Author: lindseyhemonc

Diagnosis Decisions: Surgical Options for Bladder Cancer

Choosing a replacement bladder that’s right for you

Excretory system

After being diagnosed with bladder cancer, it may be necessary to completely remove the bladder depending on the severity and location of the cancer. Medically, this is referred to as a radical cystectomy and involves the complete removal of the bladder, nearby lymph nodes, and part of the urethra. A radical cystectomy is the best treatment when the cancer has become invasive and has spread to the muscle layer of the bladder.

After the bladder is removed, the urine needs somewhere to go. Bladder cancer patients have options regarding the mechanism they would like to use to replace the role of the bladder and provide a way for urine to exit the body. This is sometimes referred to as a “urinary diversion” and there are different techniques used to divert the urine. Options include: a urostomy, neobladder reconstruction, or continent urinary reservoir construction. Each one has its unique advantages and disadvantages, and we have outlined some key factors to consider. The success of any of these options relies heavily on managing expectations. It’s critical that each patient has a realistic understanding of the advantages and disadvantages of each option.

  • An ileal conduit (urostomy) is a surgical procedure that allows urine to pass through a newly made opening on the body. In this procedure, a surgeon detaches one or both of the ureters from the bladder and attaches them to a small piece of intestine. This segment of intestine is then attached to the surface of the abdomen where an opening (also called a stoma) is made. A collection pouch then stores the urine outside the body since there are no muscles around the stoma to control the flow of urine. The segment of intestine simply acts as a “conduit” for urine to pass to the outside. Depending upon fluid intake, the external bag needs to be emptied every 6 hours and the external appliance is typically changed every 3-5 days. One can be quite active with this device and can still exercise, including swimming and running.
  • Orthotopic neobladder reconstruction is a surgical procedure in which an entirely new bladder is constructed from the intestine to replace the bladder. Typically, a small section of the small intestine is used to create a sphere shape that can store and pass urine through the body as a normal bladder would. This procedure leaves the patient with the urine storage and exit route that most closely resembles that of the original bladder. While this new bladder serves as a great replacement for the original bladder, it does require some re-learning on behalf of the patient in order to void without any difficulties. After three months post-surgery, most men and women can void quite well. Some nighttime incontinence can linger for the first year.
  • Continent urinary reservoir is a surgical procedure where an internal reservoir is made from a segment of the intestine. Instead of voiding, however, the patient needs to catheterize themselves through the belly button (umbilicus) in order to drain the urine. A valve mechanism is made in order to retain urine that the patient can drain on their own. Much like the urostomy previously discussed, a pouch to collect urine is used in this method, however now the pouch is internal. This procedure also requires ongoing maintenance to empty the pouch through intubation every 4-6 hours and can result in urinary leakage. Most patients are quite happy with this type of diversion in that they never leak urine and they do not require any external bags. They do, however, need to always have a catheter with them in order to empty their bladders.

Choosing which method to use really depends on the individual and what best meets his or her lifestyle. It is important to understand how all the options work prior to making a decision. For example, neobladder reconstruction is a good alternative for those who do not want a stoma or to deal with an external pouch involved with a urostomy, however people who choose this option must then learn neobladder training and adjust to a new normal with a bladder that has slightly different capabilities.

Here at Weill Cornell Medicine and NewYork-Presbyterian, we offer all three types of bladder reconstruction surgeries. Approximately 50% of our patients choose ileal conduits and the remaining 50% is split between neobladder reconstruction and continent urinary reservoir. We encourage you to speak with your physician about which replacement bladder is right for you.

We perform all of these surgeries robotically. Robotic-assisted cystectomy (also known as da Vinci cystectomy) is a minimally invasive surgical method that is done with cutting-edge robotic equipment guided by the hands of a surgeon. This technique is able to mimic a surgeon’s movements with even greater precision. It has several benefits ranging from less tissue and nerve damage to reduced blood loss and decreased risk of infection. Additionally, it is the only robotic surgery approved by the Food and Drug Administration (FDA).

Our medical center has the largest single surgeon robotic cystectomy experience in the world, and through this procedure we have been highly successful in removing tumors and creating replacement bladders, while simultaneously maintaining urinary continence and maximizing cancer cure rates. Learn more.

When Food and Cancer Meds Don’t Mix

Food_Meds_CancerWhat you eat and drink can affect the way your cancer medication works. It is important to have a well-balanced diet and to make sure you are getting enough nutrients, while simultaneously avoiding foods that could alter treatment or damage your body.

