Bladder Cancer - Frequently Asked Questions (FAQs)

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Who needs a cystectomy?

Any patient with bladder cancer that invades the muscularis propria or true muscle of the bladder, who does not have cancer spread outside the bladder should undergo a cystectomy. Additionally, any patients with a special type of bladder cancer called CIS that continues to re-occur despite BCG or chemicals in the bladder, cystectomy should be performed. Finally, patients who want the best chance for cure should consider cystectomy even if the cancer is not into the true muscle (T2) but is into the layer just above the muscle, but is of high grade (grade 3 T1).

If I need a cystectomy, where should I have it done?

Multiple studies have shown that surgeons who perform complicated procedures are more proficient at them. Complication rates are lower in the hands of surgeons who perform the same procedure more often and survival rates are higher. Most private practice surgeons know this information and send patients who need cystectomies to university hospitals for this reason. At the University of Colorado Hospital, we perform 1-2 cystectomies per week.

My surgeon told me he could do my surgery but that I would have to have a bag afterwards. Is that right?

Older and less experienced surgeons believe an "ileal conduit" (surgery that creates a stoma that drains urine into an external bag) is faster or better or less complicated. Although the surgery to create a new bladder takes about an hour longer than the surgery that leads to a "bag," many studies have found the surgical complication rate is the same. Patients who undergo creation of a new bladder (or neobladder) may have a slightly higher chance of electrolyte imbalances, diarrhea, or dehydration in the first month after surgery. However, the chance the cancer would recur after neobladder formation (in the urethra) is actually less, and of course, one’s body image is more natural! If a patient can tolerate the stress of bladder removal, he/she can certainly tolerate the extra hour of neobladder formation. For additional information on caring for your continent cutaneous diversion (pouch) or neobladder, please click here.

 

Do I need chemotherapy before my cystectomy?

This is a controversial question. A large, randomized trial showed that chemotherapy before cystectomy does improve a patients survival. However, this was a less than 10% difference. Additionally, if a patient has surgery before chemotherapy, if there is no spread of the cancer outside the bladder, chemotherapy is not needed, so if all patients are given chemotherapy before surgery, many are being over-treated with a toxic therapy they probably didn’t need. Additionally, chemotherapy does have a small risk of death associated with it, and, following treatment, some patients are too sick to have surgery.

What is the surgery like?

It takes 2 hours to remove all of the lymph nodes around the bladder, 3 hours to remove the bladder and 2-3 hours to create an ileal conduit or a new bladder. Patients are generally monitored in the ICU or step-down (a little less intense than the ICU) for a night or two following surgery.

How long will I be in the hospital after surgery?

Most patients are in the hospital for a week after surgery. It takes a long time for food to be able to pass through the area that is hooked together after a piece is removed to create a new urinary diversion. There are other tubes and drains that are removed during this time as well. The pain is bearable during this time with a button to push for pain medication as well as catheters near the wound that release medication slowly into the wound.

What are the complications of surgery?

Unfortunately, even in the best of hands, the list is long. First of all, there is a risk of death, that is approximately 1%. This is most often due to heart disease or a blood clot that gets to the lungs. So it is good to get checked out by a cardiologist before the procedure if there is any question about your heart risk. Then, there is a risk of bleeding - most patients require 2 units of blood so they are asked to donate 2 units prior to the procedure so they can get their own blood back. Then there is a risk that where the bowel was taken for whatever type of urinary diversion is necessary that the area where they were hooked together either gets too tight (resulting in nausea/vomiting and need for re-operation) or leaks (both are less than one percent risks) which also require re-operation. There is a chance of infection, which is generally managed with antibiotics or anti-fungals. Then, there is a high risk of problems with erections after the procedure for men and vaginal shortening for women. These conditions can be treated and should be discussed with the surgeon pre-operatively. There is a risk of incontinence following the procedure in almost all patients. After about 6 weeks, a new muscle is generally trained well enough to hold in the urine that does not work as hard prior to the surgery. However, about 10% of patients still leak during the day and 20% of patients leak at night. There are effective treatments for incontinence after cystectomy (artificial sphincters help patients regain continence in most cases). Patients with liver or renal dysfunction may not be candidates for neo-bladders because neobladders re-absorb some of the waste products sent to the bladder by the body. These can change one’s electrolytes (or blood chemistry) and creatinine levels.

What can I do to help prepare for surgery?

Cystectomy is a huge assult on the body and takes a full 3 months to recover from. Anything you can do to prepare your patience, perserverence, and optimism are encouraged. Most patients lose about 30 pounds with the surgery, although it is generally regained 3 months after surgery, so there is no need for most patients to loose weight before surgery. However, the higher one’s protein levels before surgery, the stronger he/she will be while recovering. Smokers should give up cigarettes 2 weeks prior to surgery if possible. This will improve outcomes of the surgery, decrease bladder cancer recurrence rates, and improve the patient’s overall survival rate.

What is my prognosis after surgery?

The prognosis depends on the "stage" of the cancer, or how invasive the cancer is. This is reported about a week after surgery by the pathologist after looking at the bladder under the microscope. If the cancer is confined just to the muscle of the bladder, the 10 year survival is 85%. If the cancer has spread to the fat outside the bladder, or to the prostate/vagina, the 10 year survival is 60%. If it has spread to the lymph nodes outside or the prostate the 10 year survival is 30%. Chemotherapy is generally given to the latter two groups before or after surgery.

What if I got radiation for my bladder cancer and now it is back?

Unfortunately, this is not an uncommon scenario. As long as the cancer has not spread beyond the bladder, the bladder can still be removed, but does require a skilled surgeon. Surgery following radiation is a very difficult ordeal and involves a lot of scar tissue. As long as the small intestine looks healthy, a neobladder can still be created, although the chance of complications after the surgery are greater.

What if my cancer comes back?

When bladder cancer comes back, it usually does so far away from the bladder (in the bones, liver, lungs, or brain). Chemotherapy is given but is not usually curative. This is why one needs to seek aggressive treatment from a competent surgeon as early as possible for invasive bladder cancer.

View general information about Bladder Cancer.