Transcript of How to Choose a Urinary Diversion with Dr. Robert Svatek

September 13, 2022

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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. This podcast is sponsored by Seagen/Astellas, EMD Serono/Pfizer, Genentech and Merck. I’m pleased to welcome today’s guest Dr. Robert Svatek, who makes a return visit to our podcast in a two part episode about what for many can be a very difficult decision, choosing a urinary diversion when facing radical cystectomy.

Rick Bangs:

Dr. Svatek is professor and chair of urology at the University of Texas Health San Antonio, and his practice is devoted to the care of bladder cancer patients. He provides state-of-the-art surgical options, including robotic assisted and open approaches, as well as all available urinary diversion options. Dr. Svatek is actively involved in clinical trials for bladder cancer, including one on the Japanese strain of BCG and he runs an NIH funded cancer immunology lab. Dr. Svatek, I’m so pleased to have you back today to talk about a topic of keen interest to many bladder cancer survivors, how to choose a urinary diversion.

Dr. Robert Svatek:

Hi Rick. It’s my pleasure. Agree is a very important topic and I’m delighted to have this conversation.

Rick Bangs:

So you and I both know how life changing radical cystectomy can be and choosing from the urinary diversions is never an easy option. Most of us as patients are caught off guard when the decision must be made and it’s a decision that’s going to impact our daily life, and it’s not one that’s easily changed. So let’s start with some basics. What exactly is a urinary diversion?

Dr. Robert Svatek:

So my conversation begins with the function of the urinary bladder, and there’s two functions that it serves because I think we want to understand what we need to replace since we’re removing the bladder through a cystectomy. So the urinary bladder has really two main functions and that is storage of urine. It has a fairly large capacity to store the urine, but the other function it serves is to expel the urine, to get it out of the body. And so if we’re removing the bladder, we need some means by which to, A, get the urine out of the body, expel, and B, maybe another storage capacity. And so in the diversions that we’re going to be talking about some of these have both of those functions, some have one. But that’s kind of a starting point is we want to replace the bladder’s function to some degree.

Rick Bangs:

And balance it in some cases as you pointed out. So who needs a urinary diversion?

Dr. Robert Svatek:

Yeah. I think, so those patients that are candidates for removal of the bladder. And I say candidates, because unfortunately there are some patients who are not candidates due to, let’s say, advanced disease, in certain situations bladder removal is not advisable if the disease is too advanced. And so in many ways, I like to make sure the patient that is being offered a cystectomy is aware that they’re in a unique situation where they have this opportunity to potentially get rid of the disease through this major surgery, which is bladder removal.

Dr. Robert Svatek:

So the types of patients that would be eligible would be patients that have disease that is relatively confined to the bladder and where removing the bladder gives us a chance of curing the patient. And there are another set of patients who may benefit from bladder removal for palliative reasons. And what I mean by that is, let’s say we won’t be able to cure them with bladder removal, but we might be able to significantly improve their quality of life by mitigating or getting rid of the side effects or complications that they are having as a result of having their bladder in place. For example, excessive bleeding from the bladder tumor, excessive urinary difficulty or pain as a result of the bladder. And so those are two patient populations that could benefit from bladder removal or cystectomy. And those are the patients that we would have a discussion with about urinary diversion.

Rick Bangs:

Okay. So when you have that discussion, you’re going to give them some choices. Talk to me about the choices that a patient could choose from and how are they constructed?

Dr. Robert Svatek:

Yeah. And I think it’s very good that you said choices. I have a teenage daughter and I’m always negotiating with her. And I like to put things in terms of choices so that they understand, you do have choices and you as a patient have input to what we’re going to do. And so that’s an important thing is that you do have a choice in the matter. There’s generally three different approaches and there may be some variety of these, but generally I like to break them up into continent and incontinent urinary diversions. And what does that mean? Continent would mean that the urine is, there’s a capacity feature that’s created by the diversion, meaning that there’s a storage of the urine and that it’s not leaking continuously. Incontinent would be that there’s no storage of the urine. That the urine just flows naturally out of the body.

