Saving the Bladder: Risks, Realities, and Rare Exceptions

May 7, 2025

Transcript

Voice over:

This is Bladder Cancer Matters, the podcast for bladder cancer patients, caregivers, advocates, and medical and research professionals. It’s brought to you by the Bladder Cancer Advocacy Network, otherwise known as BCAN. BCAN works to increase public awareness about bladder cancer, advances bladder cancer research, and provides educational and support services for bladder cancer patients and their loved ones. To learn more, please visit BCAN.org.

Rick Bangs:

Hi, I’m Rick Bangs, the host of Bladder Cancer Matters, a podcast for, by, and about the bladder cancer community. I’m also a survivor of muscle-invasive bladder cancer, the proud owner of a 2006 model year neobladder, and a patient advocate supporting cancer research at the Bladder Cancer Advocacy Network, or as many call it, BCAN, producers of this podcast.

I’m pleased to welcome today’s guest, Dr. John Gore. Dr. Gore is a urologic oncologist and health services researcher. He’s currently a professor in urology, adjunct professor in surgery at the University of Washington and the Fred Hutchinson Cancer Center, and interim vice chair of research in the Department of Urology in Seattle, Washington. He’s pursuing a health services and patient-centered outcomes research program toward improving access to care, quality of life, and quality of care for urologic cancers. He has active funding from PCORI, the NIH, the National Institutes of Health, and AHRQ. Dr. Gore has a long history of partnership with BCAN as the co-chair of the former patient-centered outcomes and policy working group, and he’s been co-funded on research grants with BCAN since 2014. Dr. Gore, thanks for joining our podcast.

Dr. John Gore:

Thank you so much. It’s a pleasure to be here.

Rick Bangs:

It’s our pleasure to have you. So we’re going to talk today about TURBT and partial cystectomy in the context of bladder preservation and the qualifier for select patients. So I want to start with the fundamentals. What’s a TURBT and how is maximal TURBT, which some patients have heard about, how is that different?

Dr. John Gore:

TURBT is where we place an endoscope in the bladder and we resect a bladder tumor out. And in general, when we do this for a newly diagnosed tumor, we try to resect everything that is visually apparent with a margin around the tumor, so it’s sort of the normal-appearing bladder around the tumor. And we try to resect down to a reasonable depth, which often is down to the muscle layer of the bladder. So visually what you can see are, you can see these striated muscle fibers that kind of let you know as the surgeon that you’re deep enough, and that’s what we do conventionally.

When we do a maximal TURBT, this is often done in conjunction with a plan for, for example, chemotherapy and radiation, we’re just being a bit more aggressive. We’re trying to feel like we have done enough of a job that we have removed all visible evidence of the cancer, and sometimes that means actually resecting through the muscle where we might see a bit of a fat around the bladder, but it’s a slightly increased magnitude of aggressiveness over our usual TURBT. What you’ll hear some bladder cancer experts say is, “Every TURBT for me is a maximal TURBT.”

Rick Bangs:

Yeah, yeah. And you don’t want to go too deep because then we have something called a bladder perforation, is that right?

Dr. John Gore:

Yeah, you don’t want to make a hole in the bladder, so it’s a challenging thing, because bladders are variably thick and thin, and some people have very thin-walled bladders. That’s more common among women. Others have thicker-walled bladders. That’s more common in men because men have some resistance to the outflow of their bladder, because men have prostates. And most bladder cancer patients are older. Most bladder cancer patients are in their late 60s, 70s, and early 80s, and so that tends to be associated with longstanding bladder obstruction by having a prostate, so men’s bladders tend to be thicker. So there’s maybe a little bit of a greater margin for error when you’re resecting deep into the bladder wall.

Rick Bangs:

Got it. Yeah, when that came up in our female bladder cancer podcast, the thickness and thinness, the depth was something that was interesting, so thanks for the explanation. That’s helpful.

All right, I want to talk about partial cystectomy now. I’ve always been curious as to how much would qualify as partial, and do you avoid parts of the bladder? And when we talk about radical cystectomy, we know there’s things beyond the bladder that are involved, but with a partial cystectomy, are we kind of staying with the bladder? What’s going on there?

Dr. John Gore:

A partial cystectomy is where we are taking out a more limited portion of the bladder. You can really only do it if you feel like you’re leaving a sufficient amount of bladder behind that you’re not harming that patient by decreasing the capacity of the bladder, making the bladder basically so small that it’s not a very usable bladder. So, you want to make sure that you’re balancing the benefit of not taking someone’s bladder out with the harm of decreasing the size of their bladder so much that they just have really terrible urinary frequency, possibly incontinence. What that means is, in general, we’re looking for smaller tumors, tumors that are away from the sort of funnel part of the bladder, the lower part of the bladder, so bladder tumors that are more on the top side of the bladder, and you’re looking for people that have a reasonable capacity so that we can feel confident that when we’re taking out the tumor, we’re taking out the tumor plus a margin, and not kind of narrowing the capacity of the bladder.

