When bladder cancer means bladder removal: surgical options

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Treatment for some advanced bladder cancers may include surgical removal of the bladder. Today I'm talking with urologist, Dr. Joe Jacob, about options. We'll cover bladder replacement, urinary reservoirs, and possible ways of preserving the bladder. Dr. Jacob is director of the bladder cancer program at Upstate. I thank you for making time for this talk, Dr. Jacob.

Joseph Jacob, MD: Thank you so much for having me.

Host Amber Smith: Now, I want to be clear that most people with bladder cancer can be treated without facing the removal of their bladder. Is that right?

Joseph Jacob, MD: That's correct. So 70% of the time -- which is something that we're happy about -- this'll be a superficial or a non-muscle invasive bladder cancer. So 70% of the time we can manage patient's bladders with scraping, endoscopic procedures, which are camera procedures where we look in and we can do some work through camera. And a lot of times we'll do bladder treatments. We call them intravesical treatments. So these are treatments that we give patients into their bladder, through a catheter.

Host Amber Smith: So there's 30% that may face an issue with the bladder possibly needing to be removed, is that right?

Joseph Jacob, MD: That's correct.

Host Amber Smith: What are the reasons for that? Why would a bladder need to be removed?

Joseph Jacob, MD: When the bladder cancer invades into the muscle, it has a very high chance of spreading outside the bladder. And at that point it can become very dangerous for the patient. So when you have muscle invasive bladder cancer, so very important, so there's a big distinction between non-muscle invasive bladder cancer and muscle invasive bladder cancer. So when patients have muscle invasive bladder cancer, if you don't do something aggressive, such as remove the bladder, most of the time, this will spread. Almost hundred percent of the time this will spread into the bloodstream and the lymph nodes. And then at that point, there's no cure for the patient.

Host Amber Smith: This muscle invasive bladder cancer, does it affect men and women equally?

Joseph Jacob, MD: No, sorry guys. Again, this is more common in men. But it does happen in women. And one of the important things to understand with women is, a lot of times, women present at later stages because they just are thinking that it's a UTI or their bladder symptoms are just part of, quote unquote, being a woman. And unfortunately they're diagnosed later than men are.

Host Amber Smith: So symptoms of a urinary tract infection.... do those sometime get mistaken as bladder cancer and vice versa?

Joseph Jacob, MD: Yes. Yes, exactly. And so the most common way we pick up bladder cancers is when people have blood in their urine. And so you can imagine, a woman sees blood in her urine and says, "oh, it must just be a UTI." Or even, someone that they see, some kind of provider that they see say, "Hey, take some antibiotics. You know, the most common thing would be UTI." And, possibly, bladder cancer could be missed.

Host Amber Smith: So let's go over, what are the symptoms that are most alarming? You mentioned blood in the urine. Is that the main symptom that you shouldn't ignore?

Joseph Jacob, MD: That's the main reason why people present to a urologist, and that would be the most common way that we pick up bladder cancers. The other way would be people that come in with symptoms, whether it be pain or discomfort, and we would sometimes look in with a camera. So the way to diagnose this would be someone comes in with blood in the urine. And then we would obtain a CT scan and do what's called cystoscopy, which is taking a camera and looking inside the bladder.

Host Amber Smith: So let me ask you, the cystoscopy, is that how you find out whether it's muscle invasive or not?

Joseph Jacob, MD: It is. Cystoscopy means just looking in, and then we would do biopsies with the guidance of the camera. And based on the biopsy, we send everything to the pathologist, and so the pathologic report would tell us, is this in the muscle or not in the muscle?

Host Amber Smith: You're listening to The Informed Patient podcast from Upstate Medical University in Syracuse, New York. I'm your host, Amber Smith, talking with Dr. Joe Jacob. He's a urologist and director of the bladder cancer program at Upstate. So let me ask you about the options, the typical options, for someone who has muscle-invasive bladder cancer. And if you've got to talk to them about removing the bladder, what sorts of options might a person have?

