Globally, the incidence of bladder cancer is located in the ninth place of malignant tumors, with about 330,000 new cases and 130,000 annual deaths. Muscle invasive bladder cancer accounts for about 30%. Currently, the gold standard for the treatment of invasive bladder cancer is radical total cystectomy. With the improvement of urinary diversion techniques and neuroprotection techniques, radical cystotomy has been further promoted, and the overall 5-year survival rate of MIBC patients undergoing radical cystotomy can now reach 66%. 1.What is invasive bladder cancer Usually, invasive bladder cancer refers to bladder cancer with infiltration depth reaching the muscular layer of the bladder or above. According to the TNM staging of AJCC in 2002, which includes bladder tumors of stage T2-T4, it accounts for about 20% of all bladder tumors diagnosed for the first time, and about 15%-20% of non-muscular invasive bladder cancers diagnosed at the beginning of the diagnosis will be progressed to invasive bladder cancer. 2.Treatment methods of invasive bladder cancer Firstly, radical cystectomy with lymph node dissection, and neoadjuvant systemic chemotherapy can be carried out before surgery, which can reduce the recurrence rate and improve the survival period. The decision of whether to perform total urethrectomy should be based on the margin of the specimen. The choice of urinary diversion should be fully communicated with the patients, informing them of the various surgical methods of urinary diversion and their advantages and disadvantages. Emphasis should be placed on protecting renal function and improving the patient’s quality of life. In situ neobladder surgery has a higher quality of life and can be recommended for patients with indications in medical centers where available. Ileal cystectomy has relatively few complications and is one of the preferred modalities of urinary diversion. Ureteral skin stoma is indicated in patients of advanced age, poor general condition, inability to eradicate tumors, and inability to use the bowel. Surgery for bladder preservation under special circumstances should be carefully selected, and should be supplemented with radiotherapy and chemotherapy, and closely followed up. 3.Why should invasive bladder cancer cut off the bladder completely Invasive bladder cancer, is a lethal disease, if the treatment is not timely or correct, few people can escape from the death trap set up by this devil. When the invasion of bladder cancer has not gone beyond the bladder (i.e. confined to the bladder), radical cystectomy and urinary diversion surgery can cure most (70%-80%) of the patients. If radical treatment is not available in time and the tumor invades outside the bladder or metastasizes to distant places before radical cystectomy is performed, the surgical effect will be very poor, and most of the patients will still die of recurrence or metastasis of bladder cancer after surgery, especially for bladder cancer with distant metastasis, no matter how the treatment is given, the average survival time is only about 12, and less than 10 percent of the patients have a good response to the treatment, and they can be lucky to live for more than 5 years. 4. Extent of lymph node dissection About 25% of patients undergoing cystectomy already have pathologic lymph node metastases. Several large-sample radical cystectomy studies routinely removed 7-14 lymph nodes and reported 5-year survival rates of 57%-69% in organ-confined, lymph node-negative patients and 25%-35% in extravesical infiltrating, lymph node-positive patients. 5.How to choose a good urologist for cystectomy patients ①Professional: choose a urologist who specializes in oncology, they are professional and have more experience in diagnosis and treatment. ② Ability: choose a knowledgeable and capable doctor who can skillfully apply this knowledge to your diagnosis and treatment process. Skill: Radical cystectomy for bladder cancer is difficult and time-consuming, so choose a doctor who often performs this surgery, as the saying goes, “Practice makes perfect”. Sympathy: When it comes to cancer, a lot of people are scared and creeped out by the word “cancer”. You need a doctor who understands your fears and concerns, who can help you make decisions about treatment and ease your worries. But how that choice is made is sometimes a matter of intuition. 