Treatment for bladder cancer

Most people with non-muscle-invasive bladder cancer have an operation called transurethral resection of bladder tumour (TURBT). This is done under general anaesthetic using a rigid cystoscope. A TURBT takes 15–40 minutes and does not involve any cuts to the outside of the body.

How the surgery is done

The rigid cystoscope is passed through the urethra into the bladder so the surgeon can see the inside of your bladder on a monitor. The surgeon may remove the tumour through the urethra using a wire loop on the end of the cystoscope. Other methods for destroying the cancer cells include burning the base of the tumour with an electrical current (fulguration) or a high-energy laser.

If the cancer has spread to the lamina propria or is high grade, you may need a second TURBT 2–6 weeks after the first procedure to make sure that all cancer cells are removed. If the cancer comes back after initial treatment, your surgeon may do another TURBT or suggest removing the bladder in an operation known as a cystectomy.

What to expect after a TURBT

Most people who have a TURBT stay in hospital for 1–2 days. Your body needs time to heal after the surgery.

Having a catheter – You may have a thin, flexible tube (catheter) in your bladder to drain your urine into a bag. The catheter may be connected to a system that washes the blood and blood clots out of your bladder. This is known as bladder irrigation. When your urine looks clear, the catheter will be removed and you will be able to go home. If the tumour is small, there may be no need for a catheter and you may be discharged from hospital on the same day.

Side effects – Side effects may include blood in the urine, needing to pass urine more often and bladder infections. It is normal to see some blood in your urine for up to two weeks. Your doctor may prescribe antibiotics to prevent infection.

Flushing the bladder – It is important to keep drinking lots of water to flush the bladder and keep the urine clear.

Recovery time – When you go home, avoid any heavy lifting, vigorous exercise or sexual activity for 3–4 weeks.

When to get help – Contact your medical team promptly if you: feel cold, shivery, hot or sweaty; have burning or pain when urinating; need to urinate often and urgently; pass blood clots; or have difficulty passing urine.

Check-ups after surgery

Cancer can come back even after a TURBT has removed it from the bladder. You will need regular follow‑up cystoscopies to help find any new tumours in the bladder as early as possible. This approach is known as surveillance cystoscopy.

How often you need to have a cystoscopy will depend on the stage and grade of the cancer, and how long since it was diagnosed.

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Chemotherapy uses drugs to kill or slow the growth of cancer cells. The aim is to destroy cancer cells while causing the least possible damage to healthy cells. Chemotherapy drugs are usually injected into a vein or given as tablets. In intravesical chemotherapy the drugs are put directly into the bladder using a catheter (a thin, flexible tube) inserted through the urethra.

Intravesical chemotherapy is used mainly for low-to medium-risk non-muscle-invasive bladder cancer. It helps prevent the cancer coming back (recurrence). This method of giving chemotherapy can’t reach cancer cells outside the bladder lining or in other parts of the body, so it’s not suitable for muscle-invasive bladder cancer.

Each treatment is called an instillation. People with a low risk of recurrence usually have one instillation straight after TURBT surgery. The chemotherapy solution is left in the bladder for 60 minutes and then drained out through a catheter.

People with a medium risk of recurrence may have instillations once a week for six weeks. This is usually done as a day procedure in hospital.

The chemotherapy solution is left in the bladder for up to two hours and then drained through a catheter. You may have to change position every 15 minutes so the solution washes over the entire bladder.

While you are having a course of intravesical chemotherapy, your doctor may advise you to use contraception.

Side effects of intravesical chemotherapy

Because intravesical chemotherapy puts the drugs directly into the bladder, it has fewer side effects than systemic chemotherapy (when the drugs reach the whole body).

The main side effect is bladder inflammation (cystitis). Signs of cystitis include wanting to pass urine more often or a burning feeling when urinating. Drinking plenty of fluids can help. If you develop a bladder infection, your doctor can prescribe antibiotics. In some people, intravesical chemotherapy may cause a rash on the hands or feet. Tell your doctor if this occurs.

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Immunotherapy is treatment that uses the body’s own natural defences (immune system) to fight disease. Bacillus Calmette-Guérin (BCG) is a vaccine that was originally used to prevent tuberculosis. It can also stimulate a person’s immune system to stop or delay bladder cancer coming back or becoming invasive.

The combination of BCG and TURBT is the most effective treatment for high-risk non-muscle-invasive bladder cancer. BCG is given once a week for six weeks, starting 2–4 weeks after TURBT surgery. It is put directly into the bladder through a catheter. You may be asked to change position every 15 minutes so the vaccine washes over the entire bladder. This is usually done as a day procedure in hospital, and each treatment session takes up to two hours.

