Management of Muscle Invasive Bladder Cancer

In this episode of BackTable Urology, Dr. Aditya Bagrodia and Dr. Siamak Daneshmand, Director of Urologic Oncology at USC, discuss the management of muscle-invasive bladder cancer.

First, the doctors discuss the initial workup of a referred bladder tumor patient. Because almost all bladder cancers are malignant, a transurethral resection of the bladder tumor (TURBT) is the first step. Dr. Daneshmand notes that imaging may be helpful in patients with complex anatomy. He prefers to perform a CT over an MRI scan due to patient discomfort and costs.

Next, Dr. Daneshmand shares his tips for a TURBT procedure. His main goal is to perform a complete resection of the tumor. He often uses blue light enhancement to visualize the edges of tumors better, improve the educational experiences of his residents, and stage smaller tumors more easily. He notes that doing an extensive TURBT does not lead to a higher likelihood of bladder cancer metastasis. Although uncommon, bladder perforation during TURBT is a possible and serious complication. To prevent seeding in the scenario of a perforation, he advises urologists to stop high-pressure irrigation immediately. Furthermore, he trains his residents to be vigilant of the amount of fluid going in and out of the abdomen.

Another important aspect of bladder cancer care is accurately staging the bladder cancer after the TURBT. Dr. Daneshmand usually orders a CT scan of the abdomen, chest, and pelvis in order to check for metastases. He prefers not to order a PET scan, as it results in too many false positives and false negatives. In the case of the discovery of suspicious pelvic lymph nodes, he will move on with neoadjuvant therapy and keep assessing the lymph nodes via imaging. He does not usually biopsy these lymph nodes due to their precarious location between the external and internal iliac arteries.

After staging the bladder cancer, a treatment modality must be chosen. Two common options are a cystectomy or trimodal therapy (TMT). Both Dr. Bagrodia and Dr. Daneshmand agree that variant histology results do not immediately indicate one treatment over the other—a patient’s tumor must be evaluated holistically. TMT is very effective in patients with T2-T3 unilateral, muscle-invasive bladder cancer. For patients who do not meet this narrow criteria, cystectomy remains a valid option.

Next, Dr. Daneshmand gives advice for performing a successful cystectomy. He notes that the surgeon should always handle the urethra with great care, as meticulousness can lead to a lower risk of post-surgical incontinence. Also, he notes that nerve-sparing techniques for male bladder cancer patients can help with post-surgical incontinence and erectile dysfunction. However, he warns urologists to be careful not to accidentally leave tumor tissue behind during female cystectomies involving gynecologic organ preservation.

After a cystectomy, patients can either choose to undergo a urinary diversion procedure, in which the surgeon creates a different way for urine to leave the bladder, or a neobladder (ileal conduit) procedure, in which the surgeon creates a new bladder from the small intestine. Dr. Daneshmand emphasizes that having a standardized and specific approach to the patient conversation about these treatment options is very important. He encourages urologists to be clear about the consequences of each of these options on incontinence and catheter usage. Finally, he shares contraindications of the neobladder procedure, such as liver disease, unmotivated patients, and patients without the manual dexterity for catheter usage. He also notes that chronic kidney disease is not a contraindication if acid-base balance is maintained.