How is Muscle Invasive Bladder Cancer Treated?

A cancer diagnosis can be very frightening. However, your doctor and medical team are there to help you.

Your healthcare team will discuss what you must know about all the available forms of treatment. They will tell you about possible risks and the side effects of treatment on your quality of life.

Options and Choices for Treatment

Your options for treatment will depend on how much your cancer has grown.

There are essentially two options:

  • Bladder removal (cystectomy) with chemotherapy or without chemotherapy 
  • Chemotherapy with radiation

Bladder Removal

Bladder Removal (Cystectomy) Procedures

Neoadjuvant cisplatin-based chemotherapy (NAC)

Bladder removal with chemotherapy increases survival rates for bladder cancer patients. Before removing your bladder, your physician will likely offer neoadjuvant chemotherapy. Adjuvant means, "added to." If you have MIBC, you may get chemotherapy along with having your bladder removed. Before your doctor does a radical cystectomy (removing all of the bladder), he/she may try to shrink your tumor first with neoadjuvant cisplatin-based chemotherapy (NAC). This means the drug cisplatin or a combination of drugs including cisplatin is first given as chemotherapy and then bladder removal is done afterwards.
Adjuvant chemotherapy means the drug is given after surgery. Your doctor may offer this treatment if it is appropriate for you.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. For MIBC, chemotherapy will most likely be given prior to radical (total) cystectomy. As mentioned earlier, neoadjuvant cisplatin-based chemotherapy (NAC) is recommended for treating MIBC.

Drugs are usually given by vein (intravenous). The drugs enter the bloodstream and travel throughout your body.

Typically, doctors offer chemotherapy before bladder removal for best survival rates. However, not everyone is able to have chemotherapy. You may not get chemotherapy if you have poor kidney function, hearing loss, heart problems or other health issues. Some patients may choose not to get chemotherapy before surgery. But, some may still need to have it after surgery depending on the tumor stage. You will probably have your bladder surgery about 6-8 weeks after you have completed chemotherapy.

You may have your chemotherapy treatment in an outpatient part of the hospital, at the doctor's office or at home. Rarely, you may need to stay in the hospital. Chemotherapy is sometimes given in cycles. Each cycle normally has a treatment period followed by a rest period.

There are side effects to chemotherapy. The side effects depend on which drugs are given and how much is given. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells:

  • Blood cells: If chemotherapy drugs lower the levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your healthcare team will check for low levels of blood cells. If your levels are low, you may need to stop the chemotherapy or reduce the dose of the drug. There are also medicines that can help your body make new blood cells.
  • Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back after treatment. However, your hair color and texture may be different.
  • Cells that line the digestive system: Chemotherapy can cause a poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Your healthcare team can give you medicines and suggest other ways to help with these problems. Symptoms usually go away when treatment ends. 
  • Nerve cells: Some drugs used for bladder cancer may cause tingling or numbness in your hands and feet. Your healthcare team can suggest ways to control these side effects.

Surgery to Remove the Bladder (Cystectomy)

For MIBC, because the cancer has grown into the muscle, cystectomy will be needed. Part of or the whole bladder may be removed. As mentioned, before your bladder is removed you will most likely be given neoadjuvant cisplatin-based chemotherapy.

Layers of the Bladder
Layers of the bladderPelvic node dissection for bladder cancer

Bladder cancer can spread to the lymph nodes. A pelvic lymph node dissection is used to find out if the cancer has spread beyond the bladder into the lymph nodes. A pelvic lymph node dissection is considered standard of care. Standard of care means that this is the usual treatment for this condition. For a pelvic lymph node dissection, lymph nodes (the fatty tissue surrounding the pelvic blood vessels) are removed. A pelvic lymph node dissection may also be done to treat cancer if it is only in the lymph nodes.

What happens during surgery?

Your bladder can be removed by an open or a robotic approach. It is called "robotic" because computers assist the surgeon during the procedure. In the open approach, the doctor makes one larger incision in the middle of the abdomen to remove the bladder. Open surgery may have a shorter operative time.

For the robotic process, a few smaller incisions are made in the abdomen. Your surgeon puts small instruments through the openings to reach the bladder. Often people have less pain and less blood loss with robotic surgery.

