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How is Non-muscle Invasive Bladder Cancer Treated?

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

Talk with your healthcare team 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.

Your options for treatment will depend on how much your cancer has grown. Your urologist will stage and grade your cancer and assess the best way to manage your care considering your risk. Risks are classified as low, intermediate or high and suggests the likelihood of tumor recurrence and/or progression. Treatment also depends on your general health and age.

 Options and Choices for Treatment

Treatments for non-muscle invasive bladder cancer include:

  • Cystoscopic resection of the tumor
  • Intravesical immunotherapy 
  • Intravesical chemotherapy

If these options fail to treat your cancer, your doctor may recommend removing the complete bladder.

Cystoscopic tumor resection

During a tumor resection, your doctor will remove any cancer cells that can be seen at transurethral resection of bladder tumor (TURBT).

TURBT

Transurethral resection of bladder tumor (TURBT) is usually done under anesthesia. The surgery is done during cystoscopy, so there is no cutting into the abdomen. You will be given general or spinal anesthesia.

A rigid cystoscope is what your doctor will use for this procedure. This scope is straight and does not bend. It has a light at the end and is bigger and allows surgical instruments to pass through it. Your doctor is able to see inside the bladder, take tumor samples and resect (cut away) the tumor.

If a tumor is clearly seen, the doctor will attempt to remove it all. The doctor may also remove very small samples of other areas of the bladder that may look abnormal. These samples will also be checked for grade and stage. You may be left with a Foley catheter in your bladder after this procedure to allow your bladder to heal.

You may need to have your tumor resectioned more than once. During your follow-up examinations your doctor will check to make sure all the cancer is removed. 

Intravesical Therapy

What to expect from Intravesical Therapy

Intravesical ("within the bladder") therapy, is when a treatment drug is put directly into your bladder. The drug is put into the bladder with the help of a catheter (a thin tube that is placed through the urethra). You will hold the drug in your bladder for one to two hours and then pass it out. Intravesical chemotherapy is usually given immediately after surgery.

Catheters used in intravesical therapy
Catheters used in intravesical therapy

Intravesical Immunotherapy Immunotherapy

Immunotherapy is a treatment that boosts the ability of your immune system to fight the cancer. Bacillus Calmette-Guerin (BCG) is the immunotherapy drug that is used for bladder cancer. BCG also has been used as a tuberculosis vaccine.

Your BCG therapy will probably last about six weeks for the first course. It is usually done in your doctor's office, not in the hospital or operating room. You may get BCG treatment more than once.

The BCG drug is inserted into the bladder through a catheter. The therapy triggers the immune system to attack bladder cancer cells. It is one of the most effective treatments for bladder cancer, especially carcinoma in situ (CIS). It is not recommended if you have a weak immune system or certain symptoms. Side effects can include:

  • Urinating often
  • Pain when urinating
  • Flu-like symptoms
  • Joint pain 
  • Fever or chills
  • Bacteria infecting whole body (less common)

Intravesical Chemotherapy

Intravesical chemotherapy is usually given immediately after surgery. With intravesical chemotherapy, drugs that are known to kill cancer cells are placed directly into the bladder, not in the bloodstream. As a result, many common side effects of chemotherapy - like hair loss - can be avoided. Because the drugs only reach the bladder lining, this type of treatment is only recommended for NMIBC.

Mitomycin C is the most common chemotherapy drug used for intravesical therapy. It is usually given after the initial TURBT. It helps stop cancer cells from going to another place and growing. It also reduces the recurrence rates. It can also be given as a six-week induction course similar to BCG. Common side effects include:

  • The need to urinate often
  • Painful urination
  • Flu-like symptoms 
  • Skin rash

Repeat Intravesical Therapy

Some patients may respond to repeat therapy if the cancer returns. If you have high-grade Ta or T1 cancer or CIS, or you tried BCG and it did not work, you may need something else to control the cancer. In this case, you should talk to your doctor about surgery to remove the bladder.

Maintenance Intravesical Therapy

After the bladder is free of disease, your doctor may suggest more treatment with the same drugs to keep the tumor from coming back. This may happen at the first three-month appointment after treatment.

Maintenance therapy is a good choice for people who have had BCG, less so for those who have had chemotherapy drugs. It is given for up to three years after treatment, and generally about every six months for three weeks at a time.

Your doctor will talk to you about whether you are a candidate for maintenance therapy. He/she will also talk about whether intravesical chemotherapy or BCG are good options for you.

Removing the bladder

Surgery to Remove the Bladder

If you have NMIBC, you may have to remove your bladder if intravesical BCG therapy fails. You may also need to remove it if you are at a greater risk of getting the cancer again or of it spreading. Cystectomy is being recommended more and more for tumors that are high-grade T1, T1+CIS (carcinoma in situ) and T1+LVI (lymphovascular invasion)

Male and Female Bladder and Urethra
Male and Female Bladder and Urethra

Partial Cystectomy(removal of part of the bladder)

Partial cystectomy is a good choice for some patients if the tumor is located in a specific part of the bladder and does not involve more than one spot in the bladder. The surgeon removes the tumor, the part of the bladder containing the tumor, and nearby lymph nodes. After part of the bladder is removed, you may not be able to hold as much urine in your bladder as before surgery. You may need to empty your bladder more often.

Radical Cystectomy(removal of the whole bladder)

For NMIBC, radical cystectomy is usually done if other therapies fail. The surgeon removes the entire bladder, nearby lymph nodes, and part of the urethra. In men, he/she may remove the prostate as well. In women, the surgeon may remove the uterus, ovaries, fallopian tubes, and part of the vagina. Other nearby tissues may also be removed.

Urinary diversion after bladder removal

When your bladder is removed or partly removed, your urine will be stored and made to leave your body by a different route. This is called urinary diversion. 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 sufficient bowel tissue for them to create your urinary diversion method. Before this is done, your surgeon will explain the procedure to you so that you can understand what will be done and the adjustments you will need to make. Here are some of the urinary diversion options your surgeon may offer:

  • Ileal conduit: To make an ileal conduit, the surgeon will take a piece of your upper intestine and use it to create an opening (stoma) on the surface of your abdomen. 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 the urine. 
  • Orthotopic neobladder: Your 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 the 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.