Your treatment team will tell you what safety measures to follow after you go home. This is because BCG is a vaccine that contains live bacteria, which can harm healthy people. 

BCG safety at home

• For the first six hours after BCG treatment, sit down on the toilet when urinating to avoid splashing. When finished, pour 2 cups of household bleach (or a sachet of sodium hydrochlorite if provided by your treatment team) into the toilet bowl. Wait 15 minutes before flushing with the toilet lid closed.
• If any clothing is splashed with urine, wash separately in bleach and warm water.
• If you use incontinence pads, for a few days after treatment take care when disposing of them. Pour bleach on the used pad, allow it to soak in, then place the pad in a plastic bag. Tie up the bag and put it in your rubbish bin. You may also be able to take the sealed bag back to the hospital or treatment centre for disposal in a biohazard bin.
• For a few days after each treatment, wash your hands extra well after going to the toilet, and wash or shower with soap and water if your skin comes in contact with urine.
• Drink plenty of liquids for 6–8 hours after treatment.
• For a week after each treatment, use barrier contraception (condoms) to protect your partner from any BCG that may be present in your body fluids and to prevent pregnancy.
• Speak to your medical team if you have any questions.

Ongoing BCG treatment

For most people with high-risk non-muscle invasive bladder cancer, the initial course of six BCG treatments is followed by what is known as  maintenance BCG. Maintenance treatment with BCG reduces the risk of the disease coming back or spreading. Maintenance treatment can last for 1–3 years, but treatment sessions become much less frequent (e.g. one dose a month). Treatment schedules can vary so ask your doctor for further details.

Side effects of BCG

Common side effects of BCG include needing to urinate more often; burning or pain when urinating; blood in the urine; a mild fever; and tiredness. These side effects usually last a couple of days after each BCG treatment session.

Less often, the BCG may spread through the body and can affect any organ. If you develop flu-like symptoms, such as fever over 38°C that lasts longer than 72 hours, pain in your joints, a cough, a skin rash, tiredness, or yellow skin (jaundice), contact a nurse or doctor at your treatment centre immediately. A BCG infection can be treated with medicines.

Very rarely, BCG can cause infections in the lungs or other organs in the body months or years after treatment. If you are diagnosed with an infection in the future, it is important to tell the doctor that you had BCG treatment.

Let your doctor know of any other medicines or complementary therapies you are using, as they may interfere with how well the bladder cancer responds to BCG. For example, the drug warfarin (a blood thinner) is known to interact with BCG.

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Most people with muscle-invasive disease have surgery to remove the bladder (cystectomy). This may also be recommended for high-risk non-muscle-invasive bladder cancer that has not responded to BCG.

The surgeon usually needs to remove the whole bladder. This is called a radical cystectomy. Less commonly, it may be possible to do a partial cystectomy. This removes only the tumour and a border of healthy tissue. The bladder will be smaller afterward, so you may need to pass urine more often.

How the surgery is done

Surgery to remove the bladder (cystectomy) and create a urinary diversion is a major and complicated operation. It is important to have this surgery in a specialised centre with a surgeon who does a lot of cystectomies.

Different surgical methods may be used for removing the bladder:

• Open surgery makes one long cut (incision) in the abdomen. A cut is usually made from the area below the bellybutton to the pubic area.
• Keyhole surgery, also known as minimally invasive or laparoscopic surgery, makes several smaller cuts in the abdomen. Instruments are inserted through the cuts, sometimes with help from a robotic system.

Recovery may be faster and the hospital stay may be shorter with keyhole surgery, but the surgery may be more difficult and take longer.

Surgery to remove the bladder

The most common operation for muscle-invasive bladder cancer is a radical cystectomy. The surgeon removes the whole bladder and nearby lymph nodes. Other organs may also be removed, as shown in the image below.

Click on image to enlarge

Because a radical cystectomy removes the whole bladder, the surgeon needs to create a new way for your body to collect and store urine. This is called urinary diversion and there are different options, including urostomy, neobladder and continent urinary diversion.

In general, having an experienced surgeon is more important than the type of surgery.

Talk to your surgeon about the pros and cons of each surgical method, and check what you’ll have to pay. Unless you are treated as a public patient in a public hospital, there are likely to be substantial costs not covered by Medicare or your health fund.

What to expect after surgery

When you wake up after the operation, you will be in a recovery room near the operating theatre. Once you are fully conscious, you will be transferred to the ward.

Tubes and drips – You may have an intravenous (IV) drip to give you fluid and medicine, and a tube in your abdomen to drain fluid from the operation area. These will be removed as you recover.

Pain and discomfort – After a major operation, it is common to feel some pain. You will be given pain medicine as a tablet (orally), through a drip (intravenously) or through a catheter inserted in the spaces in the spine (epidural). If you still have pain, let your doctor or nurse know so they can change your medicine as needed.

