Bladder Cancer: Surgical Therapy

The type of therapy depends on the tumor stage (depth of invasion) and the patient’s general condition. In cases of metastasis, systemic chemotherapy is given.

Resection of bladder tumors

Indication

  • Superficial (growing on the surface) tumors (TNM classification):
    • Ta-T1, Tis (carcinoma in situ, “flat tumor”); Ta (noninvasive papillary tumor).
    • T1 G1-2 (infiltration of subepithelial connective tissue with good differentiation of tumor cells; Tis (carcinoma in situ/ literally, “cancer at the site of origin”; early stage)).

The operation procedures

Transurethral Resection of Bladder Tumor, (TURB).

In transurethral resection (surgical removal through the urethra) of bladder tumors (TURB), electroresection (“surgical removal using electricity) is used to electrically “peel out” tumorous portions of the bladder, and histologic examination of each is performed to assess whether the tumor could be removed in toto (in its entirety). Fluorescence-assisted TURB with hexylaminolaevulinate has an approximately 20% higher tumor detection rate compared with conventional white-light TUR-B (EG: ST) [S3 guideline]. Because TURBT promotes tumor cell dissemination into the venous blood, it is advised to better control and not increase bladder pressure during surgery. Transurethral en bloc resection of bladder tumors, ERBT.

In 1997, tumor resection as a whole, or en bloc, was described for the first time. In these procedures, the tumor is bypassed with an electric needle or laser (Ho:YAG(holmium), Tm:YAG(thulium) laser) and then levered out from the depth as bluntly as possible. This procedure improves the quality of the histological preparation and the histopathological statement becomes more valid. This leads to more frequent avoidance of resection.Extraction of the specimen is possible up to a maximum diameter of 3 cm using grasping forceps or Ellick evacuator.According to current studies, the procedure has a lower intraoperative and perioperative morbidity (incidence of disease).

After surgery

After surgery, instillation therapy (local chemotherapy: e.g., mitomycin, docorubicin, or epirubicin) is usually given to reduce the risk of recurrence (“reappearance of the tumor”). A meta-analysis was able to show a reduction in the risk of recurrence by postinterventional (“after surgery”) early instillation of almost 40%. Installation therapy is performed depending on the risk group present in each case [S3 guideline]:

  • Low-risk stage: immediate postoperative early instillation (e.g., mitomycin C).
  • Initial diagnosis of intermediate-risk NMIBC (non-muscle-invasive bladder cancer): instillation with a chemotherapeutic agent such as epirubicin, mitomycin C, interferon, or bacille Calmette-Guérin (BCG; instillation of BCG into the bladder).
  • Recurrence after or under instillation therapy: at least one year of BCG therapy with a six-week induction phase followed by three-weekly administrations at 3, 6, and 12 months

Intravesical BCG therapy (injection of BCG into the bladder; Bacillus Calmette-Guérin = BCG) should be reserved for high-grade tumors (low-differentiated tumors (G3)), stage pT1 (and G3) and Tis carcinomas, and chemotherapy failures (see “Drug therapy” below).The EAU (“European Association of Urology”) guideline recommends resection in the following constellations:

  • Macroscopically incomplete initial resection.
  • No musculature detectable in histopathological specimen (except for TaG1 and CIS/carcinoma in situ), all T1 findings.
  • All G3 tumors, except primary CIS.

The current S3 guideline recommends, if no cystectomy is planned, resection in patients with non-muscle-invasive urothelial carcinoma of the urinary bladder (nMIBC) with the following constellation:

  • In tumors in which primary TUR was incomplete.
  • When no muscle was detectable in the histopathologic specimen in the initial TUR, except pTa Low Grade.
  • In the case of pT1 tumors
  • In all high-grade tumors, with the exception of patients with primary carcinoma in situ (pTis).

Potential complications

  • Post-bleeding
  • Bladder perforation/rupture (in which case a laparotomy/abdominal incision with suturing is required)
  • Urinary tract infections.

