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We are the only health-care provider in the western United States to offer a new diagnostic tool for urologists when they examine the inside of the bladder for cancer. The “blue light cystoscopy” helps urologists identify more bladder tumors, which are difficult to see using conventional “white light cystoscopy,” resulting in a better diagnosis. Our team pioneered and published several papers regarding the importance of extended lymph node dissections at the time of surgery. The procedure resulted in both decreased cancer recurrence and improved patient survival. USC urologists also lead the research in to various techniques and concepts of continent urinary diversion. These innovative techniques have significantly improved patient outcomes, leading to worldwide adoption. As a result, Keck Medicine of USC is now a premier destination for patients seeking major surgery for bladder cancer.
USC Institute of Urology maintains a prospective computerized registry of patients who have undergone radical cystectomy for invasive bladder cancer since 1971. The detailed data on more than 3,000 patients allows us to identify predictors of surgical outcomes in terms of cancer control and quality of life.
Keck Medicine of USC urologic surgeons and medical oncologists work as a close team to provide optimal, individualized care for our patients with bladder cancer. We strongly believe in spending ample time with patients and their families in order to discuss their cancer diagnosis and treatment options. Family support is important when making major treatment decisions.
Bladder cancer usually presents with painless blood in the urine. The blood may be visible to the patient, or it may be microscopic and only picked up when the urine is examined under a microscope. Sometimes, bladder cancer can also cause irritative voiding symptoms, including urinary urgency and frequency. This means having the urge to urinate even with an empty bladder, or urinating more often than usual. All of these symptoms could be related to non-cancerous conditions as well, so it is important to speak to your doctor if you experience any of these symptoms.
Bladder cancer diagnosis involves looking at the bladder through a scope (cystoscopy), testing the urine for abnormal cells under the microscope (cytology), and sometime involves taking a tissue sample from the bladder to check for cancer under a microscope (biopsy). Once the diagnosis of bladder cancer is established, it is important to stage the cancer to begin the appropriate treatment.
Staging and treatment relies heavily on tissue obtained at the time of transurethral resection of the bladder tumor (TURBT) where the tumor is excised endoscopically through a cystoscope. Treatment decisions are heavily based on the aggressiveness of the tumor (pathologic grade) and the layer of the bladder that is involved with the tumor (pathologic stage). It is imperative to obtain a sample of the muscle of the bladder at the base of the tumor in order to ascertain whether the tumor has invaded the muscular layer. The so-called ‘superficial’ or non-invasive bladder tumors arise from the mucosal (or the innermost) layer of the bladder wall and are usually completely removed during a TURBT. Tumors that have invaded the thin layer of connective tissue just deep to the mucosal layer called the lamina propria (stage T1), require special attention, since up to 30 percent may have evidence of invading the muscle layers on re-removal or repeat TURBT. If there is adequate muscle present in the pathology specimen to ascertain the absence of invading the muscle layers, these tumors can be treated with intravesical chemotherapy or immunotherapy (solutions placed inside the bladder through a catheter). BCG (the tuberculin vaccine) is often used for intravesical therapy and can be very effective in reducing recurrence rates. Treatment options for muscle-invasive bladder cancer differ significantly than their non-invasive counterparts.
The treatment for bladder cancer is dependent on the tumor grade and stage. Low-grade tumors can usually be treated endoscopically, through removal of the tumor using a telescope in the operating room. If the tumor is more aggressive or higher grade but limited to the mucosa or lamina propria, we recommend treating the patient with immunotherapy (BCG) or chemotherapy placed in the bladder. This is usually done in the office on a set schedule. Cancer that is higher stage or progressed through the inner lining of the bladder requires more invasive treatment.
Radical cystectomy with an extended and thorough pelvic lymph node dissection is the gold-standard treatment for high-grade, invasive bladder cancer. Most comparative studies have indicated that local recurrence and survival outcomes using bladder-sparing protocols (transurethral removal, chemotherapy and/or radiation) for muscle-invasive disease are inferior to those outcomes from radical cystectomy to control muscle-invasive bladder cancer. Continuous improvement in surgical techniques and post-operative care has greatly reduced late effects of surgery, including sexual dysfunction in select cases. At USC, we offer patients the option of minimally invasive techniques, including robotic-assisted laparoscopy, or the traditional open approach. Our surgeons are world renowned for both techniques and depending on the patient’s preferences and clinical findings, we work with the patient to develop a plan that puts the patient in charge of his or her care without compromising quality or expertise.
In men, radical cystectomy involves complete removal of the bladder, prostate, seminal vesicles and pelvic lymph nodes. At USC, we have experience in performing nerve-sparing cystectomies, and some cystectomies that spare the male reproductive organs for those who are still seeking to father children.