Rick Bangs:

And then what about lymph nodes? Are you taking any lymph nodes with a partial cystectomy, or are you leaving those alone?

Dr. John Gore:

We are. So, if you think about the indications for a partial cystectomy, the joke I make when I talk about partial cystectomy is that there’s offer in it and there’s offer in it. And for most of my patients, I offer it, but I don’t offer it, and it’s just because the people that are true candidates for a partial cystectomy are more limited.

There is a type of cancer we see that is part of sort of the family of bladder cancer is called urachal cancer. The urachus is just sort of the remnant of where your body connected to your umbilical cord, and you can get a cancer in that remnant that is typically at the top of the bladder, so it’s where the bladder is stretching toward the belly button, and the standard treatment for that is a partial cystectomy. It’s in the very tippy-top of the bladder, very away from the funnel part of the bladder, and so that’s a very common indication for a partial cystectomy.

Where we get asked as experts about doing a partial cystectomy is for people with more conventional bladder cancer, like, “Gosh, can’t you just cut up a tumor and some of the wall of my bladder, and then sew the bladder up and let me keep my bladder?” And the indications for that are more limited, and the reason they’re more limited is because doing that in a large proportion of bladder cancer patients is actually going to cause them harm. It’s going to subject them to recurrences. Recurrences are quite common. The way I always explain it when I’m in clinic with a patient is I say, “Gosh, we are in this really fortunate position right now where we are within this window of cure for what, for many patients, is a lethal cancer. We have this opportunity right now, you and me, to kill this cancer, to potentially put it in your rearview mirror, and if we were to shortcut that with a partial cystectomy, we are potentially losing this window of cure.” And so that’s kind of the framing that I often assign to it.

That being said, some people are good candidates for it. The guideline recommended criteria are number one, it has to be a unifocal tumor. This has to exist in one spot in the bladder, because if it’s in multiple areas of the bladder, then it’s the wrong thing to do. And so oftentimes, in planning for a partial cystectomy, in addition to confirming the tumor, we’ll take biopsies in other parts of the bladder just to make sure that it’s not a multifocal process, and also to make sure that it’s not associated with something called carcinoma in situ, which is where you see high-grade cancer cells on the inner lining of the bladder, because that’s also a contraindication to a partial cystectomy.

Rick Bangs:

Okay, which is CIS, right?

Dr. John Gore:

CIS.

Rick Bangs:

Yeah.

Dr. John Gore:

In general, in terms of other criteria, like I mentioned before, we want it to be away from the floor of the bladder, so we want it to be in the upper section of the bladder. And then the other really common criteria you’ll see is when you have a tumor in a diverticulum. A diverticulum is like a hernia of the bladder or an outpouching of the bladder. And then last but not least is sometimes when someone has a cancer that’s not a muscle-invasive bladder cancer, it hasn’t invaded into the deeper layer of the bladder, but we just have challenges accessing the tumor so that we could completely treat it endoscopically. Sometimes that’s an indication for a partial cystectomy.

Rick Bangs:

Okay.

Dr. John Gore:

You mentioned lymph nodes.

Rick Bangs:

Yes.

Dr. John Gore:

In all of those criteria I mentioned, we’re talking largely about invasive cancers, and so it is an arena where even though we’re not doing the full surgery, we do with a radical cystectomy where we, as a standard, perform a bilateral pelvic lymph node dissection, which means we sample the lymph nodes that run along the blood vessels to the legs on either side of the bladder. You are supposed to do that with a partial cystectomy as well.

Rick Bangs:

Okay. All right. So, if you’ve got a patient that refuses the radical cystectomy or they can’t have one, could a TURBT, maximal or otherwise, could that be an option for them, and what would the risk be for them? I think you’ve suggested some, but I want to hear you answer. And again, I want to understand the implications on bladder function.

Dr. John Gore:

I think in general, if someone is not a medical candidate for a radical cystectomy, so because of their competing health problems, we don’t think that it’s a safe thing to do. As you know, Rick, I’m a bladder cancer surgeon, but I’m not in the business of hurting people, and so if it seems like technically we could do the operation, but medically it might be hard for someone to recover from, that doesn’t mean a partial cystectomy is the right thing to do.