More hints

  • “In patients with muscle invasive bladder cancer (MIBC) who desire an organ-preserving approach, complete transurethral tumor resection should be attempted. However, perforation of the bladder wall should be avoided.”
  • The 5-year survival rate of patients with pT1G3 and BCG therapy is approximately 88%. It is thus similar in value to that of early cystectomy. BCG therapy can reduce the risk of recurrence by 56%.
  • In patients with high-grade stage Ta bladder cancer, a second resection lowers the recurrence rate (rate of disease recurrence) even after complete initial surgery. Within the following two years, the risk of recurrence (risk of relapse) was 8.7 times higher for patients without second resection than for patients with second resection.

Radical cystectomy

“In patients with muscle invasive bladder cancer (MIBC) who do not receive neoadjuvant therapy, radical cystectomy should be performed within 3 months of diagnosis if possible [S3 guideline].”

Indications [S3 guideline]

  • Patients with muscle-invasive bladder carcinoma (≥ pT2).
  • In early recurrence (early recurrence of the tumor) or tumor persistence with high-risk constellation of non-muscle-invasive bladder cancer (nMIBC) after Bacillus Calmette-Guerin induction therapy.

The surgical procedure

Radical cystectomy involves the removal of the urinary bladder in addition to:

  • Male: removal of the seminal vesicles (vesicula seminalis) and prostate gland.
  • Woman: removal of the uterus (uterine) and adnexa (fallopian tubes and ovary), depending on menopausal status if necessary, and portions of the ventral third of the vaginal wall (anterior vaginal wall).

A component of radical cystectomy is furthermore bilateral pelvic lymphadenectomy (removal of lymph nodes in the pelvis) with removal and assessment of at least 10-16 lymph nodes. The aim of this procedure is primarily diagnostic; a therapeutic value is controversial. Lymph node dissection extends to the lymph nodes in the obturator fossa and vasa iliaca externa to the junction of the internal iliac artery. Optionally, the procedure can be extended to the level of the aortic bifurcation. Surgery can be performed with continent (e.g., ureterosigmoideostomy (uretero-intestinal impaction, HDI), ileum neobladder/bladder replacement from small bowel, etc.) and incontinent (ureterodermal fistula, ileum conduit, etc.) urinary diversion. Further notes

  • Prognostic factors for perioperative morbidity (incidence of disease) and mortality (rate of death) are age and concomitant diseases.
  • Perioperative mortality (death rate) and morbidity (incidence of disease) is < 5
  • Laparoscopic (“by laparoscopy“) radical cystectomy is equivalent to open surgery in terms of recurrence-free survival, cancer-specific survival, and overall survival.
  • Alternatives to cystectomy for muscle invasive bladder cancer (MIBC) are:
    • “Radical” transurethral resection (TUR) ± chemotherapy; methotrexate and cisplatin allow a bladder-preserving approach in 60% of patients.
    • Open/laparoscopic partial bladder resection, radiotherapy ± chemotherapy [close follow-up required! ]If recurrence occurs, a salvage cystectomy (cystectomy as a palliative measure after previous failed, curatively intended radiotherapy) should be generously indicated
    • Patients with superficial high-risk tumors (pTa, pTis, pT1, each with indication for cystectomy) and T2 tumors underwent transurethral resection (TUR; tumor is removed via the urethra)) with the goal of R0 TUR) and radiotherapy (radiation therapy); salvage cystectomy was subsequently performed in the case of residual or recurrent tumor (tumor recurrence). Results: 83% of patients (290 of 369) experienced complete tumor remission at control TUR 6 weeks after radiotherapy. The CR (complete response) rate was 68% after radiotherapy alone, 86% after radiochemotherapy, and 87% after radiochemotherapy plus hyperthermia (heat therapy).
  • Partial cystectomy should not be recommended as standard therapy because of unproven equivalence [S3 guideline].