Whether it’s the earliest stages of bladder cancer or the more advanced stages, surgery is used in almost all treatments of this disease. Skilled surgeons are able to remove just a tiny portion of the diseased organ or the whole urinary bladder itself, creating a new urine-collection system out of other body tissues. For many, these kinds of radical treatments are lifesavers from a disease that’s known to lurk undetected in the body for years.
Bladder cancer is the fifth most common type of cancer in the United States and is highly treatable in its earliest stages. But, sadly, most bladder cancers are not caught early because the symptoms are relatively benign — bloody urine, painful urination and back pain. Sometimes these symptoms come and go, which may lead patients to ignore them.
Patients who have taken Actos for Type 2 diabetes will want to be extra vigilant about watching for symptoms of bladder cancer. That’s because several studies have shown that long-term Actos use increases the risk of developing bladder cancer.
What is the Bladder?
To understand bladder cancer surgery, it’s important to first understand the bladder itself. The bladder is a hollow, muscular and balloon-shaped organ that is about the size of an adult fist. In men, it’s located in front of the prostate, and in women it is between the vagina and the uterus. The two tubes called the ureters take waste from the kidneys to the bladder. From the bladder, urine is expelled from the body through the urethra. Because of its muscular structure, the bladder is designed to expand and contract. At full expansion, an adult bladder can hold up to two cups of urine.
|The bladder is made up of three primary layers:|
|The innermost layer, called the mucosa, where most bladder cancers start.|
|The submucosa, which contains the elastic fibers that help the bladder expand and contract.|
|The outer layer, which is covered with connective tissue.|
Types of Bladder Cancer Surgery
An estimated 73,000 men and women in the United States will be diagnosed with bladder cancer in 2012, and another 15,000 will die of the disease this year.
For 90 percent of people who are diagnosed with this disease, the cancer is localized and has not invaded the muscle. That makes treatment for bladder cancer highly successful. For these patients, the surgical options for are not as invasive or severe. However, this type of superficial cancer is known to recur.
For the remaining 10 percent of patients, the surgical procedures tend to be more drastic. Invasive bladder cancer, as it is called, is known to spread to nearby organs and lymph nodes. Depending on the stage of the disease, doctors perform surgery to either remove some of the damaged tissue or the whole organ.
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Transurethral Resection of Bladder Tumor (TURBT)
Transurethral bladder resection, also called a TURBT or TBR, is the standard treatment for non-invasive bladder cancers. It is the most common and effective treatment of early-stage bladder cancer. The main instrument used in this procedure is a resectoscope, a telescoping instrument that combines a camera, light and a surgical wire loop so the surgeon can visualize and burn off non-invasive tumors and tissue. Sometimes, a cystoscope is used instead. This flexible device has an outer tube-like sheath with a light and camera. The interior of the tube is hollow, so surgical instruments can be used to remove tumors or tissue.
|Both instruments — the resectoscope and the cystoscope — are inserted through the urethra into the bladder.|
|Preoperative medications — The preparation for the TURBT surgery begins a week before the procedure. Doctors require patients to stop all aspirin, aspirin-containing medications, nonsteroidal anti-inflammatory medications (NSAID) and blood thinners. These medications are known to cause uncontrollable bleeding and should be avoided for a week before and after surgery.|
|Preoperative preparation — Before the surgery, patients must undergo bowel cleansing, which includes multiple enemas and laxative medications. Patients cannot eat or drink anything except clear liquids within eight hours of surgery.|
|Surgical preparation and anesthesia — Since this surgery is typically done as an outpatient procedure and under general anesthesia or a spinal nerve block, patients will be allowed to go home following the surgery unless there are complications. If general anesthesia is used, an anesthesiologist will administer the drug via a facemask, which renders the patient unconscious and unaware of the procedure. If a nerve block is used, an anesthesiologist will introduce a fine needle into the spinal nerve. This ensures the patient will not feel pain but will remain awake. Also, an IV will be put in place to administer medications. Once the patient is sedated, the anesthesiologist and an assistant will locate the obturator nerve, which passes from the pelvic area to the upper thigh. A local anesthetic will be injected into the nerve to prevent involuntary nerve reflexes and leg jerking during the surgery.|
|Surgical tools – A surgical technologist will prepare a tray of instruments to be used for the surgery. This includes a resectoscope or cytoscope, a variety of resection loops that will be used to remove the tumor, catheters, biopsy forceps and marking pins.|
|Surgery — In both men and women, a lubricant is used at the urethral opening to ensure the instruments move easily. Then, sterile fluid is passed into the bladder through a catheter, which is a flexible, sterile tube, to inflate the organ and make it easier for the surgeon to see the bladder walls. The resectoscope, or cystoscope, is inserted through the urethra and into the bladder. Surgeons then use the instrument to view the inside of the bladder on a nearby video monitor. To visualize the whole bladder on the monitor, surgeons press down on the lower abdomen or raise the operating table. Once a tumor is identified, the surgeon uses the instrument’s cauterization ability to burn off the tissue. The tumor is then pulled out through the urethra onto a sterile gauze piece. An assistant pierces the tumor with a marking pin to identify the top or bottom of the tissue and places in a formaldehyde solution for further testing. Surgeons also burn off multiple tissue layers surrounding the tumor, including the muscular layer of the bladder, to ensure all of the cancer is removed. In some cases, biopsies of other areas of the bladder are taken to ensure there is no residual cancer. Once the surgery is completed, a catheter is again inserted into the bladder to drain urine and fluids and ensure loose tissue does not block the urethra. In all, the surgery takes about 30 minutes.|
|Postoperative care — Following several hours of observation, patients are typically permitted to go home. Depending on the severity of the bleeding, some go home with a catheter in place. When the bleeding stops, the catheter is removed. Once home, patients are given prescription antibiotics and a mild pain reliever. They are told to rest for several weeks.|
A major surgical procedure called a cystectomy is used on patients with advanced-stage bladder cancer, including cancer that has spread into the bladder walls. This is also used in recurring superficial bladder cancers.