This is an area where we try to think a little bit out of the box, and so sometimes we do things that aren’t what you would suggest in guidelines, and we try to figure out how to palliate their cancer, or at least keep them out of trouble with their cancer. And so there are some patients in whom we would do serial resections, where we just bring them back on a semi-regular basis to scrape down what has come back in the tumor to keep it from bleeding, to keep them out of the hospital, to keep them out of the ER, if we think their health problems preclude more aggressive treatments. So, that’s something that we sometimes do.

I would never say because a patient won’t submit to a radical cystectomy that’s a reason to do a partial cystectomy. They have to meet those criteria, which are fairly stringent. They have to meet those criteria. And so, I wouldn’t feel like I was doing the right thing if I did a partial cystectomy on someone that didn’t meet those stringent criteria.

Rick Bangs:

How effective would you describe these scenarios, the getting just TURBT, and you used the term serially, or getting the partial cystectomy, for these patients that we’ve qualified here? How effective is that?

Dr. John Gore:

Yeah. I would put those in two very different categories. When we’re doing this sort of what I would term more palliative approach, where we’re serially resecting the tumor, that’s someone who we think that even though muscle-invasive bladder cancer is serious, even though it’s an important and severe cancer, we think that their medical problems are also so severe that they almost are a higher priority than their cancer. And in those cases, we’re trying to help that patient stay out of the hospital, stay out of the ER, because we think their medical problems are a greater risk than their cancer, and it can be very effective. And I’ve had several patients in whom I’ve done that where they eventually did pass as a result of their medical problems, which told us we made the right decision.

I also have had one patient in whom we stopped doing the resections in the ER … I’m sorry, in the OR, because we stopped finding cancer, that actually it was this very unique circumstance where the resection alone was enough to treat their cancer, and they eventually did succumb to their health problems, their heart problems. So that’s a very different situation, and in my experience, it’s been an effective way to manage those challenging situations.

For partial cystectomy, there are some caveats, if we follow these stringent criteria, so if we’re choosing well-selected patients and we’re treating them as we would any other muscle-invasive bladder cancer. So what I mean by that is, we’re strongly considering neoadjuvant chemotherapy. We are performing a lymph node dissection concurrent with the partial cystectomy, which certainly has diagnostic value and may, in select cases, have therapeutic value. And depending on their pathology, we are carefully selecting them for adjuvant treatment, so we are treating them just like we would anyone considering a radical cystectomy. Their outcomes can be just as good as with a radical cystectomy.

Where you see reports of outcomes of partial cystectomy potentially being inferior to radical cystectomy, well, when you look at this on sort of a 100,000-foot view, so if you take a step back and look at the care we provide on a national scale, we do see that patients undergoing a partial cystectomy have a lower rate of utilization of lymph node dissection, so it’s not performed as commonly. And they have a lower rate of neoadjuvant and adjuvant systemic therapy, so they’re not getting treated before or after their partial cystectomy necessarily in the same way as their radical cystectomy colleagues. And so, it’s one of those things where our algorithms should be the same, even if the surgery is different.

Rick Bangs:

Yeah, so if we’re going to do any kind of comparison, we want to make sure they’re getting the lymphadenectomy and they’re getting the neoadjuvant if we’re going to be fair about doing any kind of comparison.

Dr. John Gore:

Yeah, that’s exactly right.

Rick Bangs:

Okay, so what’s the incidence of partial cystectomies? I mean, how many of these things are done, and is it trending up or down?

Dr. John Gore:

This is something where we have a couple of points in time that have shown us the epidemiology of utilization of partial cystectomy. And based on national data that we have available, it does seem kind of like the heyday of partial cystectomy was in the 1980s where it was being used almost one in five cases of muscle-invasive bladder cancer.

Rick Bangs:

One in five?

Dr. John Gore:

Almost one in five.

Rick Bangs:

Wow.

Dr. John Gore:

More recently, however, in the ’90s and early 2000s, it drops to less than 10% of patients with muscle-invasive bladder cancer, and it seems that it’s held pretty steady over the last 25 years. And now I would guess that about 6% to 9% of patients with muscle-invasive bladder cancer nationally are getting a partial cystectomy. When you show that data at a place like where I work, the University of Washington, what you’ll hear is you’ll hear people say, “Well, I haven’t done a partial cystectomy in three years. That can’t be right.”

Rick Bangs:

Right, right, right.

Dr. John Gore:

But it’s important to remember that we are not the only places where people get their care. Most bladder cancer is handled by our colleagues in the community, and so if they feel like a patient meets stringent criteria for a partial cystectomy, the morbidity of that surgery, the technical complexity of that surgery, it’s less than a radical cystectomy. So it likely is being more done in those settings, whereas radical cystectomies that have a greater morbidity, a greater recovery burden, a greater kind of technical complexity are more commonly done in university or academic settings, like where I work.