Joseph Jacob, MD: The most standard of care treatment is removal of the bladder, which we call a cystectomy. There are other options as well, but the most definitive treatment for patients would be the removal of the bladder. So what happens is for a man, the bladder is removed. The prostate's also removed. A lymph nodes are also removed. So once you remove the bladder, obviously you gotta figure out where does the urine go? So the kidney filters the blood and creates urine. And these kidney tubes called ureters that take urine down toward the bladder. So once you remove the bladder, you're going to figure out, what do you do with the urine?

And so there's three different options that patients have after removal of the bladder. The most common option would be what's called a urinary conduit, or a urostomy. And that's sort of similar to what it sounds, you know, conduit or a pipe. It's a small piece of small bowel, of ilium, that we turn into a pipe where it just sends urine from the kidneys right out to the skin. And then this gets collected with a stoma bag or stoma appliance. So this bag fills up with urine. When the bag fills up, you unscrew the valve and you dump the urine in the toilet, and then you go on with your day. The reason why this is the most common approach is, it's the most straightforward, it's the easiest one to sort of take care of. But it may not be the most appealing to patients from like a quality of life standpoint or an appearance or aesthetic standpoint.

Host Amber Smith: So what are the alternatives to a urinary conduit?

Joseph Jacob, MD: So one other option is called a neobladder, or a bladder replacement. And you would take more small bowel, or ilium, so just a little bit more than you would for a conduit. And I tell patients we do some origami work, but basically you're folding this bladder into a sphere. And then you connect that bladder back to the urethra, and the patient would learn how to urinate like they're used to urinating. So a guy would urinate from their penis, and a woman would urinate from the urethra or vagina.

Host Amber Smith: Interesting. Now what you've described, taking the patient's small bowel and reformatting it in some way, those sound like very extensive surgeries.

Joseph Jacob, MD: They are. This is one of the bigger surgeries that patients can receive. And you sorta want to optimize patients before, just because it's such a big surgery. I mean, they stay in the hospital for at least three days. It takes about a month or two, really, to recover from these surgeries. So you want to do the surgery, obviously, with someone you trust, but also in a center of excellence where they're used to doing a lot of these surgeries. A lot of times little issues here and there come up or, you just need someone that has experience or facility that has experience dealing with these, we call them little bumps in the road or little setbacks that can happen after such big surgery, just to get you through the first couple months.

Host Amber Smith: Does every patient who says, "well, I'd like the neobladder option," are they all candidates for that? Or are there specific things that you look for to determine whether it's going to be a success for that particular person?

Joseph Jacob, MD: That's a great question. Really it's a patient decision. There's a couple of rare things that would disqualify someone from having a neobladder. So if there's a lot of cancer near the urethra, and we have to remove the urethra, then obviously you can't, really connect the neobladder if there's no, if there's no urethra. So that would be one rare thing. And then one thing that could also happen that's rare is sometimes the blood supply to the bowel is so tight that it doesn't reach down to the pelvis, down to where you need to get it to. But most of the time, if the patient wants to have that kind of surgery, then we can get it done for them.

Host Amber Smith: Once the person recovers from a surgery like this, how long is this bladder going to function? Is it meant to last the rest of their lifetime?

Joseph Jacob, MD: It is. So as long as you take care of it, and we help patients do that. That's another thing. You can do the surgery but you also need someone that's experienced, in a facility that's experienced, that has resources to help you manage the bladder, to help, to teach you how to take care of it and to follow you and to make sure that you're surveyed properly, so that we can ensure that this is going to last the rest of your life.

Now, the other option is called an Indiana pouch, or a continent urinary reservoir. And that's similar to the neobladder except you take the right colon, and you use part of the ileocecal valve. So a lot of complicated words, but basically you're taking part of the colon, and there's a natural valve where the small bowel enters the colon so that stool doesn't go backwards into the small bowel. We use that natural valve, and so we form a pouch out of the colon, and then we use a catheterizable channel with that valve so that when patients want to empty this, they catheterize this channel, we call it. And that's the way you empty it. And so the nice thing about that is you're not using a stoma. We call it a continent diversion, so there's not always urine pouring out that has to be collected into a bag. The way you drain this is you catheterize this via small opening in the side of your abdomen, a small opening in the skin.

