Cancer involves abnormal cells growing uncontrollably, invading nearby tissues, and spreading to other parts of the body through metastasis.
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The therapeutic landscape for bladder cancer is strictly bifurcated based on the depth of invasion: Non-Muscle Invasive Bladder Cancer (NMIBC) and Muscle-Invasive Bladder Cancer (MIBC). NMIBC is managed with a strategy of organ preservation and local control, whereas MIBC typically requires multimodal systemic therapy and radical surgery. The evolution of treatment has introduced sophisticated immunotherapy agents and robotic surgical platforms, enhancing both survival outcomes and functional recovery.
For NMIBC, the primary treatment is the TURBT to remove all visible disease. However, because recurrence rates are high (up to 70%), adjuvant intravesical therapy is employed. This involves instilling drugs directly into the bladder via a catheter. Bacillus Calmette-Guérin (BCG) is the gold standard for high-risk NMIBC. BCG is a live, attenuated strain of Mycobacterium bovis. When placed in the bladder, it attaches to the urothelium and triggers a massive local immune response. This inflammation recruits immune cells (macrophages and T cells) to the bladder wall, which then recognize and destroy the cancer cells. This was the first successful immunotherapy in oncology.
For patients who fail BCG or have intermediate-risk disease, intravesical chemotherapy (such as Mitomycin C or Gemcitabine) is used. Novel delivery systems, such as hyperthermic intravesical chemotherapy (HIVEC), heat the chemotherapy solution to increase its penetration into the bladder wall, enhancing its cytotoxic effect.
For MIBC, the standard of care is Radical Cystectomy. This involves the removal of the entire bladder, prostate, and seminal vesicles in men, and usually the uterus, ovaries, and part of the vagina in women, along with extensive pelvic lymph node dissection. Today, this is frequently performed using Robotic-Assisted Laparoscopy, which offers 3D visualization and precise dissection, reducing blood loss and post-operative pain.
The most complex aspect of cystectomy is Urinary Diversion—creating a new way for urine to leave the body. There are three main types:
In the metastatic setting, the goal shifts to prolonging life and managing symptoms. Platinum-based chemotherapy remains the first line. However, the introduction of maintenance immunotherapy (e.g., avelumab) after chemotherapy has changed the paradigm, keeping the immune system active against the cancer to delay progression. For patients who progress, ADCs and targeted therapies offer new lines of defense. The “switch maintenance” strategy is crucial: a patient responds to chemotherapy and is then immediately switched to immunotherapy to sustain remission.
Surgical Innovations and Complex Management
Creating a urinary diversion using the intestine introduces metabolic challenges. The bowel segment, designed to absorb nutrients, will reabsorb electrolytes and waste products from the urine. This can lead to hyperchloremic metabolic acidosis. The kidney must work harder to excrete this acid load. Long-term, this can affect bone density and renal function. Treatment involves alkalinizing agents (such as sodium bicarbonate) and careful monitoring of blood work.
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A neobladder is a new bladder surgically created from a section of the patient’s own small intestine after the cancerous bladder is removed. It is connected to the urethra, allowing the patient to urinate relatively normally without an external bag, though it requires training to function correctly.
Chemotherapy given before surgery (neoadjuvant chemotherapy) helps to shrink the tumor, making it easier to remove, and more importantly, kills any microscopic cancer cells that may have already spread to the blood or lymph nodes but are too small to see on scans. This significantly improves long-term survival rates.
Radical cystectomy is a major surgery. Side effects can include changes in urinary function (depending on the type of diversion), sexual dysfunction (due to nerve damage), changes in bowel function, and potential metabolic changes resulting from using the intestine for the urinary tract.
Treatment for recurrent bladder cancer depends on where it comes back. If it recurs in the bladder lining (after initial sparing), more BCG or surgery might be used. If it spreads to other organs, systemic treatments such as immunotherapy, targeted therapy, or other chemotherapy drugs are used to control the disease.
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