Dr. Robert Svatek:

And that incontinent diversion is often called an ileal conduit, such that the urine is flowing from the kidneys down the ureters to a small segment of bowel. And often the ileum is used, approximately 12 to 15 centimeters of ileum. And the urine flows through that segment of bowel, just like a conduit, kind of like a PVC pipe, and it flows straight out of the body. And in that situation, we use an appliance that is applied to the skin of the abdomen to collect the urine. So the collection of the urine in that situation is done externally through a bag. And that’s an incontinent diversion. The other two types are continent diversions. And I can go into detail on that, Rick, I didn’t know if you had any questions before we get to that.

Rick Bangs:

No, I’m pretty good. I mean, you’re taking some portion of the intestine and you’re repurposing it. You called it the ileum. So you’re repurposing that and creating this kind of channel through which the urine’s going to flow for this option, which has a bag or a pouch.

Dr. Robert Svatek:

Right. And that option, you’re right, it has a bag that is applied to the skin. The bag is made out of plastic. It adheres to the skin and it has to be changed approximately every four days because the adhesive starts to wear down. Some people can change it once a week, but the vast majority of my patients are changing that appliance every four days. The bag fills with urine. How much urine can it hold? Well, it depends on the size of the bag, but generally I like to say the bags can be used to hold about as much as your bladder can. So you’ll often be, you’ll be emptying that bag about as much as you would empty your regular bladder. And it depends obviously on how much urine is made and how much water you’re drinking.

Dr. Robert Svatek:

And you’re right, we use, one thing I like to tell patients is no matter what we do for a diversion, we use your intestines. Because you have a lot of intestines and we know that taking a segment of the intestines is viable, does not affect, or in most cases does not affect the continuity of the gut and you can still have normal gut function. So we have that opportunity to use intestine. So yeah, the first one is the ileal conduit, which is incontinent. It connects to an appliance that is applied to the skin. That appliance is often called a bag. The area that you see on the skin is called a stoma, it’s also called a urostomy, and the bag is sometimes called a urostomy appliance. These are similar but different than colostomy bags. One thing that I tell patients is these are concealed by the clothes.

Dr. Robert Svatek:

So patients in the waiting room may have the appliance you didn’t notice that they have them. I mean, they’re not exposed in most cases and they’re concealed by the clothes. And many patients wear them underneath their pant line. There’s also different clothing apparatuses that patients can wear, like a waistband that can be applied around the waist to insert the appliance into if they wanted to do it that way. And I also tell patients that with that bag, with that appliance, it doesn’t preclude them from doing day to day activities. And it doesn’t mean they can’t fly. They can certainly fly on an airplane. They can certainly go swimming. They can get in a hot tub. They can maintain their activities. All of that is possible with any of these diversions. But one question that often comes up is, well, if I get this bag, can I do X, Y, or Z? And I say, yes, you can do the activities that are important to you with this appliance.

Rick Bangs:

And this is the most popular choice.

Dr. Robert Svatek:

Oh no, no. I would say it really is patient dependent and it’s surgeon dependent. The other two options, or let’s say they’re continent diversions are where we use a, let’s say a larger segment of intestine and we create a reservoir on the inside of your body where urine is stored, and you periodically empty that reservoir. Those are continent diversions. And there’s two types that are commonly done. One is called a neobladder. Neo is another form for new. So it’s like a new bladder. And the other one is often called an Indiana pouch or a continent catheterizable urinary diversion. So let’s talk about those two. The neobladder is a reservoir that is created out of intestine and it is attached, or what we call an anastomosis, or attached to the urethra.

Dr. Robert Svatek:

And so that the urine flows from the reservoir through the urethra. And in that situation, there’s no appliance. There’s no bag. There’s no external device. The urine is stored in a reservoir inside the body and the urine comes out of the urethra. The other one, the continent catheterizable urinary diversion or Indiana pouch has a reservoir inside the body made out of intestine, but it has this channel that is connected to the skin. Usually it’s near the umbilicus, the belly button, sometimes it’s even made at the side of the belly button, but it is a channel through which a catheter is inserted periodically to drain the reservoir.

