Bladder Cancer Treatment – Transurethral Resection, Radical Cystectomy and Non-Surgical Methods.
The most common method used for bladder cancer treatment in early stage bladder cancer is called transurethral resection. This is endoscopic, also known as ‘bloodless’ surgical method in which from the urethra it is penetrated into the bladder. Then the entire tumor formation together with a portion of the bladder wall is cut. Transurethral resection is the gold standard in the treatment of tumors of the bladder.
Tumors of the bladder have two types of growth – towards the interior (lumen) of the bladder, where it is expanded like a cauliflower or to the muscles of the bladder, where it begins to cover the layers of the bladder wall, which reaches the venous vessels with a larger caliber and the risk development of metastases is high. In the early stages, bladder cancer is suitable for transurethral resection. Transurethral resection is impossible in stages when the cancer has reached deep into the muscle wall and then the treatment is surgical removal of the entire bladder – known as cystectomy.
Bladder Cancer Treatment
Transurethral resection is performed with a special instrument called resectoscope. It is equipped with an optical system that enables the surgeon to see increased tenfold and detailed image, a light source and loop resection.
Removal of the tumor is performed successively into smaller pieces; similar to the trimming bush while gradually comes to its base. It is a mistake to cut the entire tumor from the base as it begins to move freely in the lumen of the bladder and can not be evacuated. The base of the tumor in the bladder wall is cut and sent for examination separately from the rest of the material because it is important to determine whether the tumor is sprout deep or is found only in the lining. This is important for making plans for further treatment and prognosis. Around the base of the tumor is performed coagulation electricity, which aims to reduce late (postoperative) bleeding and on the other hand to reduce the chance of relapse.
After completion of transurethral resection, there often is local (inside bladder) chemotherapy, i.e. the bladder is inserted with a special medicament – a cytostatic, which destroy any remaining cancer cells. This is done under a special scheme for several weeks. Following contol cystoscopies are made on every three months because despite good operating technique of the surgeon tumors have a 50-70% chance of recurrence within the first year. After this period, cystoscopy may be made on every six months.
In case the bladder cancer is entered deep into the muscles, endoscopic (transurethral) therapy does not provide the necessary radicalism and requires complete removal of the entire bladder which is the second method for bladder cancer treatment. It is known as radical cystectomy.
According to the latest standards cystectomy is held in proving of carcinoma, especially in cases of recurrence of such cancer, even without having to sprout muscles.
Cystectomy or bladder removal surgery is one of the largest and most complex operations in urology and represents complete removal of the bladder. It is performed through an incision in the lower abdomen. The operation can be divided into two parts that follow one after the other:
1. Removal of the membranes – cystectomy, which are generally carried out in the same way in all patients
2. The discharge of urine out of the body – derivation of urine. Methods for subsequent derivation of urine are dozens, each of them has its own indications and contraindications, but they are not the subject of this article. Very briefly, we will try to introduce readers to some of the basic principles and types of derivations:
– Displaying the ureters to the skin – ureteral are displayed on the skin directly or stitched into the intestinal segment that is displayed on the skin. In both cases, the urine is collected outside the body in a special bag.
– Insertion of the ureters in particular composed of intestine tank, which is connected with colon (urine goes out through the anus) or brought to the skin. In both cases, the urine is collected in the special tanks created in the body.
– Plastic building of “new” bladder of bowel segment – called orthotopic bladder or for short – neo bladder. The new bladder is constructed in place of the removed bladder and connects to the ureter from the kidney and coming from a urethra. It is possible physiological operation allowing an optimal standard of living for the patient, with the proviso that it may be applied at relatively early cases of bladder cancer and the absence of germination of the urethra.
The decision on the type derivation shall be taken individually, after discussion and conversation between the patient and urologist tailored to the specific situation and not least of options available in the clinic. Although cystectomy is kind crippled operation it is currently the only option for patients with advanced bladder cancer or those with proven G3 recurrent cancer.
Partial resection of the bladder
In this operation, instead of removing the entire bladder, it is cut only a part of it, in the area around the tumor. Although almost rejected by the new European standards, it is – a little less traumatizing, being compared to radical cystectomy and has its own, albeit very limited, evidence – old age and – a little malignancy, tumor in the diverticulum, etc.
In bladder cancer treatment, in addition to surgical treatment, in combination or separately there may be used other non-surgical methods:
1. Intravesical chemotherapy
According to the “rules of art” transurethral resection is a method that radically could remove Ta and T1 tumors. Notwithstanding the operational approach, these tumors often recur or progress to muscle-invasive stage. High variability and high relapse rate after transurethral resection testified that resection alone is not always sufficient and require further chemotherapy in these patients. It is performed by periodically inserting into the bladder of chemotherapeutic which stand on average about 1 hour, then is peed out.
The two main drugs that are used in practice are Mitomycin – at a lower risk cases and immunotherapy with Bacillus Calmette-Guérin (BCG) – at a higher risk cases.
The mechanism of action of the two types of drugs is different, but the goal is one – destroying of potentially missed during transurethral resection small tumor formations, which in consequence may develop recurrence. In essence Mitomycin is chemotherapy, which kills cancer cells while BCG is a powerful immune stimulator that activates the immune system, which in turn destroys cancer cells.
2. Systemic chemotherapy
Besides from local chemotherapy in patients after radical cystectomy or positive lymph nodes without the presence of distant metastases can be held and systemic (intravenous) chemotherapy, but still under discussion, because data from clinical studies is lacking evidence in favor of routine and use.
Radiation therapy may be an alternative bladder cancer treatment for patients with advanced muscle-invasive stage of bladder cancer, which is not appropriate for surgical treatment (cystectomy). Also, radiation therapy may be administered in order to stop bleeding in patients with invasive tumors in which this can be achieved by transurethral manipulation.