Host Amber Smith: It sounds like there would be a lot of education that would come with how to live with these bladder alternatives afterwards.

Joseph Jacob, MD: Definitely. You need someone that understands all the nuances and all the different things that can come up, all the little setbacks that can come up and be able to deal with them. But in general, if the patient wants that kind of procedure and is willing to work at it and learn, we can get them there and make it work for them. Everyone has different priorities in their life and so for example, younger men, a lot of times they don't want to deal with a stoma, and they want to be able to feel like they're peeing sort of normally. So neobladder would be common in younger men. Younger females, again, aesthetically may not want to deal with a stoma bag. So the Indiana pouch may be a little bit more popular with them because there's not a lot that you can, you can see on the outside, you can cover the opening up with just a small little Bandaid or a little piece of tape and a lot of times you can hide this opening in different areas. And they want to be dry, so this valve allows patients to be dry. And then when they're ready, they catheterize it to empty the urine.

Host Amber Smith: So for these bladder alternatives, if the muscle invasive bladder cancer has already spread by the time you diagnose it, are these options for patients still available?

Joseph Jacob, MD: So in general, when we remove the bladder, we're trying to cure patients. So we're trying to prevent patients from having spread of disease. And so if someone already has spread of disease, usually they're not going to be a good candidate for removal of the bladder. To put someone through such a major operation, and probably it's not going to help them from a cancer standpoint, and you would delay them from getting the treatment that they need to get like systemic therapy or chemotherapy or immunotherapy. So usually if the bladder cancer has spread, then you're probably looking at mainly treatment with chemotherapy and immunotherapy.

Host Amber Smith: I was going to ask you to explain the possibility of bladder preservation. Are there other treatments for someone who has advanced bladder cancer, are there other procedures that you can recommend if someone really is against bladder removal?

Joseph Jacob, MD: Definitely. Definitely. We talk to patients about all their options and again, a lot of these options have been studied very well, so we have good data. Bladder preservation is a term used to describe patients that have muscle invasive bladder cancer and they, instead of getting their bladder removed, they get radiation with chemotherapy. And so it's a combination of radiation and chemotherapy. And patients can do very well with this. The reason why maybe a removal of the bladder is a little bit more common is because removal of the bladder is more definitive. But that doesn't mean that bladder preservation is a bad option. Patients just have to know what they're getting into. So when you do radiation to the bladder with chemotherapy someone like myself, a urologist, would have to continue to really look at the bladder closely, do the camera procedures pretty often, do biopsies every once in a while just to make sure that the bladder cancer is not coming back.

So if you look at some of the big trials that were done for bladder preservation, about 70% of the patients were able to keep their bladders, but about one third of the patients did require removal of the bladder after the radiation. So, for some patients it was great for them. For some patients, unfortunately, they had to have their bladder removed anyways, after the procedure.

Host Amber Smith: Do you advise patients that they can try the chemo and radiation and have the bladder removal as a backup plan, so to speak?

Joseph Jacob, MD: So I give them their options, and I try to find out what their priorities are, what their goals are, if they're the type of patient that wants something definitive and just wants to get it over with, then maybe removal of the bladder is a better option for them. If they're the type of patient that is very averse to radical surgery, or sometimes patients may be worried about how they're going to do in a long operation, so, they may be a better candidate for bladder preservation.

Host Amber Smith: Well, I really appreciate you taking the time to explain all of this.

Joseph Jacob, MD: I appreciate you having me.

Host Amber Smith: My guest has been urologic oncologist, Dr. Joe Jacob, director of the bladder cancer program at Upstate. The Informed Patient is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York. Find our archive of previous episodes at upstate.edu/Informed. I'm your host, Amber Smith, thanking you for listening.