Muscle-invasive bladder cancer treatment

When bladder cancer has invaded the muscle layer (muscularis propria), the main treatment options are:

• surgery to remove the whole bladder (cystectomy), sometimes with chemotherapy given before surgery (neoadjuvant chemotherapy) or after surgery (adjuvant chemotherapy)

• bladder-conserving surgery (TURBT), followed by radiation therapy with or without chemotherapy. This is called trimodal therapy.

Surgery (cystectomy)

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

The surgeon usually needs to remove the whole bladder and nearby lymph nodes. This is called a radical cystectomy. Other organs may also be removed. After a radical cystectomy, a urinary diversion is needed so your body can store and pass urine. For out more about about urinary diversion.

How the surgery is done

Surgery to remove the bladder and create a urinary diversion is a complicated operation. Different surgical methods may be used to remove the bladder:

• Open surgery makes one long cut (incision) in the lower abdomen. A cut is usually made from below the belly button 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.

It is important to have this surgery in a specialised centre with a surgeon who does a lot of cystectomies. 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, you are likely to have lots of costs not covered by Medicare or your health fund.

Radical cystectomy in males

Radical cystectomy in females

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 moved to intensive care or 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) or along the wound (wound catheters). If you still have pain, let your doctor or nurse know and they may change your medicine.

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

Passing urine – Because a radical cystectomy removes the whole bladder, the surgeon needs to create a new way for your body to store and pass urine. See Urinary diversion.

Sexual activity and fertility after a cystectomy

A cystectomy can affect sexual activity 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.

For more information, see Sex, intimacy and cancer and Fertility and cancer and listen to Cancer Council's Sex and Cancer podcast episode.

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 want an erection.

Orgasm changes

If the prostate and seminal vesicles are removed along with the bladder, you will not be able to ejaculate after a radical cystectomy. 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 might 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 atpharmacies) 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 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 symptoms of menopause.

Systemic chemotherapy

Chemotherapy uses drugs to kill or slow the growth of cancer cells. For muscle-invasive bladder cancer, drugs are injected into a vein (intravenously) and travel throughout the body. This type ofchemotherapy is called systemic chemotherapy. It is different to the intravesical chemotherapy used for superficial bladder cancer, which is delivered directly into the bladder.

Systemic chemotherapy for muscle-invasive bladder cancer is used:

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

How chemotherapy is given

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 chemotherapy over a few months. Usually, a combination of drugs works better than one drug alone.

Systemic chemotherapy can sometimes be combined with radiation therapy (chemoradiation) and TURBT 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

These may include: fatigue; nausea and vomiting; constipation; mouth sores; taste changes; itchy skin; hair loss; ringing in the ears; and tingling or numbness of the fingers or toes. Side effects usually last for only a few weeks or months, although some can be permanent. Talk to your doctor about ways to reduce your risk or manage any side effects you develop.

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.

Immunotherapy (checkpoint inhibitors)

This type of drug treatment uses the body's own immune system to fight cancer. In muscle-invasive bladder cancer, immunotherapy drugs may be used with chemotherapy before surgery (neoadjuvant treatment) or after surgery (adjuvant treatment).

How immunotherapy is given – Immunotherapy is given in the same way as chemotherapy.

Side effects of immunotherapy – This treatment may trigger an immune response that leads to side effects anywhere in the body. Other side effects include fatigue, headaches and nausea and vomiting.

Radiation therapy

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 may be used on its own, combined with chemotherapy (chemoradiation) or as part of trimodal therapy.

How radiation therapy is given

You will meet with the radiation oncology team to plan your treatment. It is common to have imaging scans to help locate the area to receive the radiation. 

During treatment, you will lie on an examination table and a machine will direct the radiation towards your bladder. The treatment is painless.

Side effects of radiation therapy

Temporary side effects may include: needing to urinate more often and more urgently; a burning sensation when you urinate; fatigue; loss of appetite; diarrhoea; and soreness around the anus. Symptoms tend to build up during treatment and usually start improving 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. It may also lead to premature menopause. Learn ways to manage these changes.

If the therapy affects the lymph nodes, there may be an increased risk of lymphoedema (swelling in the legs caused by a build-up of lymph fluid).

Trimodal therapy

Instead of a cystectomy, you may have trimodal therapy as the main treatment for muscle-invasive bladder cancer. 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 who have smaller cancers that haven’t spread.

Trimodal therapy involves:

• surgery to remove the tumour from the bladder (TURBT)
• radiation therapy combined with chemotherapy (chemoradiation) to destroy remaining cancer cells. People who are not fit enough for chemotherapy will have radiation therapy on its own.

Studies have shown that trimodal therapy has similar outcomes to radical cystectomy for certain small cancers. However, there is a chance the cancer may come back in the bladder and cystectomy may still be required.

Having trimodal therapy

If you have trimodal therapy, chemotherapy or other medicines are given to make the cancer cells more sensitive to radiation. 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 chemotherapy once a week a few hours before or after a radiation therapy session. Other people take a tablet or have an infusion over several days.

During and after chemoradiation, you may have side effects from the chemotherapy and the radiation therapy. The bladder is not removed in trimodal therapy, 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.