Transitional cell carcinoma surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Suveenkrishna Pothuru, M.B,B.S. [2]

Overview

Surgery is the mainstay of treatment for transitional cell carcinoma. The feasibility of surgery depends on the stage of transitional cell carcinoma at diagnosis. Adjunctive chemotherapy, radiation therapy, and immunotherapy may be required.

Surgery

Transitional Cell Cancer of the Bladder

Surgery is the mainstay of treatment for transitional cell carcinoma of the bladder. The type of surgery depend on the stage of the tumor:

Stage	Treatment
Stage 0	Transurethral resection with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy Transurethral resection with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy followed by periodic intravesical instillations of BCG Segmental cystectomy (rarely indicated) Radical cystectomy (in rare, highly selected patients with extensive or refractory superficial high-grade tumors)
Stage I	Transurethral resection with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy Transurethral resection with fulguration Transurethral resection with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy followed by periodic intravesical instillations of Bacillus Calmette-Guérin (BCG) Transurethral resection with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy followed by intravesical chemotherapy Segmental cystectomy (rarely indicated) Radical cystectomy in selected patients with extensive or refractory superficial tumors
Stage II and Stage III	Radical cystectomy Neoadjuvant combination chemotherapy followed by radical cystectomy External beam radiation therapy with or without concomitant chemotherapy Segmental cystectomy (in selected patients) Transurethral resection with fulguration (in selected patients)
Stage T4b, N0, M0 or any T, N1–N3, M0	Chemotherapy alone Radical cystectomy Radical cystectomy followed by chemotherapy Radical cystectomy alone External beam radiation therapy with or without concomitant chemotherapy Urinary diversion or cystectomy for palliation
Stage any T, any N, M1	Chemotherapy alone or as an adjunct to local treatment External beam radiation therapy for palliation Urinary diversion or cystectomy for palliation

Transurethral resection of the bladder (TURB)

• A transurethral resection 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 transurethral resection 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 drain urine after the bladder is removed. This may include:

Urinary diversion surgery
Ileal conduit
Continent urinary reservoir
Orthotopic neobladder

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

Localized Transitional Cell Cancer of the Renal Pelvis and Ureter

Standard treatment options for localized transitional cell cancer of the renal pelvis and ureter may include:

• Nephroureterectomy with cuff of bladder
• Segmental resection of ureter

Nephroureterectomy

• This is the most common surgery for cancer of the renal pelvis or ureter.
• Removes all of the kidney, the layer of fat around the kidney, all of the ureter, and the tissue where the ureter enters the bladder (called the bladder cuff).
• With large tumors, the renal vein and parts of the large vein in the abdomen (vena cava) may be removed.

Segmental resection of ureter

• This surgery removes the part of the ureter with the tumor in it.
• A segmental resection is usually only used to remove tumors in the lower third of the ureter.
• The surgeon will remove a margin of healthy tissue above the tumor and all of the ureter below the tumor to the bladder.
• The ureter is then usually reattached, or reimplanted, to the bladder (called ureteroneocystostomy).
• In rare cases, a segmental resection is done for tumors higher in the ureter.
• The surgeon removes the tumor with some healthy tissue above and below it.
• The two remaining ends of the ureter are joined together.