Bladder Cancer: Surgery
You have to be healthy for surgery to be an option for you. Before surgery, you'll meet with your surgeon, who is an urologist. This is a doctor who specializes in problems with the urinary tract, including the bladder. In this meeting, you’ll talk about the details of the type of surgery to be done, what, if any, other organs may need to be removed, and how you’ll pass urine after surgery. You'll also be able to ask questions and address concerns you may have. You may want to ask about the possible short- and long-term side effects of the surgery and risks. You may also want to ask your healthcare provider when you can expect to return to your normal activities. You may want to ask where the scars will be and what they’ll look like.
The surgeon will ask if you’re taking medicines. This is to make sure you're not taking medicines that could affect the surgery. After you’ve talked about all the details with the surgeon, you’ll sign a consent form that says he or she can do the surgery.
Your healthcare team will review the surgical options for your condition. To help deal with the information and remember all of your questions, it’s helpful to bring a family member or close friend with you to checkups. You should also bring a written list of concerns. This will make it easier for you to remember your questions.
You may also want to consider getting a second opinion before starting any treatment. Certain health insurance companies require a second opinion in some cases. According to the American Cancer Society, it’s very rare that the time it will take to get a second opinion will have a negative impact on your treatment. The peace of mind a second opinion gives you may be well worth the effort.
Types of bladder cancer surgery
Your healthcare provider will use the stage of your cancer to help decide the type of surgery you should have. There are several types of surgery for bladder cancer.
Transurethral Resection (TUR)
In this surgery, all of the cancer in your bladder is removed. This type of surgery may be done if your cancer is only in the lining of the bladder (superficial) and a grade I or II.
This may also be called transurethral bladder resection (TURBT).You stay in the hospital for this surgery. After you get to the operating room, you'll be given anesthesia to prevent pain. You may get a local anesthesia. This keeps you from feeling what is going on while you’re still awake. Or you may have a general anesthesia. This puts you to sleep and keeps you from feeling pain. You won't need to have any cuts, or incisions, to get this treatment. This is because it's done using a special tool called a cystoscope.
The cystoscope is a thin, lighted tube. Your healthcare provider puts it through your urethra (the tube that carries urine out of your body) up into your bladder. Using the cystoscope, your healthcare provider looks at the inside of your bladder, usually on a computer monitor. If he or she sees bladder cancer, he or she will use a special tiny attachment at the end of the cystoscope to cut out the tumor. After the cancer has been taken out, the area may be burned. Or your healthcare provider may use a laser to kill any cancer cells that may be left behind.
You may be able to go home the same day, or you may stay in the hospital 1 to 2 days after TUR. A soft tube (catheter) is left in your urethra after the procedure. The tube prevents blockage of your urethra. It also helps stop bleeding and gives your bladder time to heal. Your healthcare provider will remove the catheter when the bleeding stops. Your bladder will then work the way it did before surgery.
You may feel the need to urinate more often when the tube is removed. You may feel a little pain when you urinate. There may also be blood or even clots in your urine. These problems are normal and go away after a day or two. Call your healthcare provider if there's a lot of pain or bleeding, or if the pain or bleeding doesn't get better within a day or two.
There's a good chance that you won't have any cancer left after TUR. But you'll still need to see your healthcare provider every 3 to 6 months. Superficial bladder cancer often comes back. In some cases, TUR may be followed by some type of intravesical therapy. This treatment, such as chemotherapy or immunotherapy, is put right into your bladder. In follow-up visits, your healthcare provider will look at the inside of your bladder with a cystoscope. This procedure is called a cystoscopy. For it, your healthcare provider uses a similar thin, lighted tube that was used for the TUR. It's put into your bladder through your urethra. You’ll also give urine samples for testing. This is done to make sure the cancer doesn't come back or to find it early if it does.
This surgery may be done if your cancer has a grade higher than II. Or it may be done if your cancer has spread to tissue beneath lining of the bladder, but is small and only in one place. In this case, only the part of the bladder with the cancer is removed.
This type of surgery is not often possible. But you may have it if a small tumor has invaded the muscle layer of your bladder, and the cancer is only in one place.
You’ll receive general anesthesia. This puts you to sleep and keeps you from feeling pain. A cut (incision) is made in the skin of your lower abdomen. Then your healthcare provider takes out the cancer and nearby bladder wall. Your lymph nodes may be removed, too. In some cases, this surgery is done through small cuts instead of one big one. A long, thin tube with camera (laparoscope) is put in one cut. Then your healthcare provider puts special tools in the other cuts to do the surgery. This is called laparoscopic surgery. After the cancer is removed, your healthcare provider will close the hole in your bladder wall with stitches. After healing, the bladder works like it did before surgery. But the bladder is smaller, so it may not hold as much urine. A concern with this surgery is that the cancer may come back in another part of your bladder.
This means all of your bladder is taken out during surgery. You may need this if your cancer has a grade higher than II or has spread to tissue beneath lining of the bladder, and is large or in more than one part of the bladder. When all the bladder is removed, you’ll need reconstructive surgeryto create a new path for urine to leave your body. You’ll only have one surgery at one time.
In men, the prostate gland and seminal vesicles are also removed. This is because the cancer can come back in these areas. In women, the uterus, fallopian tubes, ovaries, cervix, and the top of the vagina may need to be removed. Your healthcare provider will talk to you about which organs may need to be taken out. He or she will also talk to you about side effects.