Recovery time – You will probably be in hospital for 1–2 weeks, but it can take 6–8 weeks to fully recovery from a cystectomy. The recovery time will depend on the type of surgery, your fitness and whether you have any complications. Depending on the type of work you do, you will probably need around 4–6 weeks leave from your job.

Urination – A cystectomy will affect how you store urine and urinate.

Sexuality and fertility after cystectomy

A cystectomy can affect sexuality and fertility in many ways. You may find these changes upsetting and worry about how they’ll affect your  relationships. Ask your treatment team for information about ways to manage these changes. It may be helpful to talk about how you’re feeling with your partner, family members or a counsellor.

Changes for males

Nerve damage to the penis – A cystectomy can often damage nerves to the penis, but the surgeon will try to prevent or minimise this. Nerve damage can make it difficult to get an erection. Options for improving erections include:

• oral medicines prescribed by a doctor that increase blood flow to the penis
• injections of medicine into the penis
• vacuum devices that use suction to draw blood into the penis and make it firm
• an implant called a penile prosthesis – under general anaesthetic, flexible rods or thin inflatable cylinders are inserted into the penis and a pump is placed in the scrotum; you can then turn on or squeeze the pump when you need an erection.

Orgasm changes – You will not be able to ejaculate after a radical cystectomy if the prostate and seminal vesicles were removed along with the bladder. You can still feel the muscular spasms and pleasure of an orgasm even if you cannot ejaculate or get an erection, but it will be a dry orgasm because you no longer
produce semen.

Fertility changes – If the prostate and seminal vesicles are removed, you will no longer produce semen. This means you won’t be able to have children naturally. If you may want to have children in the future, talk to your treatment team about whether you can store sperm at a fertility clinic before treatment. The sperm could then be used when you are ready to start a family.

Changes for females

Vaginal changes – Sometimes, the vagina may be shortened or narrowed during a cystectomy. Nerves that help keep the vagina moist can also be affected, making the vagina dry. These changes can make penetrative sex difficult or uncomfortable at first. Ways to manage these changes include:

• using a hormone cream (available on prescription) or vaginal moisturiser (available at pharmacies) to keep your vagina moist
• asking a physiotherapist how to use vaginal dilators to help stretch the vagina – vaginal dilators are plastic or rubber tube-shaped devices that come in different sizes
• when you feel ready, trying to have sex regularly and gently to gradually stretch the vagina
• using a water-based or silicone-based lubricant (available from pharmacies and supermarkets) to make sex more comfortable.

Arousal changes – A cystectomy can damage the nerves in the vagina or reduce the blood supply to the clitoris, which can affect how you become aroused and your ability to orgasm. Talk to your surgeon or nurse about ways to minimise potential side effects. You can also try exploring other areas of your body that feel pleasurable when touched, such as the breasts, inner thighs, feet or buttocks.

Menopause and fertility – Sometimes, the uterus and other reproductive organs are removed during a radical cystectomy. This will cause menopause if you have not already been through it. Your periods will stop, you will no longer be able to become pregnant, and you may have menopausal symptoms such as hot flushes and vaginal dryness. Talk to your doctors about ways to deal with the symptoms of menopause.

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Chemotherapy uses drugs to kill or slow the growth of cancer cells. The aim is to destroy cancer cells while causing the least possible damage to healthy cells.

For muscle-invasive bladder cancer, drugs are injected into a vein (intravenously). As the drugs circulate in the blood, they travel throughout the body. This type of chemotherapy is called systemic chemotherapy. It is different to the intravesical chemotherapy used for non-muscle-invasive bladder cancer, which is delivered directly into the bladder.

Systemic chemotherapy for non-muscle-invasive bladder cancer is used:

• before surgery (neoadjuvant chemotherapy) – to shrink the cancer and make it easier to remove; it can also reduce the risk of the cancer coming back
• after surgery (adjuvant chemotherapy) – if there is a high risk of the cancer coming back.

You will see a medical oncologist to plan your chemotherapy treatment. Chemotherapy is commonly given as a period of treatment followed by a break. This is called a cycle. In most cases, you will have several cycles of treatment over a few months. Usually a combination of drugs works better than one drug alone. The drugs you are offered will depend on your age, fitness, kidney function and personal preference. Your medical oncologist can answer any questions you have.

Systemic chemotherapy can sometimes be combined with radiation therapy (chemoradiation) as part of trimodal therapy. Systemic chemotherapy may also be used for bladder cancer that has spread to other parts of the body.