6. For patients with invasive bladder cancer, why preserve the bladder Since the standard treatment for invasive bladder cancer is total bladder removal and urinary diversion, why should we still consider the treatment of preserving the bladder? The bladder is an organ responsible for storing and emptying urine, and no other human tissue or organ can replace its function. No matter what kind of urinary diversion (ileocecal bladder, in situ bladder), it will be accompanied by certain complications (infection, fluid retention, urinary retention, electrolyte disorders, acid-base imbalance, etc.). No matter what kind of diversion method is used, it will be accompanied by a decrease in the quality of life (stoma care, regular urination, blood tests, etc.), and the dignity of the human being will be affected, so that only when you lose the ability to urinate, you will miss the days when you could urinate normally. ④. Regardless of the technique used, the vast majority of patients after radical cystectomy affect sexual function. ⑤. Radical cystectomy is a major surgery with more complex techniques and more postoperative complications, which not all patients can tolerate. It is based on the above unfavorable considerations that the treatment of bladder preservation for progressive bladder cancer has recently emerged internationally. No single approach has been shown to achieve similar efficacy in tumor control as radical total cystectomy. A “sandwich” of systemic chemotherapy, pelvic radiotherapy with TURBT to the plasma membrane, or partial cystectomy may be the best treatment option to achieve optimal tumor control, but specific treatment plans are still being explored. Currently, bladder preservation therapy for invasive bladder cancer patients is only applicable to patients who are physically unable to tolerate radical surgery, or who voluntarily participate in a well-justified clinical trial, or who are unwilling to undergo radical cystectomy after being fully informed of their condition. 7, Neoadjuvant chemotherapy Neoadjuvant chemotherapy is mainly applied to surgically treatable T2-4a tumors, and is aimed at treating micrometastatic lesions that are already present at the time of diagnosis. This is particularly important for patients with muscle-invasive bladder tumors, as half of the patients with muscle-invasive bladder tumors have pre-existing occult micrometastases. Advantages are better evaluation of tumor responsiveness to chemotherapy, good tolerability, and reduced tumor load prior to surgery. Disadvantages are that neoadjuvant chemotherapy may delay the timing of surgical treatment, there is chemotherapy-related toxicity, and neoadjuvant chemotherapy is based on clinical staging, which is subject to error. The improvement of survival with neoadjuvant chemotherapy remains controversial. Postoperative adjuvant chemotherapy For postoperative adjuvant chemotherapy for bladder cancer, due to the lack of large-scale randomized prospective controlled clinical studies and the conflicting conclusions of some of the corresponding clinical studies, it cannot be confirmed that adjuvant chemotherapy can delay recurrence or prolong survival at this stage. It is usually believed that for bladder cancer patients with pathological stage of T2 and below and without lymph node metastasis, the risk of recurrence is low and postoperative adjuvant chemotherapy is not recommended. As for patients with pathological stage of T3 and above, or lymph node metastasis, due to their high risk of recurrence, it has been confirmed that postoperative adjuvant chemotherapy for this group of high-risk patients can reduce the mortality rate by 30%, therefore, if this group of patients do not receive neoadjuvant chemotherapy before surgery, postoperative adjuvant chemotherapy is usually recommended, and the evidence of the recommendation is level 2B. 9.Systemic chemotherapy for bladder cancer Bladder tumor is a systemic disease, and surgery is only a local treatment, so systemic chemotherapy is necessary for muscle invasive bladder cancer and some patients with high grade. Systemic chemotherapy is an important method of adjuvant treatment after surgery for bladder cancer, and even some patients have to undergo systemic chemotherapy before radical surgery. The more commonly used clinical programs include: bladder cancer is more sensitive to cisplatin-containing chemotherapy program, with the total effective rate of 40%-75%; methotrexate, vincristine, epirubicin combined with cisplatin program. 10.Side effects of systemic chemotherapy (1) Myelosuppression Myelosuppression is the main side effect of systemic chemotherapy, which can be anemia, decreased white blood cells and thrombocytopenia. (2) Gastrointestinal reactions Mild liver transaminase abnormalities in about 2/3 of patients, and nausea and vomiting reactions in about 1/3 of patients. (3) Allergy Rash in about 25% of patients and pruritus in 10%. (4) Mild proteinuria and hematuria 11. How to reduce the side effects brought by systemic chemotherapy (1) Blood routine and liver and kidney functions should be closely monitored during chemotherapy (2) If white blood cells and platelets are reduced, leukocyte-raising drugs and platelet-raising drugs can be given. (3) Liver and kidney protection treatment should be given during chemotherapy (4) Gastric protection and antiemetic treatment should be given during chemotherapy (5) Drinking water should be given during chemotherapy (6) Nutrition should be paid attention to during chemotherapy In a word, side effects brought by