6 - Surgery for bladder cancer

Summary

Introduction

The majority of patients (approx 70%) who present with bladder cancer have superficial disease. Thirty percent of these patients will progress to muscle invasive disease. The remaining patients will present with disease that is already invading the muscle (pT2 – 4) or metastatic. The surgical management of these two types of disease is distinct. The principle objective when treating patients with superficial disease is to prevent progression, the secondary objective is to prevent recurrence. The primary aim in the management of patients with muscle invasive disease confined to the bladder is to prevent further progression and so if a cystectomy is undertaken the aim is oncological cure.

Transurethral resection of bladder cancer

The diagnosis of bladder cancer is based on examination of the histological specimen obtained by transurethral resection. In patients with superficial disease the tumor, along with bladder wall, including some muscle is resected. This allows the histopathologist to accurately stage the patient and if the tumor has been completely resected with clear margins, treatment may be considered adequate and the patient will commence follow-up or surveillance.

In patients proved to have muscle invasive disease at histology, transurethral resection should be considered a diagnostic procedure only. Random biopsies are not usually indicated but areas suspicious for carcinoma should be biopsied. Patients with muscle invasive bladder cancer can be treated with either radical radiotherapy or cystectomy.