The therapeutic options for bladder carcinoma vary due to the different tumor characteristics and individual aggressiveness of each tumor. The therapy ranges from simple removal of a small tumor via the urethra to complete removal of the bladder. In the following, we would like to give you an overview of the range of treatments to give you a good basis for possible questions in a personal conversation.
THERAPY OF A NON-MUSCLE INVASIVE TUMOR
Transurethral resection of the urinary bladder (TUR-B)
A transurethral resection of the urinary bladder (the tumor is removed via the urethra with the aid of an electrical sling) is performed on detection of a tumor in the previous bladder cystoscopy or a reliable sonographic suspicion. In this method, on the one hand, tissue is obtained for precise diagnosis and, in addition, the depth extent and the aggressiveness of a tumor are determined.
On the other hand, the TUR-B is the primary therapy of a superficial growing bladder cancer. In this operation it is the aim to remove all non-muscle invasive tumors in the bladder.
TUR-B - The operation
Preparation for surgery:
If you are under general anesthesia, you can usually eat and drink as usual until midnight the day before; We recommend a light dinner. The day before the operation no special disinfection of the surgical site is made; This happens in the operating room just before the operation.
The procedure usually lasts between 20 and 40 minutes, depending on the extent of tumor infiltration of the bladder, so that anesthesia is calculated for this period.
After the procedure:
After the procedure, a catheter is usually placed which, depending on the size of the findings, is left for 1 to 2 days. In addition, it is decided during the operation whether a so-called early instillation with a chemotherapeutic agent in the bladder needs to be performed. After the procedure you will be brought back to the ward and after a certain time you will be able to eat and drink normally again.
EN BLOC RESECTION OF A BLADDER TUMOR
In the so-called en bloc resection of urinary bladder tumors the surgeon attempts to remove an existing tumor in the urinary bladder in one piece, if possible without direct tumor contact. This has the advantage that the tumor does not have to be broken up into small pieces and can swim around in the bladder. In addition, a more accurate pathological assessment of the removed material is possible because the structures of the tumor and the orientation of the tissue are preserved. However, this method is limited to tumors small to medium sized tumors, as they must be recovered at the end of the operation in one piece via the urethra. Also, the localization of a tumor within the bladder may make an entire resection impossible. Please contact us for the individual options available to you.
THE COMPLETE REMOVAL OF THE URINARY BLADDER (RADICAL CYSTECTOMY)
Imaging procedures before performing a cystectomy
If TUR-B or a bladder biopsy is used to diagnose muscle-invasive or refractory non-muscle-invasive tumors, the current guidelines of the European Society of Urology (EAU) recommend specific imaging examinations. https://uroweb.org/
This so-called staging is the determination of tumor spread. Of interest are local tumor spread, the detection of possible lymph node metastases, as well as the detection of metastasis to other organs (e.g., liver, lung, bone, etc.).
As a rule, a computed tomogram with contrast agent or magnetic resonance imaging with contrast imaging is recommended. For patients with histologically confirmed, muscle-invasive tumor growth, a CT scan of the thorax (lung area), the abdomen and the small pelvis with urography of the complete urinary tract should be performed.
Forms of urinary diversion
A “new bladder” created from the intestine, connected to the original urethra, is closest to the natural urinary bladder in terms of storage and deflation, and is now widely used.
A neobladder can not be offered if the tumor has already affected the urethra or there is an inflammatory bowel disease that prohibits the use of a larger piece of intestine.
After removal of the bladder, the neobladder takes over the storage function for the urine, with the new bladder being placed at the original site of the urinary bladder and then connected to the urethra. The urine can now be delivered via the urethra as before.
In the first weeks after surgery, the volume of the new bladder is still relatively limited, so it can still come to urine loss with only small storage capacity of the bladder. After a short time, however, the system should be so well revered that a good continence can be achieved during the day and later also at nighttime.
The ileum conduit is considered an established option of urinary diversion, which has been practiced with excellent results for over 60 years. The decision to apply an ileal conduit is frequently made in older male and female patients who have a very advanced tumor or need simultaneous urethrectomy (removal of the urethra) for urethral involvement. Primary incontinence or the desire of the patient for this form of urinary diversion may also be decisive for the choice of this method.
For the ileal conduit a 12-15 cm long small intestine piece is used, and the ureters are sewn on one side either together or individually in the separated intestinal part. The severed intestinal portion is rejoined and continues to serve for the bowel passage.
The outward-facing end of the intestine, in which the ureters are inserted, is discharged through the skin in the lower abdomen. This intestinal portion now serves as a connection between the ureters and the skin. Now, a bag system can be stuck to the skin, which collects the urine and must be emptied and changed by the patient at appropriate intervals.
Another option for urinary diversion is a catheterizable pouch; It is a created from the small intestine to serve as a urine reservoir, which opens via a tight-fitting stoma in the lower abdomen or navel. The pouch is emptied by the patient at certain intervals by means of a catheter. This form of urinary diversion is particularly suitable for patients in whom there is a desire for a continent stoma, with a primary connection of a neobladder to the own urethra is not possible.
NEOADJUVANT CHEMOTHERAPY (BEFORE CYSTECTOMY)
Neoadjuvant chemotherapy prior to radical cystectomy involves cisplatin-based polychemotherapy administered after initial diagnosis of muscle-invasive urothelial carcinoma, regardless of lymph node status. Following chemotherapy, radical cystectomy and / or radiotherapy will be performed.
"Recommendations from the current S3 guideline":
Overall, neoadjuvant chemotherapy leads to a reduction in total mortality of 14% after 6.4 years. There is no preferred combination of chemotherapeutics and there should applied be 3-4 cycles. Only for combination therapy with cisplatin, there is reliable data, so only for patients with good renal function (GFR> 60 ml / min / 1.73 qmKO) and in good general condition (ECOG 0-1) "
Adjuvant chemotherapy is defined as chemotherapy indicated after cystectomy and histopathologic diagnosis of organ-invasive muscle invasive (> pT3) or T-stage independent pathologically regionally lymphocytic metastatic (pN1) urothelial cell carcinoma of the bladder.
Overall, adjuvant chemotherapy leads to a moderate reduction in all-cause mortality. There is no preferred combination of chemotherapeutic agents and the number of cycles is not fixed. In contrast, a combination with cisplatin is important, so that only patients with good renal function (GFR> 60 ml / min / 1.73 qmKO) and with a good general condition (ECOG 0-1) are eligible for adjuvant chemotherapy.
THERAPY OF THE ADVANCED OR LOCALLY NOT LIMITED TUMOR
In the presence of such a tumor, the individual interdisciplinary therapy planning takes place together with the oncologists, radiotherapists, pathologists and urologists in a special tumor board in order to offer the best possible treatment option.
You are welcome to introduce yourself to a second opinion in our interdisciplinary consultation.