Bladder cancer arises from the epithelial lining of the urinary bladder. It is the tenth most commonly diagnosed cancer worldwide, with an estimated 573,000 new cases and 213,000 deaths in 2020 alone. Surgery is one of the primary treatment modalities for bladder cancer and is used at various stages depending on the extent and nature of the disease.

This article outlines the different surgical options available for bladder cancer, ranging from minimally invasive procedures for early-stage tumours to extensive surgeries for advanced disease. Understanding these options can help patients and caregivers make informed treatment decisions.

Overview of bladder cancer types and stages

Bladder cancer is typically classified into two main categories: non-muscle-invasive bladder cancer (NMIBC) and muscle-invasive bladder cancer (MIBC). NMIBC is confined to the inner layers of the bladder and has a lower risk of spreading to other tissues. MIBC, penetrates the muscular wall of the bladder, making it more aggressive and likely to metastasize.³

The choice of surgical procedure depends largely on the stage and grade of the cancer. In general, NMIBC can be managed with less invasive procedures, while MIBC often requires more radical approaches to remove the entire bladder and affected tissues. Understanding the type and stage of the cancer is critical for determining the appropriate surgical strategy.

Transurethral resection of bladder tumor (TURBT)

TURBT is the primary surgical approach for patients with NMIBC.³ It removes visible tumours from the bladder through the urethra using a specialized instrument resectoscope. This minimally invasive technique is typically used to diagnose, stage, and treat early-stage bladder cancer. During the procedure, the surgeon inserts the resectoscope into the bladder and uses a wire loop with an electrical current to excise the tumour. Sometimes, a laser is used instead of an electrical current.

After TURBT, patients may receive intravesical chemotherapy or immunotherapy to reduce the risk of recurrence. However, NMIBC has a high recurrence rate, ranging from 50% to 70% within five years, making regular follow-up essential. ² Repeated TURBTs may be necessary if new tumours are detected during follow-up cystoscopies. This procedure is considered the gold standard for NMIBC treatment and is often performed as an outpatient surgery.

Partial cystectomy

Partial cystectomy involves removing only a part of the bladder. It is done in select cases of MIBC or for tumours that are confined to a single location and do not affect the entire bladder. This surgery allows for preserving bladder function, which can be particularly beneficial for maintaining quality of life. A partial cystectomy may be considered when the tumour is located at the dome (upper part) and has not invaded other areas.

The main advantage of partial cystectomy is that it retains a portion of the bladder, allowing the patient to urinate normally. However, this procedure is not widely applicable and has limitations. It is only recommended for low-grade tumours that have not spread beyond the bladder wall. Because of the restricted application, partial cystectomy is performed less frequently compared to more extensive surgeries like radical cystectomy.¹

Radical cystectomy

Radical cystectomy is a more extensive surgical procedure that involves the complete removal of the bladder. This surgery is recommended when the cancer has invaded the muscular layer of the bladder or is located in multiple areas of the organ.

During radical cystectomy, adjacent organs may also be removed to ensure that no cancerous tissue remains. In men, this may include the prostate and seminal vesicles, while in women, the uterus, ovaries, and part of the vaginal wall may be removed. The extensive procedure requires urinary diversion to create a new pathway for urine to leave the body.²

There are three main types of urinary diversion procedures:

1. Ileal conduit: A segment of the small intestine is used to create a channel through which urine can pass from the kidneys to an external urostomy bag
2. Continent urinary reservoir: The surgeon constructs a reservoir inside the abdomen using parts of the intestine, allowing the patient to self-catheterize periodically
3. Orthotopic neobladder: A neobladder is created from a section of the intestine, enabling the patient to void urine through the urethra

Each option has benefits and drawbacks, depending on the patient’s preference, overall health, and lifestyle considerations. Radical cystectomy is associated with a significant impact on quality of life, including changes in urinary function and sexual health, deciding on this surgery.

Robotic-assisted radical cystectomy

Recent advancements in minimally invasive techniques have led to the development of robotic-assisted radical cystectomy. This approach uses robotic arms controlled by a surgeon, providing enhanced precision and minimizing blood loss.¹ Robotic surgery offers several benefits over traditional open surgery, including shorter hospital stays, reduced postoperative pain, and quicker recovery times.

However, robotic surgery is limited to specialized centres, and not all patients are suitable candidates. Further studies are ongoing to compare the long-term outcomes of robotic versus open radical cystectomy.

Bladder-sparing approaches

Bladder-sparing approaches are an alternative to radical cystectomy for select patients who wish to retain their bladder or are not suitable candidates for extensive surgery. One such approach is trimodal therapy (TMT), which combines TURBT, chemotherapy, and radiation therapy. TMT aims at tumour eradication while preserving the bladder.

The success of TMT depends on the cancer’s response to initial treatment and the patient’s ability to tolerate chemotherapy and radiation. Patients must be closely monitored for recurrence, and radical cystectomy may still be needed if the cancer returns. Bladder-sparing therapies are particularly suited for patients who prioritize quality of life and wish to avoid the life-altering consequences of bladder removal.

Post-surgical care and recovery

Recovery from bladder cancer surgery varies depending on the type of procedure performed. Patients who undergo TURBT usually recover quickly, with minimal disruption to their daily lives. In contrast, radical cystectomy requires a longer recovery period due to the extent of surgery and the need for adaptation to urinary diversion.

Complications after bladder cancer surgery can include infections, bleeding, and issues with the urinary diversion. Patients may also experience psychological challenges, such as body image concerns and anxiety related to changes in urinary function. Rehabilitation, including physical therapy and psychological support, is essential in recovery.

Future directions in bladder cancer surgery

Ongoing research is focused on refining surgical techniques and improving patient outcomes. New technologies, such as enhanced imaging methods and precision-guided instruments, are being developed to increase the accuracy of tumour removal and reduce complications. Immunotherapy and targeted therapies are also being investigated as potential adjuvants to surgery, aiming to reduce recurrence rates and enhance survival.

Summary

Surgery remains a key treatment option for bladder cancer, with various procedures tailored to the cancer’s stage and patient preferences. While TURBT is effective for early-stage disease, radical cystectomy is often necessary for advanced cases. Emerging techniques, such as robotic-assisted surgery and bladder-sparing therapies, offer hope for improved outcomes and quality of life. Patients should work closely with their healthcare team to choose the best surgical approach based on their needs and treatment goals.