|The two types of cystectomy — partial and radical — are performed either through a traditional abdominal incision or by using minimally invasive robotic techniques or laparoscopic surgery.|
|Preoperative procedures — Much like the TURBT procedure, patients must stop all blood thinners and other medications that may encourage bleeding. Also, in the days before the surgery, the patient’s diet will be restricted to clear liquids. The patient must also use an enema and other means to ensure the bowels have been emptied. Often, patients are instructed to begin antibiotics prior to the procedure. Since this procedure is performed in a hospital and a multi-day stay is required, it is important follow all of the hospital’s pre-admission requirements.|
|Surgical preparation and anesthesia — The night before or the morning of the surgery, patients are required to take a shower using a medical-grade antibacterial soap. This removes excess bacteria from the skin. Patients are typically given continuous epidural (spinal) anesthetic and a general anesthesia simultaneously during the procedure.|
|Surgical tools – For the partial and radical cystectomy, the instruments that are used differ slightly, including scalpels, needle, ports and laparoscopic tools, if needed.|
In a partial cystectomy, also called a segmental cystectomy, surgeons remove the diseased portion of the bladder. This procedure is mainly used in a select group of patients with normally functioning bladders and one tumor. It is often followed by radiation or chemotherapy.
In a traditional surgical procedure for a partial cystectomy, the anesthetized patient lays face up on the operating table with a sterile surgical cloth covering most of the body. A catheter is placed in the bladder to remove urine. Using a scalpel, the surgeon cuts a vertical abdominal incision from the belly button to just above the pubic bone, and the bladder is exposed. At this point, some surrounding lymph nodes may be removed for further testing.
The surgeon then cuts open the bladder to check for the cancer damage. Then, the surgeon uses the scalpel to cut away the section of the bladder wall that contains the tumor and sews together the remaining bladder. The organ is filled with a saline solution to check for leaks. A drainage tube is placed in a separate incision in the pelvis to pull excess fluids from the body; it is later removed.
In laparoscopic and robotic-assisted partial cystectomies, the same general process as open surgery is used to cut away and remove the diseased portion of the bladder, but the surgeon’s hands never enter the patient’s body. Instead, the abdomen is inflated with carbon dioxide gas to create a space between the abdominal wall and the organs. For laparoscopic surgery, a surgeon uses two long-handled instruments and inserts them into the body through two small incisions. The excised piece of bladder is removed through one of those incisions. The use of laparoscopic tools is known to have a limited range for the surgeon.
For robotic surgery, four 2-inch incisions are made across the abdomen and four robotic arms perform the surgery. The surgeon directs the robot from a nearby computer console and video monitor. It is known to closely mimic a surgeon’s movements.
A radical cystectomy, which is used in the most invasive bladder cancer cases, removes the entire bladder and some surrounding tissue. In men, the bladder, seminal vesicles, vas deferens, prostate and nearby lymph nodes are removed.
In women, the procedure includes removing the bladder, ovaries, fallopian tubes and part of the vagina, as well as affected lymph nodes.
In the past, the only option following complete bladder removal was a stoma — a surgically created opening on the right side of the body where urine is expelled — and an external urine-collection bag. Today, reconstructive measures are in place to utilize existing organs to replace the bladder. The three most popular urinary diversions are the neobladder, continent diversion and ileal conduit.
|For these procedures, surgeons follow the same surgical method as with the partial cystectomy, but remove the whole bladder and create a urinary diversion system.|
|For the neobladder, a 2-foot segment of the end section of the small intestine, called the ileum, is removed and used to create a new bladder. To make this, surgeons remove the piece of intestine, cut the tube open, lay it flat and then sew it into a pouch form. It is then attached to the existing ureters and urethra. Urine will expel through the normal channels.|
|The continent diversion procedure is used in patients who have had their urethra removed. While the surgery is performed in much the same way as the neobladder, the urine-collection pouch must be emptied through a stoma and a catheter that is inserted four to six times a day.|
|For some patients, the ileal conduit procedure is the best option. For this, the existing ureters are grafted to a 6- to 8-inch section of the ileal bowel. One end of the bowel is sewn shut, while the other end is attached to a stoma. The urine drains into an urine-collection bag, also called an ostomy bag, which is worn under clothing. While the neobladder and continent diversion surgeries can take up to six hours, the ileal conduit takes about three, making it a better choice for older or sickly patients.|
|Postoperative care — Following all three surgical procedures, patients are advised not to lift anything heavy or drive for several weeks. Patients who undergo traditional surgery must remain hospitalized for several days to several weeks, while those who undergo minimally invasive procedures typically go home after a one-night stay.|