Surgery For Bladder Cancer
Bela Denes (Urologist) gives expert video advice on: Why is bladder cancer more expensive to treat than other cancers?; Can I live without my bladder? and more...
What is transurethral resection surgery?
Transurethral resection refers to approaching the bladder through the urethra. This is done using a special set of instruments that not only have the ability to examine the bladder, but have the ability to operate within the bladder. Most patients with bladder cancer present with superficial, low risk or intermediate risk tumor, so the tumors are confined to the bladder. The bladder is relatively easily reachable through a variety of instrument scopes. Today, we have got great instruments that are able to reach virtually any and all areas of the bladder, and by going through the urethra, or transurethrally, we avoid making any kind of incisions, therefore recovery is quick, and without any real subsequent functional impairment of the bladder.
What is a 'cystectomy'?
Cystectomy is the surgical term, or the medical term, that refers to the removal of the bladder. Patients generally do not present with bladder cancer that requires cystectomy, but patients who do have rapidly recurrent tumors, progressive tumors, tumors that are muscle invasive – in other words, clearly show a high degree of malignant potential, metastatic potential – will be advised to have cystectomy as a curative procedure.
What is a 'segmental cystectomy'?
A segmental cystectomy refers to just removing a segment of the bladder. A segmental cystectomy is attractive because it spares the bladder, and once the bladder is healed, the patient can go on and urinate through his natural bladder function. Although bladder capacity may be transiently compromised, the bladder recovers relatively quickly. A segmental cystectomy, however, is only recommended for a highly selected group of patients with bladder cancer. These are patients who present with a solitary bladder cancer, generally, that is localized to an area of the bladder where it is easily resectable. There are areas of the bladder that are not amenable to segmental cystectomy, for instance where the ureters come in. Single lesions, localized lesions, primarily in the top part of the bladder that's referred to as the dome - those patients may be offered a segmental or a partial cystectomy.
What is a 'radical cystectomy'?
Radical cystectomy is cystectomy done for cancer. It is a major surgery, and it will take more than a month to recover after the surgery. It is different for males and females. For males, it is the cancer in the prostate gland - cystectomy is done in the gland for men. For women, it is in the uterus - the cancer is found in the uterus for females, and the cystectomy is done in uterus.
What is a 'urostomy'?
A urostomy, traditionally, has been formed by hooking the uretors that drain the kidneys into a small segment of the terminal ileum, which is the portion of the small intestine right before the appendix. A small segment of that small intestine is isolated. The bowel is then hooked back together, and bowel function continues normally. That small portion is then washed extensively, the uretors are sewn into it, and one end of it is brought out, usually below the belt line on one side or the other, so that some sort of collection device can be applied to it to collect the urine.
Why is bladder cancer more expensive to treat than other cancers?
Bladder cancer is thought to be either the second or the third most expensive cancer to treat, through the healthcare system. The reason is that patients live years and decades, and do not succumb to the disease, but have frequent recurrences, frequent relapses, and need very close and careful follow-up examination. Most of these examinations, the cystoscopic examinations, are either done in the office or in a clinic. When they require a transurethral resection, if a tumor is found and you have to come to the hospital to have it resected or removed, it requires a hospital procedure, although it's outpatient. Hospital costs tend to be staggering, so when you figure that it's not unusual for a patient to live ten or fifteen years with bladder cancer, that currently the recommendation is that at the time of diagnosis, they be cystoscoped every three months for two years, every four months for the next year or two, and then every six months for an additional couple of years, and once a year at least for the rest of their life. All of those costs tend to add up. When you add in the cost of intravesicle therapy with either chemotherapeutic agents or biologic agents like BCG, those are administered on a weekly basis for six weeks at a time, and then the maintenance is every three weeks, or every three months. Again, if you multiply that by the number of years that these patients are alive, cared for and treated, the costs are staggering.
Can I live without my bladder?
The answer is yes. Bladder removal, or cystectomy, has been performed for many years. Initially, when the bladder was removed, surgeons were able to create any kind of reservoirs or conduits out of other parts of the small intestine. Once the bladder was removed, the uritals were simply plugged into the coli, into the sigmoid portion of the colon, so that the urine just went in there and mixed with the stool. It is a difficult situation - not only was it difficult to hold that, because now your stool and urine are mix all together, but that when you actually defecated, you had to eliminate your urine content as well. Because of the constant contamination, bacteria had open access to the kidneys that was complicated by recurring and severe kidney infections and urinary tract infections. In 1952, the first true bladder urinary diversion was done at Washington University in St. Louis, where I trained, and a piece of the small intestine was removed isolated, and the uritals were sewn in through the small intestine. That small intestine was then closed on one end that was inside the body, and the other end was then brought out to the patient's lower abdomen, or through the side of the lower abdomen, and applicants applied a bag to it. This was the so called ilio conduit, which was the mainstay and goal standard - urinary diversion, up until the mid to late 1990's, when newer procedures were being perfected and being accepted, and being done in a broad range of patients.