Side effects of systemic chemotherapy

The side effects of chemotherapy vary. They may include fatigue, nausea and vomiting, constipation, mouth sores, taste changes, itchy skin, hair loss, ringing in the ears, and tingling or numbness of fingers or toes. In most cases, side effects last for only a few weeks or months, although sometimes they are permanent. Talk to your doctor about ways to reduce or manage any side effects you have.

During chemotherapy, you may be more prone to infections. If you develop a temperature over 38°C, contact your doctor or go immediately to the emergency department at your nearest hospital.

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Radiation therapy, also called radiotherapy, uses a controlled dose of radiation to kill or damage cancer cells. The radiation is usually in the form of x-ray beams. Radiation therapy to treat bladder cancer is used as part of trimodal therapy, either on its own or combined with chemotherapy.

You will meet with the radiation oncology team to plan your treatment. It is common to have more imaging scans to help pinpoint the exact area to receive the radiation. During a radiation therapy session, you will lie on an examination table and a machine will direct the radiation towards your bladder. The treatment is painless and can’t be seen or felt.

Side effects of radiation therapy

Radiation therapy for bladder cancer can cause temporary side effects, including needing to urinate more often and more urgently, burning when you pass urine, fatigue, loss of appetite, diarrhoea and soreness around the anus. Symptoms tend to build up during treatment and usually start improving over a few weeks after treatment ends.

Less commonly, radiation therapy may permanently affect the bowel or bladder. Bowel motions may be more frequent and looser, and damage to the bladder lining (radiation cystitis) can cause blood in the urine.

Radiation therapy for males may cause poor erections and make ejaculation uncomfortable for some months after treatment. For females, radiation therapy can cause the vagina to become drier, narrower and shorter.

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Instead of cystectomy, you may have trimodal therapy as the main treatment for muscle-invasive tumours. Trimodal therapy may be used if a person is unable to have surgery to remove the bladder or would prefer to keep their bladder. It is most suited for people whose bladder is working well and smaller tumours that haven’t spread.

Trimodal therapy involves:

• a shorter surgery to remove the tumour from the bladder, followed by
• radiation therapy combined with chemotherapy (chemoradiation). Some people who are not fit enough for chemotherapy will have radiation therapy on its own.

Studies have shown that trimodality therapy has similar outcomes to radical cystectomy. Talk to your medical team to discuss whether trimodal therapy may be an option in your situation.

Having trimodal therapy

If you have chemoradiation, the chemotherapy makes the cancer cells more sensitive to radiation and can increase the success of the treatment. You will usually have radiation therapy as daily treatments, Monday to Friday, over 4–7 weeks as an outpatient.

There are different options for receiving chemotherapy. Some people will have it once a week a few hours before or after a radiation therapy session. Other people may take a tablet or receive an infusion over several days through a small plastic tube and pump.

During and after chemoradiation, you may experience side effects from both the chemotherapy and the radiation therapy. Talk to your treatment team about ways to manage the side effects of chemoradiation.

Trimodal therapy has the advantage of not removing the bladder, so you can still urinate in the usual way. You will need to have regular cystoscopies after treatment to check that the cancer has not come back. Some people who have had trimodal therapy for muscle-invasive bladder cancer will later need their bladder removed because the cancer has come back.

Immunotherapy uses the body’s own immune system to fight cancer. BCG is a type of immunotherapy treatment that has been used for many years to treat non-muscle-invasive bladder cancer. A newer group of immunotherapy drugs called checkpoint inhibitors work by helping the immune system to recognise and attack the cancer.

Some people with advanced bladder cancer may have checkpoint immunotherapy drugs such as pembrolizumab or avelumab after a course of chemotherapy. The drugs are given directly into a vein through a drip (infusion) and the treatment is repeated every 2–6 weeks. How many infusions you receive will depend on how you respond to the drug.

Some drugs may be available through clinical trials for people with bladder cancer that has come back or not responded to treatment. Ask your doctor about recent developments in drugs for bladder cancer and whether a clinical trial may be an option for you.

Side effects of immunotherapy

Like all treatments, checkpoint inhibitors can cause side effects. Because these drugs act on the immune system, they can sometimes cause the  immune system to attack healthy cells in any part of the body. This can lead to a variety of side effects such as skin rash, diarrhoea, breathing  problems, inflammation of the liver, hormone changes and temporary arthritis. Your doctor will discuss possible side effects with you.

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If you have palliative radiation therapy, you may have one session or up to 20 sessions given Monday to Friday over four weeks. Your doctor will explain your treatment schedule. Some people may have radiation therapy combined with chemotherapy (chemoradiation).

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Palliative treatment is one aspect of palliative care, in which a team of health professionals aims to meet your physical, emotional, practical,  cultural, social and spiritual needs. The palliative care team will work with your cancer specialists to manage side effects from treatment. The team also provides support to families and carers.

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