Rick Bangs:

Okay. All right. So now, for these patients that are getting the serial or repeated TURBT, what are the implications on urinary function and daily living?

Dr. John Gore:

Usually they do very, very well, and part of it is that we chose to do that surgery because we believed they had adequate bladder capacity to support it, and so we are reducing the size of the bladder, but not so much that it affects their daily living. There’s always the early recovery, right? There’s always the period of time where you’re getting out of surgery, you’ve just had catheters and drains in, and that affects your urinary quality of life, but it gets better. As the bladder kind of recovers from the insult of surgery and stretches, those patients can have a very normal urinary quality of life.

Rick Bangs:

So what’s that recovery period look like? And I assume I’m not in the hospital as long, I assume I’m back to my normal faster, but what does that really look like?

Dr. John Gore:

Yeah, the joke I always make when trying to talk about the morbidity of a radical cystectomy is that, being someone who takes care of a lot of bladder cancer patients, one of the unfortunate things about bladder cancer surgery is, you know all too well, Rick, is that when you take out the bladder, you have to replace it. If the bladder were just kind of sticking off of your shoulder and weren’t connected to important structures, you could lop it off and that patient can move on with their life.

Rick Bangs:

Yeah.

Dr. John Gore:

But the burden of a radical cystectomy is not the removal of the bladder and the removal of the prostate, it’s the surgery we do to replace it. It’s that even in 2025, we haven’t figured out a better way to do that than taking out a small or moderate piece of the intestines to reconfigure it in a way that allows the urine to leave the body. And it’s that removal of part of the intestines that is where the morbidity comes from, because when you remove part of the intestines, they freeze up, and what that means is that you have to wait for those intestines to wake up before people can go home.

On average, when you look at national averages, people are in the hospital for about a week after that kind of surgery, and then beyond that, there is about a one-year period of recovery of bowel normality. That doesn’t mean that people have bad bowel function, it just means they’re recovering, so that recovery is very different. When you’re just taking out a piece of the bladder, and this is a surgery that more and more of us are doing when we have to do it, doing it with robotic surgery, oftentimes those patients are in the hospital a night or two. The burden and morbidity is much lower than it is when you’re taking out the whole bladder, and so the recovery is a lot more straightforward.

Rick Bangs:

So would you be more … Would the incidence of robotic be higher for the partial cystectomy than for the radical cystectomy?

Dr. John Gore:

I think that’s hard to know.

Rick Bangs:

Oh.

Dr. John Gore:

I think that you can see using national data that robotic radical cystectomy has been increasing over the last decade quite a bit. I would estimate that about 80% of the radical cystectomies at my institution currently are robotic, or performed with robotic-assisted techniques.

Rick Bangs:

Wow.

Dr. John Gore:

With partial cystectomy, it’s probably pretty similar, to be honest.

Rick Bangs:

Oh, okay.

Dr. John Gore:

Because technically, robotically, it’s a pretty straightforward operation, and you can see very well and do kind of just as good a job as you could do open.

Rick Bangs:

Okay. All right. So if I’ve had a partial cystectomy and I probably had the neoadjuvant chemotherapy and you removed some lymph nodes, but what treatments might I get beyond that for my bladder cancer?

Dr. John Gore:

So, a couple things. In the immediate aftermath of the partial cystectomy, we would want to know what your pathology is. In an ideal world, that chemotherapy worked so well that what we took out was a scar, in an ideal world. We looked in your bladder, we saw the scar, we used that to localize our approach to the partial cystectomy, and it is almost as if we took out a normal piece of the bladder. We know it’s not normal. We know there was a cancer there, so it still needed to come out, but that’s an ideal.

If there is residual cancer present, it depends on the severity of the cancer. And so, if the residual cancer that’s present is still into the muscle, or God forbid, deeper, that’s a patient in whom we would recommend adjuvant treatment. And right now, that treatment would be adjuvant immunotherapy, and there are some options for that. That’s just in the immediate aftermath. Typically, people would get that for a year, so every three weeks you would get an IV infusion of an immunotherapy for a year, and in that year, we would closely follow you with scans and cystoscopies where we would look in the bladder.

After that, treatment really kind of depends on what happens. So, because we’re leaving the bladder behind, unlike in the situation of a radical cystectomy, the follow-up includes CT scans, and the CT scans are to look for enlarged lymph nodes, or spread to other areas of the body, but we would also do cystoscopies.

Rick Bangs:

Sure.

