Advanced cancer that calls for aggressive treatment
When bladder removal is recommended, patients have options
BY AMBER SMITH
Bladder cancer is considered advanced when the cancer invades the muscle.
In these cases, patients may face removal of the bladder in order to treat the cancer.
“If you don’t do something aggressive, such as remove the bladder, most of the time the cancer will spread,” explains urologic oncologist Joseph Jacob, MD. “Almost 100 percent of the time, the cancer will spread into the bloodstream and the lymph nodes. And then at that point, there’s no cure for the patient.”
It may sound extreme, but removing the bladder can be lifesaving. The procedure is called a cystectomy.
The kidneys ﬁlter blood and create urine. Tubes called ureters carry the urine to the bladder. If that organ is removed, Jacob says, most patients have three options:
-- A urinary conduit, called a urostomy. In this procedure, surgeons turn a small segment of the patient’s small bowel into a pipe that carries urine from the kidneys out through a new opening in the skin, into a bag. The patient would periodically empty the bag.
“This is the most common approach because it’s the most straightforward,” Jacob says. “But it may not be the most appealing to patients.”
-- A neobladder, or bladder replacement. This makes use of a slightly longer segment of small bowel.
“I tell patients we do some origami work. Basically, we fold this into a sphere, and then you connect that bladder back to the urethra. Then the patient would learn how to urinate like they’re used to urinating.”
-- A continent urinary reservoir, known as an Indiana pouch. Surgeons form a pouch using part of the colon, with a natural valve. Urine collects in the pouch. To empty it, the patient uses a cathether, or tube, from a small opening in the side of the abdomen.
These are all major operations. Jacob says most patients remain hospitalized afterward for at least three days, and it takes a month or two to recover from surgery.
-- Bladder preservation. Some patients who oppose bladder removal opt for treatment that includes a combination of radiation and chemotherapy, Jacob says. He adds that studies of bladder preservation have shown about 70 percent of patients are able to keep their bladders, but about a third require bladder removal after radiation and chemotherapy.
Jacob helps patients decide which option is best for their situations. “I try to ﬁnd out what their priorities are, what their goals are.”
If urinating normally is most important to a young man, for instance, the neobladder might work best. For a young woman who wants to avoid a bag, the Indiana pouch opening can be covered with a small bandage. Someone who is concerned about how well they will do in a lengthy operation may be more suited for bladder preservation. A person who wants deﬁnitive treatment may choose the straightforward urostomy.
Regardless of which option a patient wants, Jacob says it’s important to select an experienced surgeon at a center of excellence where many patients with bladder cancer are cared for. “You need someone who understands all the nuances and the little setbacks that can come up and will be able to deal with them.”
Question: What’s the most common symptom of bladder cancer?
Answer: Blood in the urine.
Kidney stones, urinary tract infections and other conditions can cause blood in the urine, but so can bladder cancer. The blood may appear pink, red or cola-colored, and it usually is not painful. Some medications and foods, including beets and red berries, can discolor the urine.
Your primary care provider may be able to identify the cause of blood in your urine – or refer you to a urologist.