FAQs – Robotic Bladder Surgery
1. What are the signs and symptoms of bladder cancer?
The most common sign of bladder cancer is blood in urine that can be easily seen. Sometimes it may be that the tumors do not produce enough blood for a patient to see (microscopic hematuria) and are only detected with the help of special chemicals and a microscope after a urine test is done by a physician.
The overwhelming majority of patients who have microscopic hematuria do not have cancer. Irritation while urinating, as well as urgency, frequency and a constant need to urinate may be symptoms a bladder cancer patient initially experiences.
2. What types of tests will the doctor conduct to determine if I have bladder cancer?
Ultrasound, CT IVU scans (computed tomography), can detect irregularities in the bladder wall, which would suggest a possible cancer. The urologist will also look inside the bladder with a Cystoscope to visually examine your bladder and remove samples of any suspicious areas for biopsy. Urine cytology will be performed to detect cancer cells in the urine.
3. What is a Cystoscopy?
The Cystoscope is inserted through the urethra. Today with the widespread use of the flexible Cystoscope most of the diagnostic Cystoscopies are done in the outpatient setting with little or no discomfort.
As the Urologist looks through the Cystoscope, the locations where abnormal features appear are noted and recorded. During the cystoscopy, the Urologist may choose to take a small piece of what appears to be an abnormal tissue (biopsy) and send it to the Pathologist to read and analyze. In addition, a urine sample is frequently sent for analysis (cytology) to determine if there are any cancer cells. The biopsy specimen as well as the urine sample will help the doctor make recommendations about the patient’s future care.
4. What is meant by 'staging and grading' a tumor?
If bladder cancer is diagnosed, the doctor needs to know the stage or extent of the disease to plan the best treatment. Staging is a careful attempt to find out whether the cancer has invaded the bladder wall, whether the disease has spread, and if so, to what parts of the body. Grade refers to what the cancer cells look like, and how many cells are multiplying. The higher the grade, the more uneven the cells are and the more cells are multiplying. Knowing the grade can help your doctor predict how fast the cancer will grow and spread.
Urologists typically send the sample of cancer tissue to a Pathologist, who specializes in examining tissue to determine the stage and grade of the cancer. The Pathologist writes a report with a diagnosis, and then sends it to your Urologist.
5. What types of treatments are available?
Knowing the stage and grade helps your doctor decide which methods are most suitable for treating your cancer.
Ta papillary tumors are usually low grade (most closely resemble normal cells) and, even though a large majority will recur multiple times after the initial diagnosis and removal, 85-90% will never invade the bladder wall and become life-threatening. Further treatment beyond removal may not be necessary, but regular follow-up is required.
Ta non-invasive tumor will probably be treated with more aggressive therapies, including immunotherapy. Once the tumor has invaded the lamina propria, it is considered an invasive tumor with the potential of spreading through the muscle wall and ultimately affecting organs that border the bladder (prostate, uterus, etc.) or other organs such as the lung, bone, and liver. Intravesical therapy and surgery may be considered.
6. What is a Trans Urethral Resection of a Bladder Tumor (TURBT)?
Generally, after the diagnosis of a bladder tumor, the urologist will suggest that the patient have an outpatient procedure in the hospital to examine the bladder more completely under anesthesia (general or spinal) as well as to remove, if possible, those tumors which are suitable for resection. The doctor may refer to this procedure as a TURBT (transurethral resection of a bladder tumor).
The TURBT is “incision-less” surgery usually performed in the hospital as an outpatient procedure. It is the first-line surgical treatment for bladder tumors. Like the cystoscope, the resectoscope or the instrument used to remove the tumor in the TURBT. It is also introduced through the urethra into the bladder. Attached to this scope is a small, electrified loop of wire which is moved back and forth through the tumor to cut and remove the tissue.
All the specimens from the TURBT will be sent to the pathologist for review. The pathologist will confirm the type of bladder cancer and the depth of invasion into the bladder wall, if any. These findings, along with results from x-rays, will determine if further treatment is necessary.
7. What is intravesical therapy?
There are two principal drugs that are used as intravesical chemotherapy or immunotherapy.
Mitomycin C is an intravesical, anti-cancer drug that has been shown to be effective after the TURBT in reducing the number of recurrences of bladder tumors by as much as 50%. This drug may be delivered into the bladder immediately after TURBT.
Bacille Calmette-Guerin or BCG is intravesical immunotherapy which causes an immune or allergic reaction that has been shown to kill cancer cells on the lining of the bladder. The Urologist may also suggest maintenance therapy using BCG. The rationale for maintenance therapy is that the initial therapy plus intermittent therapy for 2 to 3 years may provide a decreased likelihood that the tumors will recur.
8. When is surgery to remove the bladder necessary?
If a bladder tumor invades the muscle wall or if CIS or a T1 tumor still persists after BCG therapy, the urologist may suggest removal of the bladder or a radical cystectomy. Before any radical surgery is performed, a series of CT scans will be ordered to exclude the possibility of metastatic or “distant” disease in other parts of the body. If the patient has metastatic disease, chemotherapy will be prescribed.
A complete radical cystectomy requires complete bladder removal, and in men, it always involves removal of the prostate as well. For women, in addition to removing the bladder, the surgeon may also remove the uterus, fallopian tubes, ovaries and cervix. In addition, the surgeon will remove lymph nodes surrounding the bladder, and perhaps even more, to determine whether the cancer has progressed to the lymph nodes, which then could result in metastasis. The lymph node removal is an important method of accurately staging the progression of the disease.
9. What are the types of urinary reconstructions available if I need to have my bladder removed?
An ileal conduit is the easiest and most common reconstruction performed by the urologist. A small portion of the ileum or small intestine is disconnected. One side of the piece of ileum is attached to a skin opening on the right side of the abdomen and a small stoma or mouth is created. A plastic appliance or ostomy bag is placed over the stoma to collect the urine. The ureters are sewn or re-implanted near the other end of the ileum. Because the nerves and the blood supply are preserved, the conduit is able to propel the urine into the appliance.
A neo-bladder is also a type of internal reservoir for storing urine. Using a portion of small intestine, the urologist reconstructs the tubular shape of the intestine and creates a sphere. The surgeon then connects the pouch to the urethra, creating a neo-bladder, in which case the patient can void (pass urine out of the body) normally. By tensing the abdominal muscles and relaxing certain pelvic muscles, the patient is able to push the urine through the urethra.
A radical cystectomy is considered major surgery and at least 20% of patients have complications as a result of either operation. The choice of which type of reconstruction to utilize is a highly-individualized decision between the patient and the doctor, and depends on a variety of factors, including the patient’s overall health, age, and extent of disease. There are advantages and disadvantages to each type of reconstruction.
10. When is chemotherapy used?
Chemotherapy refers to drugs used to treat cancer systemically. These drugs are administered by injection directly into the patient’s veins, and attack cancer cells anywhere in the body. Chemotherapy is typically used to treat bladder cancer that has metastasized, which means the cancer cells have spread beyond the bladder to other organs.
Neo-adjuvant chemotherapy is the term used for chemotherapy prior to surgery. Adjuvant chemotherapy is the term used for chemotherapy following surgery. Typically, removal of the bladder also involves removal of a number of lymph nodes surrounding the bladder, which are then sent to the pathology lab for analysis. If the pathology results indicate that the cancer has spread to the lymph nodes, the doctor may recommend chemotherapy to help prevent any cancer recurrence.