There are several things to think about before choosing open or robotic bladder removal:

  • Your body weight 
  • History of prior surgery 
  • History of prior radiation
  • Where to go for surgery: there is some evidence that complex surgery (such as bladder removal) has better outcomes when performed at Centers of Excellence facilities rather than hospitals, etc.
  • Surgeon's experience: ask your surgeon about his/her familiarity with this type of operation. If you have concerns, get a second opinion.

 Radical Cystectomy (removal of the whole bladder)

For MIBC, the most common type of surgery is radical cystectomy. The surgeon removes the entire bladder, nearby lymph nodes and part of the urethra. In men, the surgeon also may remove the prostate. In females, the surgeon may remove the uterus, fallopian tubes, ovaries and vaginal wall. Other nearby tissues may also be removed.

When the entire bladder is removed, the surgeon makes another way for urine to be collected from the kidneys and stored before passing from your body. This is called urinary diversion. Your doctor will discuss the risks of cystectomy and the different methods of urinary diversion.

Partial Cystectomy (removal of part of the bladder)

For MIBC, partial cystectomy is a less likely option as the cancer may be more advanced. Partial cystectomy may be considered in select cases of bladder cancer, in which the tumor is located in a specific part of the bladder and does not involve more than one spot in the bladder. Ask your surgeon whether you are a candidate for this type of surgery.

Bladder removal and urinary diversion

When your bladder is removed or partly removed, your urine will be stored and made to leave your body by a different route. If you have a radical cystectomy, you will need to know about urinary diversion options.

Because the surgeon uses tissue from your intestines for bladder reconstruction, you must have enough bowel tissue for a urinary diversion. Before this is done, your surgeon will go over the procedure. Your doctor will talk about what will be done and the changes you will need to make.

Here are some of the urinary diversion options your surgeon may offer:

  • Ileal conduit. An ileal conduit is when a piece of your upper intestine is used it to create an opening (stoma) on the surface of your stomach. The ureters are connected so that the urine leaves your body by the opening. A bag will be attached to collect the urine and you will "dump" the bag several times a day. This is the most simple, and most commonly used diversion after bladder surgery. 
  • Continent cutaneous reservoir. Your surgeon creates a pouch inside your body and you will learn to use a catheter to remove your urine.
  • Orthotopic neobladder. The surgeon creates an internal pouch, much like your bladder, to store urine. Your ureters are connected to this new "bladder" and you are able to empty through your urethra the same way you did before surgery.

In some instances you may need to use a catheter to remove the urine.

Talk with your doctor about your options for a urinary diversion. Having a urinary diversion will greatly impact your quality of life. 

For more information on urinary diversion visit our Urinary Diversion article .

Chemotherapy with radiation

Bladder Preservation

Chemotherapy with radiation may be used for bladder preservation (keeping the bladder or parts of it). Bladder preservation may be suggested for select patients where radical cystectomy is not an option or is undesired. The right health circumstances must be present for bladder preservation.

Your surgeon will cut the tumor out (transurethral resection of bladder tumor, TURBT), remove lymph nodes, as well as give you chemotherapy and radiation. This is called a multi-modal approach (several methods). Some drugs that may be used along with radiation are cis-platin, 5-FU and Mitomycin-C. This regimen must be carefully followed up with ongoing cystoscopy exams, cross-sectional imaging (e.g. CT scan) and other procedures to monitor and evaluate the tumor.

For about 30% of patients who use the multi-modal approach to bladder preservation, MIBC will return. It is important for you to have close monitoring by your healthcare team in case the tumor progresses and cystectomy becomes needed.
Radiation alone for MIBC is not an option for controlling the spread of bladder tumors. However, radiation may be offered along with bladder removal.

Radiation therapy

Radiation as a single form of treatment is not given for MIBC. It is usually done along with chemotherapy and after surgery.Radiation therapy uses high-energy rays to kill cancer cells.

The radiation comes from a large machine. The machine aims beams of radiation at the bladder area in the abdomen. You may go to a hospital or clinic five days a week for several weeks to get radiation therapy. Each treatment session takes about 30 minutes. 

Radiation therapy is painless, but it may cause other side effects. Problems with radiation include nausea, vomiting or diarrhea. Also, you may feel very tired during radiation therapy. Your healthcare team can suggest ways to treat or control these side effects.