several days for the pathologist to examine these tissues.
Transurethral laser treatment is similar to TURBT in that the laser vaporizes the tissue, has some penetration depth and coagulation, bleeds minimally, sometimes eliminates the need for a postoperative catheter, has a low incidence of intraoperative bladder perforation and has no closed nerve reflex. Commonly used lasers are Nd:YAG (neodymium-yttrium aluminum garnet) laser, Ho:YAG (holmium-yttrium aluminum garnet) laser. Photodynamic therapy (PDT) is to inject photosensitive substance through intravenous, which can selectively reach the lagging tumor, and to irradiate the bladder mucosa with special wavelength of light through cystoscope into optical fiber, which can produce direct destructive effect on tumor, and at the same time destroy blood vessels and produce immune effect, especially for in situ cancer and recurrent tumor. However, the above treatment modalities still do not exceed TURBT in terms of overall effect. Radical cystectomy for bladder cancer is a radical cystectomy, which is an operation to remove the entire bladder in 3 steps: (1) removal of the diseased bladder (2) clearance of lymph nodes (3) creation of a new urinary storage sac. In men, the prostate, vesicourethral gland and part of the vas deferens are usually removed; in women, the uterus, cervix and part of the vagina are removed and the ovaries can be selectively preserved. In women, the uterus, cervix and part of the vagina are removed.
The body will still produce urine after cystectomy. Therefore, the best approach is to replace the original bladder with an artificial one. However, so far, all artificial materials soaked in urine for a long time form stones and cannot really be used in patients. The only way is to use the patient’s own organ. Currently urologists have successfully used the small intestine, large intestine and stomach to replace the bladder. For most patients who have not received radiation therapy, a small section of the ileum is the best replacement for the bladder. Because the large intestine is relatively unaffected by radiation therapy, patients who have received prior radiation therapy can choose a segment of the large intestine as a replacement.
Currently, most urologists will allow patients undergoing radical bladder cancer surgery to choose one of the following three methods of urinary diversion
1. Ileal cystectomy: The simplest method of urinary diversion. It uses a section of ileum as the output tract to drain urine through the skin to the outside of the body and then collects the urine through a stoma bag. The ureter is anastomosed at the proximal end of the ileal output tract, while the distal end of the ileal output tract is sutured to the skin of the abdominal wall to form a papilla. The nipple is covered with a stoma bag to collect the outflow of urine, and the patient only needs to empty the bag periodically every 4-6 hours. Patients wearing an ostomy bag are not affected in any way by wearing clothes and no one can tell you are wearing an ostomy bag. After a short period of adaptation, almost all patients can live a normal life as before.
2. Controlled urinary diversion: It also uses a section of ileum instead of the bladder, but the difference is that with this method, the patient does not have to wear an ostomy bag, and the urine formed in the body is first diverted into a storage sac made of ileum, which is connected to the skin of the abdominal wall through a long, thin tube. The output tract made of intestinal tubing has an opening in the skin surface of the abdominal wall the size of a rubber eraser. Patients undergoing this procedure only need to have a catheter inserted through the papillae of the skin of the output tract several times a day to drain urine from the urinary bladder. This procedure is a bit more complicated than the first method, and patients need to carry a catheter with them. However, it also has the obvious advantage that the patient does not have to wear an ostomy bag. It is important to note that if the storage bladder does not drain the urine in time, then too much urine may accumulate and even trigger the rupture of the storage bladder.
3.Neobladder surgery: It is the most complicated one, and this surgery basically allows the patient to return to normal urinary function before surgery. Like the above two procedures, it replaces the bladder with a section of ileum, but the length of the intestine is longer, about 50 cm to 60 cm. As with controlled urinary diversion, the surgeon first uses the intestine to make a urinary bladder that can store urine, and then implants the ureters on both sides of the bladder. Next, the capsule is not attached to the skin of the abdominal wall through the output tract, but is anastomosed directly to the urethral stump, which allows the patient to urinate through the original urethra as before the bladder was removed. The advantages of this procedure are clear, but not all patients are suitable for this approach. The new bladder, unlike the original normal bladder, does not have a forcing muscle and the patient must learn to contract the abdominal wall muscles to increase the pressure in the new bladder and urinate. The muscles that control urination in the new bladder are weak, so some patients may experience urinary incontinence after surgery, although they can mostly return to normal after 2-3 months through pelvic floor muscle lifting exercises.
Partial cystectomy is suitable for limited muscle invasive bladder cancer, and the tumor location is favorable for a certain range of resection, and the possibility of in situ cancer should be excluded before surgery. Some non-muscle invasive bladder cancers that are not suitable for TURBT in terms of size and location, tumors within the bladder diverticulum, and tumors located around the ureteral opening are also amenable to partial cystectomy. However, this procedure is not a radical surgery, does not achieve optimal tumor control, and may lead to postoperative tumor incisional implantation, and is now less commonly used, with less than 5% of patients suitable for this procedure. For patients with invasive bladder cancer, radical cystectomy should be chosen as long as it is tolerated.
Comprehensive treatment Bladder preservation is any treatment that attempts to preserve the bladder of patients with muscle-invasive bladder cancer from total cystectomy. Bladder preservation is treated in a variety of ways, the vast majority of which are based on a combination of chemotherapy and radiation combined with transurethral resection of the bladder tumor. In the past, researchers have attempted radiation or chemotherapy alone, but the results have been unsatisfactory. Combining radiation, chemotherapy and surgery can save patients from having their entire bladder removed. Despite the success of current research, the standard treatment for muscle-invasive bladder cancer is still radical cystectomy, or radical cystectomy. If the lesion cannot be completely removed, chemoradiotherapy may be considered postoperatively. Only about 40% of patients who opt for bladder-preserving treatment ultimately succeed in preserving their bladders.
Drug therapy Urothelial carcinoma of the bladder is more sensitive to chemotherapy. Early stage non-muscle invasive bladder cancer can be treated with intrathecal chemotherapy or immunotherapy after transurethral surgery to reduce the recurrence rate after surgery and to slow tumor progression. For muscle-invasive bladder cancer in the limited stage, chemotherapy is used before and after radical surgery to achieve downstaging, improve surgical resection rate and prolong survival. In addition, systemic chemotherapy in the comprehensive treatment of preserved bladder can not only kill micro metastases, but also increase the sensitivity of radiotherapy. In advanced metastatic bladder cancer, systemic chemotherapy is the only treatment that can prolong patient survival. Therefore, chemotherapy has an indispensable place in the treatment of patients with bladder cancer of different stages and grades.