Transitional cell carcinoma surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Surgery

Transitional Cell Cancer of the Bladder

Surgery is the mainstay of treatment for bladder cancer. The type of surgery depend on the type and the stage of the tumor.

Transurethral resection of the bladder (TURB)

• A transurethral resection (TUR) is also called a cystoscopic resection or a transurethral resection of bladder tumor (TURBT).
• Cancerous bladder tissue is removed through the urethra.
• Transurethral resection is used as the first treatment for all bladder cancers.
• It may be the only treatment needed for bladder cancer that hasn’t grown into the muscle layer of the bladder wall.
• For bladder cancer that has grown deeper into the bladder wall, a TUR usually removes most of the tumor and also acts as a biopsy before other treatment is given.

Partial Cystectomy

• Partial cystectomy is a segmental cystectomy removes the tumor and part of the bladder.
• Partial cystectomy may be an option if:

• The patient has a small tumor that can easily be removed with clear margins.
• The tumor is in an abnormal pouch on the bladder wall.
• The patient isn't healthy enough to have more extensive surgery.

Radical Cystectomy

• Radical cystectomy removes all of the bladder along with the surrounding fatty tissue and nearby lymph nodes.
• Many people with stage II or III bladder cancer may need to have their bladder removed (radical cystectomy).

Urinary diversion

Surgery may also be done to help your body drain urine after the bladder is removed. This may include:

Ileal conduit

• A small urine reservoir is surgically created from a small piece of bowel
• The ureters that drain urine from the kidneys are attached to one end of the bowel segment.
• The other end is brought out through an opening in the skin (a stoma).
• The stoma allows the patient to drain the collected urine out of the reservoir.

Continent urinary reservoir

• A pouch to collect urine is created inside the body using a piece of your colon.
• You will need to insert a tube into an opening in your skin (stoma) into this pouch to drain the urine.

Orthotopic neobladder

• This surgery is becoming more common in patients who had their bladder removed.
• A part of the bowel is folded over to make a pouch that collects urine.
• It is attached to the place in the body where the urine normally empties from the bladder.
• This procedure allows you to maintain some normal urinary control.

Transitional Cell Cancer of the Renal Pelvis and Ureter

Contemplation of anything less than total excision must take into account the potential risk for tumor recurrence anywhere in the upper tract unit. In other than unifocal, low-grade, low-stage renal pelvic tumors, the probable extensive involvement of both contiguous and noncontiguous sites would appear to make segmental excision an unnecessary option with a potentially serious risk. However, an operative possibility includes segmental excision of a particular lesion. If the extent of a tumor can be determined by intraoperative assessment, and frozen section histologic diagnosis confirms low-grade, unifocal tumor of limited size, then segmental excision is possible. However, this approach should be reserved for highly selected patients. This includes those patients who have a solitary kidney or those with decreased renal function and who require maximal preservation of renal tissue. The likelihood of tumor recurrence in this setting, and of extension of disease outside the renal pelvis once the pelvis has been violated, is a serious risk that must be heavily weighed in offering a patient this therapeutic option.

Ureteral transitional cell cancer may more readily offer the possibility of segmental excision if the absence of proximal disease can be documented. In this setting, attention is focused on the ease of reconstruction of the ureter and restoration of ureterovesical continuity. This is most feasible if the cancer is in the distal ureter. If partial ureterectomy is possible and proximal disease has been excluded, then segmental excision and ureteral reimplantation can be performed.

Systematic regional lymph node dissection in conjunction with nephroureterectomy or segmental excision has not been found to enhance the effectiveness of surgery if tumors are of high grade or high stage, since in these instances the overall results are so poor. Correspondingly, lymph node involvement is uncommon in low-stage disease, and lymphadenectomy is therefore unlikely to remove additional tumor. Thus, lymph node dissection at the time of nephrectomy may offer prognostic information, but little, if any, therapeutic benefit.