C38. Urothelial carcinoma: Treatment modalities

Management

Management for non-metastatic disease (stages I - III) involves either cystoscopic surgical removal of the tumour (TUR-B), complete surgical removal of the bladder (radical cystectomy), or radiotherapy + chemotherapy. For metastatic disease, only chemotherapy and/or immunotherapy is indicated.

Transurethral resection of the bladder

Transurethral resection of the bladder (TUR-B) is a cystoscopic procedure where the tumour and surrounding bladder tissue are removed with a transurethral resectoscope. After the resection, chemotherapeutical drugs or BCG are instilled into the bladder to reduce any residual cancer cells.

TUR-B is both diagnostic and therapeutic and is indicated for all stages of bladder cancer. If the histological examination following TUR-B shows no muscle invasion and shows complete removal, the patient should receive regular installation of chemotherapy or BCG in the bladder for months/years. If there is evidence of muscle invasion, radical cystectomy or bladder preservation therapy is indicated.

Radical cystectomy

Radical cystectomy is indicated for muscle-invasive disease. It involves removal of the bladder, prostate, seminal vesicles, uterus, and adnexae. Lymph node dissection should also be performed. Without a bladder, a bladder substitute should be made. There are multiple options:

• An ileal conduit urinary diversion, also called a Bricker conduit. A new bladder is made from part of the ileum, with the ureters connected to one end, and the other end opens through the abdominal wall like an enterostoma. Urine is collected in a bag connected to the stoma. This is the most common option
• Continent cutaneous urinary diversion. A reservoar for urine is made from a portion of the bowel remade to be like a "sack", which is opened to the abdominal wall. To empty the reservoar of urine, the opening must be catheterised with aseptic technique.
• Continent orthotopic diversion or neobladder. It is similar to an ileal conduit except that the urethra is connected to the new bladder, which allows urination through the urethra as normal.

Bladder preservation therapy

Bladder preservation therapy, also called trimodal treatment, refers to extensive TUR-B followed by radiochemotherapy. This option preserves the bladder.

BCG

BCG (Bacille Calmette-Guérin) is a live vaccine used to prevent tuberculosis. Somehow someone discovered that administering it into the bladder acts like an immunotherapy, where it stimulates the immune system to kill the cancer cells. It may be administered into the bladder following TUR-B for non-muscle-invasive disease.

Chemotherapy

Chemotherapy is usually a combination of gemcitabine and cisplatin. It is indicated as part of bladder preservation therapy or for palliation in metastastic disease.

Immunotherapy

Immunotherapy, usually with immune checkpoint inhibitors like anti-PD-L1 or anti-PD-1 antibodies, is indicated for palliation in metastatic disease.

Radiotherapy

Radiotherapy may be part of bladder preservation therapy or be used palliatively for metastatic disease.