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Although most superficial bladder cancers can be managed conservatively with TURBT alone or in combination with intravesical immunotherapy, once the tumor has invaded the muscularis propria, the likelihood of disseminated disease increases significantly and, therefore, more intensive treatment is necessary. In general, the treatment options for patients with muscle-invasive bladder cancer include:

• Radical cystectomy
• Multimodality therapy with bladder preservation approaches (i.e., chemotherapy plus radiation therapy)

Radical Cystectomy

Radical cystectomy is an open surgical procedure performed by cutting through the abdomen to remove the bladder. In addition to resecting the entire bladder, a bilateral pelvic lymph node dissection and resection of nearby organs is also performed. The organs that may be resected include:

• In men - the prostate gland and seminal vesicles
• In women - the uterus, ovaries, part of the vagina, and fallopian tubes

In the U.S., radical cystectomy and bilateral lymph node dissection is considered the "gold" standard treatment for muscle-invasive bladder cancer. Several studies have demonstrated inferior survival outcomes for patients with muscle-invasive disease who do not undergo radical cystectomy.

Side-effects that may develop following radical cystectomy include:

• Urinary tract infections
• Bleeding
• Urinary incontinence
• Blockage of urine flow
• Sexual dysfunction

Postoperatively, patients who undergo a radical cystectomy will require urinary diversion reconstructive surgery and will also have to learn to cope with sexual dysfunction issues that may develop as a consequence of radical cystectomy.

Urinary Diversion Reconstructive Surgery

Patients who undergo a radical cystectomy for muscle-invasive bladder cancer also require urinary diversion reconstructive surgery to collect and eliminate urine. Urinary diversion, also known as urostomy, is the general term used to describe reconstructive surgical procedures that bypass the normal structures of the urinary system by creating a "diversion" or conduit for the passage of urine through an opening in the abdominal wall called a stoma. There are several types of urinary diversion surgical reconstructive procedures that may be performed:

• Ileal conduit procedure - In this type of urostomy, a section of the ileum (end of the small bowel) is surgically removed and is relocated to serve as a conduit for the passage of urine from the kidneys through the ureters to the outside of the body via the stoma. The urine is collected and drains into a bag that is attached outside the abdomen.

• Cecal conduit procedure - This procedure is similar to the ileal conduit procedure with the exception that, instead of the ileum, the surgeon uses the cecum (the beginning of the large bowel) to create a conduit for the passage of urine from the kidneys to the outside of the body. Again, the urine is collected and drains into a bag that is attached outside the abdomen.

• Continent diversion - In this type of urostomy, the surgeon creates a reservoir or pouch inside the abdomen using a segment of either the small or large bowel and a valve is created within the pouch to collect and store urine from the ureters. The patient then uses a catheter that is inserted through the stoma several times a day to drain the urine that has accumulated in the pouch.