The kidneys make urine, which is a liquid containing waste products from the body. Urine then travels to the bladder through tubes called ureters. The bladder stores urine before it exits the body through the urethra. The bladder is made up of cells, which typically grow in an orderly way. Sometimes, these cells can start dividing abnormally, and this abnormal growth is called cancer.
In the case of bladder cancer, the abnormal growth begins in the bladder. This can lead to tumors, which are essentially clusters of abnormal cells. These abnormal cells continue to divide uncontrollably and can eventually extend into the thick muscular layer deep within the bladder wall. This is known as muscle-invasive bladder cancer and is a more advanced stage of bladder cancer. If left untreated, the cancer can continue to grow and may extend outside the bladder into surrounding tissues or even lymph nodes, lungs, liver, or other parts of the body.
Grade and Stage
The grade and stage of bladder cancer are ways to characterize the cancer. The grade is a measure of how abnormal the cancer cells appear under a microscope. They can be either low-grade or high-grade. The higher the grade, the more abnormal the cells appear. High-grade cells are more serious because they are more likely to extend into the bladder muscle or beyond. The stage is a measure of how far the cancer has spread. This is determined by taking tissues of the bladder and surrounding structures to determine if cancer is present. The stages are listed below:
- Ta: Tumor is located on the bladder lining and does not extend into any deeper layers of the bladder.
- Tis (Carcinoma in situ): This high-grade cancer appears to be a reddish, velvety patch located on the bladder lining.
- T1: Tumor extends through the bladder lining but does not reach the muscle layer.
- T2: Tumor extends into the muscle layer of the bladder
- T3: Tumor extends past the muscle layer into tissues surrounding the bladder
- T4: Tumor extends outside of the bladder to nearby structures (lymph nodes and prostate in men or lymph nodes and vagina in females)
Bladder Removal (Cystectomy)
You have likely already discussed treatment options with your urologist and know that the right treatment depends on you and your type of bladder cancer. A radical cystectomy (surgery) is typically performed as an attempt to cure bladder cancer that has extended into the bladder wall, is high grade, or has returned following initial treatment. This procedure involves removal of the entire bladder, nearby lymph nodes, part of the urethra, the prostate (in men), and the uterus, ovaries, fallopian tubes, and part of the vagina (in women). Once the bladder is removed, your body will need another way to transport urine out of the body. There are a few different ways this may be accomplished.
In this case, urine is transported out of the body via “urinary diversion”, also known as an ileal conduit or urostomy. A portion of your intestinal tract will be reconfigured to act as a short pipe to move urine from your kidneys and ureters to the outside of your body. The two ends of the remaining intestinal tract will be rejoined. The ureters (which previously carried urine from the kidneys to the bladder) will be attached to this ileal conduit. The front end of the conduit will be brought through your abdominal wall through a small opening or a stoma. A plastic pouch will then cover the stoma to collect the urine that is produced by the kidneys.
To create a neobladder, a piece of the intestinal tract is removed and used as a reservoir to hold urine. This reservoir is connected to the ureters at one end and the urethra at the other. This type of diversion is similar to how the urinary tract functions normally. However, the reservoir does not function as well as the natural bladder since it does not have nerves to tell patients when the bladder is full. Therefore, the patient will need to “train” the bladder via timed voiding. In some cases, the patient must also self-catheterize through the urethra to ensure the reservoir is completely empty. This type of diversion is associated with a high chance of urinary incontinence (urine leaking out) and retention (unable to urinate). This procedure requires patient compliance and is not recommended to everyone. Furthermore, it cannot be performed in all patients due to their anatomy.
Indiana Pouch or Continent Cutaneous Diversion
A continent cutaneous diversion involves an internal reservoir that a surgeon creates from a section of the intestinal tract. The reservoir is connected to a small opening through the abdominal wall, also known as a stoma. A valve is created to prevent urine from leaking out of the stoma. The patient drains this reservoir several times throughout the day by inserting a catheter through the stoma. Due to the complications and side effects seen with this procedure, it is not often recommended.
Preparing for Surgery
Support at Home
Patients should plan to have someone stay with them upon returning home as they will be limited in activity for at least one to two weeks.
FAQ: Are there any accommodations available for patients and families coming from out of town?
- Yes, the SECU Family House is a place where family members may stay during the patient’s hospitalization. Patients coming from further distances may want to consider staying here the night before surgery if you are required to be at the hospital early in the morning. Here is a link to their website. https://www.secufamilyhouse.org/
We highly encourage patients to increase exercise prior to surgery as this can help improve recovery. Exercise will increase your energy level and can help minimize muscle mass loss following surgery. Increasing your endurance prior to surgery will also allow you to engage in physical activity sooner after surgery. This can include as little as a 30-minute walk at least 5 days per week. If walking is difficult, you can try a stationary bike, elliptical, or even swimming.
To maintain your weight, we recommend patients follow a diet containing sufficient protein and calories prior to surgery. This can help minimize the weight loss that often occurs following surgery. We also encourage patients to start trying different protein shakes to use upon returning home as these will be an easy source of protein and calories. For more details and specific recommendations regarding nutrition, please see the postoperative nutrition section.
Smoking and Alcohol
Both smoking and alcohol can increase the risk of complications following surgery. Some complications include poor wound healing and breathing difficulties that can lead to pneumonia. We recommend that patients quit smoking and reduce their alcohol intake as early as possible. Quitting at any point will start to improve your recovery! If you need help with either, please let us know so we can provide you with the appropriate resources. You can also check out our online resources for helping you quit: https://www.med.unc.edu/fammed/tobacco/ndp/
Patients should discuss with their urology care team whether they should stop the use of aspirin or any other anti-platelet medications (I.e. Plavix, Aggrenox, Pletal) prior to surgery as they might lead to excess bleeding. Your urology care team can determine when and if you should stop these medications.