Surgical Intervention
Transurethral Resection of Bladder Tumors (TURBT)
- Standard treatment for non-muscle-invasive bladder tumors (Ta, T1, Tis) & cTa low-grade tumors w/ the goal of removing all visible lesions
- Therapeutic option in patients w/ muscle-invasive bladder tumor if tumor growth is limited to the superficial muscle layer & if re-staging biopsies are negative for invasive tumor
- The strategy of resection depends on the size of the lesion
- In small tumors (<1 cm in diameter), en bloc resection can be done, where the specimen contains the complete tumor plus part of the underlying bladder wall including muscle
- For large tumors, resection is done in parts, which include exophytic part of the tumor, the underlying bladder wall w/ the detrusor muscle & the edges of the resection area
- Separate resection of larger tumors provides good information about the vertical & horizontal extent of the tumor & helps to improve resection completeness
- Complete & correct TURBT is essential to achieve a good prognosis
- An absence of detrusor muscle in the specimen is associated w/ a significantly higher risk of residual disease, early recurrence & tumor understaging
- Selected mapping biopsies & transurethral biopsy of the prostate must be considered if sessile lesion or Tis or high-grade disease is suspected
- A second TURBT is performed:
- After 2-3 wks of incomplete initial TURBT
- If there is no muscle in the specimen after initial resection, w/ the exception of TaG1
- When a high-grade, primary CIS, T1 tumor & possibly a Ta has been detected at the initial TURBT
- A second TURBT can increase recurrence-free survival, improve outcomes after Bacillus Calmette-Guerin (BCG) treatment & provide prognostic information
Radical Cystectomy
- Indicated in patients w/ non-muscle-invasive bladder cancer that have failed BCG treatment & in patients w/ highest risk of tumor progression
- Standard curative treatment for patients w/ muscle-invasive bladder cancer
- Appropriate procedure in men involves cystoprostatectomy
- While in women a cystectomy & a hysterectomy
- Followed by the formation of a urinary diversion
- Should include the essential pelvic lymph node dissection
- Immediate radical cystectomy is suggested in patients w/ non-muscle invasive bladder cancer if:
- TURBT staging accuracy for T1 tumors is low
- Patients w/ non-muscle invasive bladder cancer experience disease progression to muscle-invasive disease
- Delaying cystectomy for >3 mths may increase the risk of progression & cancer-specific mortality
Partial Cystectomy
- Indicated if the lesions develop on the dome of the bladder & have no associated Tis in other areas of urothelium
- The procedure begins w/ a laparotomy (intraperitoneal) & resection of the pelvic lymph nodes
- If the intraoperative findings preclude a partial cystectomy, a radical cystectomy is performed
Fulguration
- Fulguration w/out biopsy is considered in patients w/ recurrent non-muscle-invasive bladder cancer if all of the following are present:
- No previous bladder cancer that was intermediate- or high-risk
- A disease-free interval of at least 6 months
- Solitary papillary recurrence
- A tumor diameter of <3 mm
- In patients w/ a history of small, Ta LG/G1 tumors, fulguration of small papillary recurrences on an outpatient basis can reduce the therapeutic burden & can be a treatment option