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Bladder Preservation Options

Although complete removal of the bladder for muscle-invasive bladder cancer has been the standard for many decades, after research and clinical trials, it is now accepted that bladder preservation is a safe alternative for carefully selected patients.

The bladder-preserving approach to the treatment of muscle invasive bladder cancer is usually a combination of three treatments – radiation therapy, chemotherapy and complete TURBT. The combination of these three treatments is called Trimodal Therapy, (TMT) or Combined-Modality Therapy (CMT). There is also an option for removal of part of the bladder.

Who is suitable for bladder preservation therapy?

Not every bladder tumour is suitable for TMT. Your medical team will help you make a treatment decision to determine what is best for you, based on several important factors.

Radiation is less effective if the bladder tumour is too bulky. This means that TMT is not recommended if it measures more than 5 cm (about 2 inches), can be felt by the physician during a physical examination, or if the tumour causes blockage of urine flow from one or both kidneys, called hydronephrosis.

Radiation is also less effective if there are cancer cells in multiple areas of the bladder or if they are associated with areas of carcinoma in situ which are flat tumours, a cancer stage called Cis or Tis, due to the increased risk of recurrence of the cancer.

It’s also important that you have good bladder function before starting TMT. If you have a lot of problems with frequent and urgent urination, TMT may not be suitable.

In up to 25% of patients, cancer remains in the bladder despite TMT. In this case, complete removal of the bladder is then required and a path to divert the urine to the outside of the body is created.

If complete removal of the bladder is needed, the option for a neobladder would not be recommended. This is because radiation delivered during TMT can affect the small bowel and the area of the sphincter (the valve that opens and closes to allow urine to leave the body), even with the best choice of dose and targeting. As a result, there is an increased risk of incontinence, although some patients who receive a neobladder even after radiation can be continent.

The Partial Cystectomy Option

We should mention at this point that there may be an option for a small number of patients to remove only a part of the bladder, called partial cystectomy. While removal of part of the bladder has the normal risks associated with surgery, it preserves urinary and sexual function and avoids the need to replace the bladder with a section of bowel. The bladder is roughly triangular. There is a roof or dome at the top of the bladder, and side walls tapering down to the neck where urine leaves the body through a tube called the urethra.

Partial cystectomy is generally considered only in carefully selected patients with a single tumour located on the dome or high up on the side walls, particularly those with a rare form of bladder cancer called adenocarcinoma, a type of cancer that begins in the cells that produce mucous.

The tumour should not be greater than 3 centimeters (just over 1 inch),
No carcinoma in situ (a cancer stage called Cis or Tis) or flat tumours,
Good bladder capacity, approximately normal capacity which is 400 to 600 millilitres (about 14 to 21 ounces).

Chemotherapy

Chemotherapy (or chemo) uses drugs to destroy cancer cells. In this sense, chemotherapy has the same effect as radiation therapy. Some chemotherapy drugs are given on their own or several chemotherapy drugs may be given together. Certain chemotherapy drugs have been shown to make the cancer cells more responsive to radiation therapy. For this reason, radiation therapy and chemotherapy are often done together, called concurrent or concomitant therapy. In some cases, chemotherapy is given over several weeks before radiation treatments start, called neoadjuvant. Combining radiation and chemotherapy offers you the best chance of killing the bladder cancer cells in your body.

Most chemotherapy drugs are put right into your bloodstream through intravenous or IV treatment. Each treatment can last from a few minutes to a few hours. As with radiation therapy, chemotherapy can have side effects, which you should discuss with your doctor. Side effects vary widely, and treatments are often available for any side effects that you may have.

Radiation Therapy

Radiation therapy uses high-energy radiation (most commonly x-rays) to shrink tumours and kill cancer cells. Radiation kills the cancer cells by damaging their DNA. Cancer cells whose DNA is damaged beyond repair stop dividing or die. When the damaged cells die, they are broken down and eliminated by the body’s natural processes.

While radiation therapy can also damage normal cells, your medical team will take potential damage to normal cells into account when planning a course of radiation therapy. Doctors know how much radiation normal tissue can safely receive. You may have chemotherapy before or during radiotherapy, or both, to help make the radiotherapy more effective.

In some cases, your radiation team may first implant a fiducial marker into the bladder. This marker is an object, or sometimes a special liquid, that is visible on scans of the bladder and may help more accurately define and target the tumour site. This process is known as image-guided radiotherapy.

Radiation therapy is given in the hospital radiotherapy department as a series of short daily treatments typically available on an outpatient basis. Each treatment may take up to 10 to 15 minutes, and is usually given Monday through Friday, with a rest on the weekend. A course of radiotherapy for bladder cancer may last four to seven weeks.

External radiotherapy does not make you radioactive and it is perfectly safe for you to be with other people, including children, after each treatment session. Side effects vary widely; report any side effects to your doctor as soon as possible as there are treatments that may help. In the years following radiation therapy, patients need to be followed closely – both for the possibility of recurrence in the bladder that may require surgery, but also because a few patients might develop bladder or bowel complications because of the radiation.

Transurethral Resection of Bladder Tumor (TURBT)

When you’re having bladder preserving therapy, you may need a repeat TURBT to remove as much of the bladder tumour as possible before starting chemotherapy and radiation. TURBTs may be repeated as treatment progresses to remove any additional tumours that may have grown. These tumours are identified using cystoscopies which is the process of inserting a tube through the urethra and using a small camera to see inside the bladder. You will have likely had a cystoscopy prior to determining a bladder preservation regime.

Bladder Cancer Consensus Guidelines for TMT

The Canadian Urological Association (CUA) has developed consensus guidelines, and all recommend the use of trimodal therapy (TMT) for many presentations of muscle-invasive bladder cancer. Consensus statements are often developed to provide guidance when information is evolving, and standards of care are not clear. They are developed by a panel of experts who review the research literature to advance the understanding of procedures and methods. You can read the statements and guidelines from the CUA here.

How to Advocate for Bladder Preservation

If you have muscle invasive bladder cancer, and your doctor has not suggested bladder preservation and you wish to keep your bladder, you should discuss the possibility of preservation with them. A good candidate for bladder preservation, particularly TMT, should consider:

Is my tumour less than 5 cm (about 2 inches)?
Do I have good bladder function?
Are my kidneys in good shape without swelling?
Can I tolerate radio-sensitizing chemotherapy, pelvic radiation and repeated cystoscopies?

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