In female patients, a radical cystectomy (referred to as anterior exenteration) traditionally involves removal of the bladder, uterus, fallopian tubes, ovaries and the anterior vaginal wall. While this is still necessary in some patients, the pelvic organs and the vagina can sometimes be spared in certain female patients without compromising cancer control. At USC, we have been able to perform uterine-sparing cystectomies in women of child-bearing age, without compromising the cancer surgery.
Cystectomy provides the best survival outcomes and the lowest rate for cancer to reoccur in that area. The recurrence-free and overall survival is significantly related to the pathological stage with overall survival rates of about 50 percent at five years. Patients who have lymph node negative, organ confined cancer have a five-year survival of about 80 percent, whereas patients with disease extending outside the bladder into the perivesical fat or patients with lymph node involvement have five-year survival of 35-58 percent. Remarkably, patients with lymph node involvement still have an approximately 35 percent chance of long term survival with a radical cystectomy and extended pelvic lymph node dissection.
Pelvic lymph nodes are one of the first sites to which bladder cancer spreads. Although the extent or absolute limits of the lymph node removal remain to be better defined, a growing body of data supports a more extended lymphadenectomy at the time of cystectomy in all patients who are appropriate surgical candidates. An extended lymph node dissection should include the distal para-aortic and paracaval lymph nodes as well as the pre-sacral nodes, known anatomic sites of lymph node drainage from the bladder and potential sites of lymph node metastases in patients with bladder cancer.
An extended dissection may provide a survival advantage in patients with node-positive as well as node-negative tumors. The extent of the primary bladder tumor (p stage), the number of lymph nodes removed, and the lymph node tumor burden are important prediction outcomes in patients undergoing cystectomy with evidence of lymph node metastases.
At USC, we not only believe in this principle, we were some of the pioneers in this field. We have been performing an extended lymph node dissection as routine practice for years, and we have published the survival advantage in many academic journals.
Types of Urinary Diversion
Once the native bladder is removed, the kidneys will need to drain the urine into another space. There are several options for bladder cancer patients in terms of urinary diversion. At USC, we work with the patient to determine the optimal choice in urinary diversion that would cater best to the patient’s lifestyle and needs.
Ileal Conduit (Urostomy)
The ileal conduit is constructed from a small segment of the intestine and brought out to the skin as a stoma to collect urine. The ureters are sutured together directly into the bowel segment used, and urine passes freely from the conduit into an external collection device (stoma bag), which is emptied periodically. This is the least technically demanding method of urinary reconstruction and is what is performed at a majority of institutions. Patients who have impaired kidney function or who are otherwise not a candidate for an orthotopic neobladder are offered this form of urinary diversion.
The orthotopic neobladder offers the advantages of a superior cosmetic appearance (without the need for a cutaneous stoma or urostomy appliance) and allows for a more natural voiding pattern via the patient’s existing urethra. The sense of body image, however, is very personal and subjective and varies considerably from patient to patient. In fact, most patients are quite content with their choice of urinary diversion whether it is continent or incontinent.
All patients undergoing cystectomy should be properly informed of the various urinary diversion options. There are established contraindications to a continent urinary diversion and certain clinical indications that may favor a conduit diversion but the majority of patients today undergoing cystectomies are candidates for a continent urinary diversion, and should be counseled accordingly. We believe that each patient facing urinary diversion should have a long discussion with the surgeon to discuss the risks and benefits of all forms of diversion.
USC has been a world-renowned center for bladder cancer treatment over the past several decades. In fact, the first orthotopic bladder reconstruction, which provides a viable alternative to a colostomy bag, was developed here. The recent addition of a strong robotic and laparoscopic team further bolsters the already strong open surgical excellence for treatment of invasive bladder cancer.
With more than 500,000 bladder cancer survivors in the United States alone, treatment options, such as surgery, have proven to be extremely effective. Transurethral resection (TUR) is a surgical procedure that is used both to diagnose bladder cancer and to remove cancerous tissue from the bladder while cystectomy is the surgical removal of all or part of the bladder (and possibly surrounding pelvic organs) to treat cancer that has spread into the bladder wall.
Cystectomy traditionally has been performed using an open approach, meaning the surgeon must make a large abdominal incision to access the bladder. Another approach, conventional laparoscopy, is less invasive but limits the doctor’s dexterity, field of vision and control, compared to open surgery.
However the precision and dexterity offered by the advanced instrumentation of robotic surgery allows for a minimally invasive approach to treating bladder cancer. USC surgeons have pioneered the use of minimally invasive cystectomy and urinary diversion and have performed many more of these cases than other centers throughout the world. Furthermore, USC urologists have performed extended pelvic lymph node dissection using robotic and laparoscopic techniques with comparable number of nodes retrieved as open surgery.