Dr. John Gore:

Because by leaving the bladder behind, we’re leaving a place where the cancer could come back. And if a cancer did come back, the treatment would really just depend on its unique characteristics, so there are patients who get a partial cystectomy, and then three years later, because whatever prompted them to get the cancer in the first place means that they’re at risk for it coming back. But three years later, a cancer comes back and it’s not quite as bad as the original cancer. We could treat that with more local therapies.

Rick Bangs:

Got it. All right. So, if I get the partial and my cancer progresses, I can move to a radical cystectomy?

Dr. John Gore:

It just depends on the context. Usually, when we kind of use the term progresses, we’re thinking about a cancer that got worse, so if it’s a cancer that was a muscle-invasive bladder cancer and has now spread to other parts of the body, that’s where, philosophically, systemic disease needs systemic treatment, meaning that when cancer has spread to other parts of the body, we need to treat that with something that’s going to treat the whole body, so that’s usually something intravenous. The current standard of care for that is a combination of something called immunotherapy, which activates your immune system to fight the cancer, and something called an antibody drug conjugate, where basically the medication targets the cancer cells, that’s what the antibody does, and then it deploys an anticancer drug into the cancer cells. That’s sort of the current standard for that.

If the muscle-invasive bladder cancer recurs but has not spread, then most of us would advocate a radical cystectomy, and the treatment of that would just kind of depend again on the context. If that patient did not get chemotherapy before or after their partial cystectomy, we would probably advocate neoadjuvant chemotherapy and then a radical cystectomy.

Rick Bangs:

All right. Is there any research being done that includes partial cystectomies and chemo or immunotherapy? Or is this kind of a dead-end and the incidence is going to eventually go away?

Dr. John Gore:

Yeah, I think so. Where we hope things could go in the future is this idea that, gosh, does everyone need a radical cystectomy? We know that currently available neoadjuvant chemotherapy completely eradicates any sort of obvious residual tumor about 40% of the time, 35% to 40% of the time, so meaning that when we take out someone’s bladder after chemotherapy, a little over one-third of the time, there’s no cancer in the bladder and no cancer in the lymph nodes. In those cases, could we avoid radical cystectomy some of the time? Maybe, so there are some groups that are looking at restaging patients after chemotherapy and determining if there’s obvious residual cancer present, and then treating them with a partial instead of a radical cystectomy. And I think we’ll learn more about that approach going forward as some of those results play out.

Rick Bangs:

All right, so we will stay tuned.

Dr. John Gore:

Stay tuned.

Rick Bangs:

Okay. Any final thoughts?

Dr. John Gore:

No. I mean, I think this is a great topic, because this is one of the commonest questions we get in clinic.

Rick Bangs:

Of course.

Dr. John Gore:

“Can’t you just take out part of my bladder?” It is one of the commonest questions we get, and honestly, a big part of my job is to explain why it’s not a good idea. That being said, sometimes it is a good idea, so rules are always rules except when they are not, and there are some good indications for a partial cystectomy. When you see that nationally, it’s only about 6% to 9%, that tells you that the people that are true candidates for it are just limited. And so, that average patient that walks in the door with a newly-diagnosed muscle-invasive bladder cancer is not a candidate for a partial cystectomy.

Rick Bangs:

All right, all right. It’s rare for a reason. Okay. Dr. Gore, I want to thank you for explaining how TURBT and partial cystectomies are done and where they fit into treatment options for select patients.

Dr. John Gore:

Absolutely. Always a pleasure, Rick.

Rick Bangs:

All right. If you’d more information on bladder cancer, please visit the BCAN website, www.BCAN.org. In case people wanted to get in touch with you, could you share some contact information?

Dr. John Gore:

Absolutely. I’m happy to share my email, which is JL, as in Lima, G-O-R-E, just like my last name, @uw.edu. I’m also available on social media at Bluesky, @johngoremd.bsky.social.

Rick Bangs:

Okay, great. Just a reminder, if you’d like more information about bladder cancer, you can contact the Bladder Cancer Advocacy Network at 1-888-901-2226. That’s all the time we have today. Be sure to like, comment, and subscribe to this podcast so we have your feedback. Thank you for listening, and we’ll be back soon with another interesting episode of Bladder Cancer Matters. Thanks again, Dr. Gore.

Dr. John Gore:

Thank you.

Voice over:

Thank you for listening to Bladder Cancer Matters, a podcast by the Bladder Cancer Advocacy Network, or BCAN. BCAN works to increase public awareness about bladder cancer, advance bladder cancer research, and provide educational and support services for bladder cancer patients. For more information about this podcast and additional information about bladder cancer, please visit BCAN.org.