chemotherapy are inevitable. However, by actively cooperating with doctor’s treatment, the occurrence of side effects can be effectively reduced and a better quality of life can be maintained. Radiotherapy Radiotherapy for bladder cancer mainly includes radical radiotherapy, preoperative radiotherapy and postoperative radiotherapy. Patients receiving radical radiotherapy should have sufficient bladder capacity without urethral stricture and urinary incontinence. There are no randomized controlled clinical trials comparing the efficacy of radical radiotherapy as well as radical resection surgery. The largest clinical study of preoperative radiotherapy to date showed pathologic downstaging in 40%-65% of patients, tumor control rates of 10%-42%, a 5-year overall survival rate of 44%, and pelvic and distant recurrence rates of 16% and 43%, respectively. The major disadvantage of postoperative radiotherapy is the late development of severe gastrointestinal complications in 20%-40% of patients. Postoperative radiotherapy is appropriate for patients with high risk of recurrence and may prevent local and distant recurrence rates. Immunotherapy The progress of bladder cancer treatment mainly focuses on PD-1/PD-L1 monoclonal antibody immunotherapy. PD-L1 monoclonal antibody has been approved for the second-line treatment of better-stage bladder cancer, and PD-1 monoclonal antibody, which has been “shining” in other tumors, has also received preliminary data from clinical studies on uroepithelial carcinoma of the bladder, expecting more clinical data on immunotherapy. Atezolizumab, as the first PD-L1 monoclonal antibody approved for the second-line treatment of advanced bladder cancer, has been hailed as a breakthrough in the treatment of advanced bladder cancer in the past 30 years, and while achieving a breakthrough in the second-line treatment, we all pin our hopes on whether PD-L1 monoclonal antibody can be successful in the first-line stage of treatment. In a study published in the journal Nature, scientists at Queen Mary University of London achieved a major breakthrough in the treatment of advanced bladder cancer. 68 patients with advanced bladder cancer were treated with MPDL3280A, a cancer immunotherapy drug developed by Roche, for 12 weeks, and the tumors shrank in 52% of the PD-L1-positive patients. Subsequent treatments revealed no more signs of cancer on radiologic imaging tests in 2 of them. 14.What are the postoperative health care for bladder cancer (1) Patients with preserved bladder should have cystoscopy review every 3 months for 2 years after surgery, and change to every 6 months for those who have no recurrence within 2 years. Other optional reviews include: urine exfoliative cytology, intravenous urography, routine urinalysis, ultrasound and CT. (2) Daily care and health care of patients undergoing ileal access surgery: Because the patient’s urine flows out of the ileostomy in the abdominal wall, a urine collector needs to be permanently placed. The urine collector consists of two parts: the sump and the urine bag. Generally, the sump is replaced once every few days and the urine bag is replaced once every 1~2 days. Nursing care should pay attention to: ① permanent skin fistula should protect the skin around the fistula port, daily cleaning and disinfection, topical zinc oxide ointment, etc.; ② found that the urine has flocculent mucus, you can drink more water, and oral baking soda tablets, so that the urine alkalinization, mucus thinning, in order to facilitate the smooth flow of urination; ③ 2 years after the operation, a comprehensive review of every three months, two years after every six months, a review of every six months; ④ pay attention to urinary retrograde infections If sudden high fever occurs, it is also necessary to go to the hospital in time; ⑤ If bloody secretion appears in the urethra, it should be alert to the possibility of residual or occurrence of urethral tumor, and come to the hospital in time for consultation. (3) Daily care and health care for patients with in situ ileocecal substitute bladder: Since urine is still discharged from the original penile urethra, in order to prevent urinary incontinence, one should do muscle training to exercise the perineum and pelvic floor muscles, 30 times for 1 group, and complete 30 groups every day. Initially, you should urinate once every 2 hours, sit to urinate, relax the pelvic floor muscles, add abdominal pressure, each time you urinate to ensure that the urine is drained, the night alarm clock should be used every 2 hours to wake up, urinate on time. 3 to 6 months later gradually extend the interval between urination for 3 to 4 hours, change to standing urination, drink 2 to 3 liters of water every day, eat more salt as appropriate. Within 6 months after surgery, check liver and kidney function and electrolytes every 1~2 weeks to prevent electrolyte balance disorder. Comprehensive recheck every 3 months for 2 years after surgery.