After oral medications are ingested, the drugs are broken down and absorbed by the body. This process begins in the digestive system. Sometimes, certain drinks, foods, and medications don’t mix. That’s because levels of certain enzymes in our gut (which are responsible for breaking down large substances into smaller substances) change during the digestive process. These changes can increase or reduce the level of the medication that gets absorbed by the body, making some meds weaker and others stronger. This is problematic because doctors intentionally prescribe a specific dosage based on your type and stage of cancer, as well as other factors such as your height and weight.

Additionally, there are several negative “food-drug interactions” that are well established. For example, grapefruit interferes with the action of some cancer medications since it affects the way enzymes work. Grapefruit has the ability to increase absorption of the drug into the bloodstream, which can be very dangerous. By amplifying the effect of a drug, the medicine is no longer working in the way it was intended and there is increased risk for unexpected side effects and liver damage. This can be very harmful to the body and make the treatment side effects more difficult.  

When in doubt, check the label or package insert of your medication. More than likely, there will be certain foods that your medicines should not be mixed with and directions on how the meds should be taken. For example, the time of day and whether they should be taken with water or food, on an empty or full stomach, etc. These directions are there for a reason, but don’t hesitate to ask your doctor or pharmacist if you are uncertain about these instructions or specific restrictions.

Sometimes, cancer patients turn to vitamins and supplements after learning of a cancer diagnosis. Whether the goal is to seek out alternative medicine, strengthen the immune system, or lessen the treatment side effects, it’s important to always speak with your physician before taking anything. However, there is no conclusive data showing that supplementation benefits cancer patients, so it is not recommended that vitamins and supplements be used. They can interfere with treatment and cause discomfort.

Our team includes dietitians who specialize in cancer care and can provide you with additional information about what to eat and what to avoid in order to reduce side effects and potential negative drug interactions.

Read more about supplement usage with cancer treatment from our oncology dietitian, Shayne Robinson, RD, CSO, CDN, who recently wrote a great piece on the topic for the Weill Cornell Medicine Lymphoma Program’s blog.

Is Surgery Critical for Advanced Kidney Cancer?

Drs. Ana Molina, Jim Hu and David Nanus address key issues in an editorial published this week in the Journal of Clinical Oncology

Surgical HandsUntil the last decade, there was much debate on the standard of care treatment for patients with metastatic renal cell carcinoma (mRCC), commonly referred to as advanced kidney cancer. Some physicians believed that the best treatment was to surgically remove the kidney, a process called cytoreductive nephrectomy (CN), while others argued that surgery did more harm than good.

In 2001 and 2004, two randomized clinical trials compared the two approaches (cytokine therapy alone vs. surgery plus cytokine therapy) in a controlled, side-by-side fashion and demonstrated a survival benefit for patients who had surgery followed by cytokine therapy. Cytokines are man-made versions of naturally occurring proteins that can enhance the immune response to cancer. This research found that patients that underwent surgery in addition to being given the cytokine interferon medication showed an average survival of 13.6 months, compared with 7.8 months for those who only received the interferon treatment, demonstrating a 31% reduced risk of death. Based on this study, urologists and oncologists continued to recommend surgery, seeing major improvements in disease-free and overall survival in patients who had their primary kidney tumors surgically removed.

Over the past ten years, there have been critical advancements in the treatment of kidney cancer and targeted therapies (i.e. vascular endothelial-growth factor inhibitors) have replaced cytokine therapy as the standard of care. Targeted therapies block the growth and spread of cancer by interfering with specific molecular targets associated with cancer. The role of surgery has become unclear since the introduction of targeted therapy. Of note, nearly 90% of patients enrolled in the early studies examining targeted therapies had undergone nephrectomy.

Retrospective studies suggest that surgery improves outcomes and reduces the risk of death from cancer by more than 50%. Despite possible improved outcomes, we have seen a decline in the use of surgery. A recent study sought to evaluate current utilization rates of surgery and examined the survival benefit of surgery compared with no surgery. They noted that currently only three out of 10 patients receiving targeted therapy undergo surgery. In addition, socioeconomic and racial disparities were associated with these declines. Younger, white people with private insurance and earlier stage cancer are more likely to have their tumors removed. These declines are also more significant at community hospitals than academic centers. This is important to point out because research also shows that African Americans with metastatic kidney cancer have a poorer prognosis than white patients, and inferior survival is more pronounced in black patients who do not undergo surgery.

Two large, phase 3 randomized clinical trials (CARMENA and SURTIME) will provide answers about the role of surgery in the era of targeted therapy. The CARMENA study is enrolling patients in France and comparing the outcomes of surgery followed by targeted therapy versus targeted therapy alone. The European SURTIME study is comparing the impact of patients undergoing immediate surgery and then receiving targeted therapy with patients first receiving targeted therapy and then deferred surgery. Until these two studies are completed and the results are available, we recommend that all medical oncologists and urologists carefully evaluate each patient and consider surgery when feasible.