You’ll stay in the hospital for about a week for this surgery. In the operating room, you’ll receive general anesthesia. This puts you to sleep and keeps you from feeling pain. A cut will be made in your lower abdomen. In some cases, the surgery may be done laparoscopically. Your surgeon must create a new way for urine to leave your body. So, right after radical cystectomy, you’ll have bladder reconstruction.
Reconstructive bladder surgery
There are many ways to rebuild a "bladder" after it’s been removed to treat cancer. Urine made by your kidneys will need to be stored and moved out of your body in a new way. This is called reconstructive surgery. Your surgeon does reconstructive surgery at the same time that you have your bladder removed. There are 2 main types of reconstructive surgery.
Incontinent urinary diversion
This is also called an urostomy. After this type of surgery, you no longer urinate the way you once did. You’ll wear a bag on the outside of your body to collect urine.
Continent urinary diversion
This surgery creates a new bladder for you. This way, you can control when the urine leaves your body and do not have to wear a bag. There are 2 main types of this surgery. One type is cutaneous continent diversion. This requires that urine be drained though a hole in your abdomen. This is called a stoma. This is done with a catheter, several times a day. The other type is orthotopic neobladder. This is the creation of a new bladder that’s emptied through your urethra the same way you did before surgery.
Incontinent urinary diversion or urostomy
This procedure is also called an ileal conduit. To do it, your healthcare provider makes a pouch out of a small piece of your intestine. Then, he or she connects it to your ureters. These are the tubes carrying urine out of your kidneys. The opening of the pouch is connected with your skin to direct urine through a stoma. Urine passes out of the opening into a plastic bag that’s attached to your skin. You then empty urine from the bag several times a day.
After the operation, urine will constantly flow through the ileal conduit into the external pouch. Right after surgery, a drainage tube from the ileal conduit will come out through stoma. This tube may be in place for 2 to 3 weeks after surgery. Your surgeon may take X-rays to check how well your bladder has healed. He or she will also make sure there isn't leakage before taking out the drainage tube.
Once the tube is removed, you'll use an adhesive patch to hold a plastic pouch to your skin over the stoma. When the pouch is full, you empty the urine through a valve at the bottom of it. You’ll need to change the pouch every 3 to 5 days. A special nurse (enterostomal nurse) will help watch your care when you've had a urostomy. The nurse will teach you how to keep the urine bag, catheter, or abdominal opening clean. The nurse will also give you advice on lifestyle issues, such as having sex or cleaning your urine bag at work.
Continent urinary diversion
During surgery, your healthcare provider takes a piece of your intestine and connects it to your ureters. This is done to make a new path for your urine to flow. The pouch made from the intestine is directed to a stoma. Your surgeon then creates a one-way valve that allows you to drain the pouch several times a day. You do this by inserting a catheter through the stoma. The catheter drains urine out of the pouch into a container. You can then dispose of the urine in the toilet. Many people prefer this approach because they don't need to wear a urine collection bag on the outside of their body.
After the operation, urine will flow through the ureters into the pouch inside your body. The pouch will hold about a pint of urine a few months after the operation, but will hold more urine as time goes by. You’ll learn to recognize the sensation when the pouch is getting full of urine. Then you’ll pass a catheter into the stoma to let the urine out. For a few weeks after the surgery, you'll likely need to drain the pouch every few hours. As the pouch stretches, you will probably empty it every 4 to 6 hours.
An enterostomal nurse will help teach you how to care for the stoma and use a catheter to get the urine out. The nurse will also give you advice on lifestyle issues, such as having sex or emptying your diversion at work.
This surgery may also be called orthotopic continent urinary reconstruction. You can only have it if your urethra was not removed during the surgery.
Your surgeon takes out a piece of your intestine and creates a pouch to hold urine. The pouch is called a neobladder or new bladder. It’s attached directly to your ureters and to your urethra. With this approach, you can pass urine through your urethra, just as you did before the surgery. Compared with other reconstructive surgeries, this type is most like your normal urinary system. Many people who have a neobladder say they feel the same urge to urinate as they did before surgery. It may take you awhile, though, to learn the sensations that mean you need to urinate. Right after surgery, you’ll have a catheter to drain out urine as your body heals. Urine control does not come right away after your catheter is taken out. You’ll learn the routine you should follow to help train your new bladder.
The ability to control urination during the day is better than 90% with a neobladder. Your ability to control urine flow at night may not be quite as good, especially in the first 6 to 9 months after surgery. You may be able to manage the problem by drinking less before bedtime. Men may also want to talk with their healthcare providers about a condom catheter. This attaches to the penis like a condom and connects to a tube that collects urine in a bag.
Recovering at home
Make sure you know how to take care of yourself after surgery and are able to manage the way you have to get urine out of your body. Also be sure you have supplies and know where to get more. It may help to have someone learn along with you, so you have a helper and support person at home.
When you get home, you may get back to light activity. But you should avoid strenuous activity for 6 weeks. Your healthcare team will tell you what kinds of activities are safe for you while you heal.
When to call your healthcare provider
Let your healthcare provider know right away if you have any of these problems after surgery:
Redness, swelling, or fluid leaking from the incision site
Irritation, redness, or swelling around the stoma
Damage or injury to the stoma
A blockage of urine flow
The physical and emotional changes from your cancer surgery may be significant. Ask your healthcare team for resources that will help you and your family manage the physical effects of cancer treatment, and also the mental and emotional changes.
Call your healthcare provider or stoma nurse if you have any problems. Know what to do and have a number to call if you have problems or questions after hours or on weekends or holidays.
March 21, 2017
Levin, Mark, MD,Stump-Sutliff, Kim, RN, MSN, AOCNS