Dr. Robert Svatek:

So the reservoir keeps urine and when it fills up, then you insert a catheter through this small little opening in the abdomen, you insert the catheter through and by doing that the urine can then flow out of the catheter and it maybe takes a few minutes to empty the reservoir and then you pull the catheter out. So that is a catheterizable urinary diversion. So Rick, so maybe you could add to that and tell me what it’s like for you and that type of diversion.

Rick Bangs:

So I have the neobladder. And so the first thing I would say from a daily routine is I have to time my voiding or my urination. So I would look at the clock and not rely on the sensation, because it’s a totally different animal. So it’s pretty much every four hours would be my pattern, but you have to adjust that. So if you eat a lot of watermelon or you’re having soup for lunch, you have to kind of think about that. And it’s, I think relatively easy to forget, at least for me it is. And then nighttime, nighttime’s a little more challenging from a continent’s point of view. During the day, I think my surgeon used to talk about being trampoline dry. And so during the day I don’t have any issues, but at night I would have more challenges and have more problems.

Dr. Robert Svatek:

Yeah. Usually when I have this discussion, patients will immediately gravitate to the neobladder because it seems more natural. It’s like, “Well, you’re just replacing my bladder. I want that one.” And then I will say, “Okay, it sounds great. There’s just two downsides and one of them is the nighttime leakage because,” and the way that I explain that is that the neobladder is very dependent on the urethral sphincter to maintain continents.

Dr. Robert Svatek:

And at nighttime, as you sleep, the urethral sphincter is relaxed and you will experience some incontinence at night or you’ll have to have some strategy to mitigate that. And then the other potential downside with the neobladder is that in some cases, the neobladder may not empty completely. And if that happens, then the patient has to be able to catheterize themself in order to empty the neobladder. If they don’t, if the neobladder is not emptying well, the urine just sits there and it could form stones, it could cause infections, it could cause backup and eventually lead to kidney damage. And so I would say one of the turnoffs for some of my patients is the possibility of having to catheterize.

Rick Bangs:

Right. And I know in some clinics, I don’t know how you do it, but I know in some clinics they want patients to try self catheterizing before the surgery, because they want to make sure that they’re going to be able to do it if the need arose.

Dr. Robert Svatek:

Yeah. And I think that’s a wise way to go about it. Generally, there are certain patients for a variety of reasons. Let’s say they have some cognitive impairment or there is problems with manual dexterity and they just simply cannot categorize on their own or they don’t have the social support system to facilitate that. And sometimes you’re just not aware of what the patient’s capable of doing until you actually ask them to commit and try self catheterization. So I think that is a creative way to go about the decision making.

Rick Bangs:

Yeah. And some practices, I think have people wear a wafer and a pouch too, to just kind of test that out. I’ve heard some practices do that.

Dr. Robert Svatek:

Yeah. I do that often. I’ll keep an appliance in my white coat and as we’re having this discussion, I mean, to me, there’s nothing better than a visual. And I’ll actually set them up on the table and say, “Okay, if you were to choose the bag, the ileal conduit, this is what it looks like.” And I’ll put it on the abdomen and they can get a real fill for it, a sense of it. And I think that may be helpful.

Rick Bangs:

Oh yeah. I think, anytime you get close to the real experience it helps you, because in your imagination, you’re hearing these words and you’re kind of imagining, but it’s a whole different thing if you’re actually experiencing it. So I think those are good practices.

Dr. Robert Svatek:

I think sometimes it’s just, it’s such a shocker, Rick, for some patients just, it’s like, I just don’t want this. I don’t want this bag and I just don’t want my bladder removed because I don’t want to have to live with this. And I feel so bad for patients that express that and I want to say, I know it seems bad. I know it seems like such a life changing event, but I have so many patients that live with it and that are doing great. And I just kind of wish they could see that other aspect of things.

Rick Bangs:

Yeah. I remember my mother when I was in recovery, I was complaining about my neobladder because I was in that kind of training period. And my mother said, she just kind of flipped it around and she said, “Aren’t we so lucky that we have these neobladders?” And it was a complete frame of reference. I mean, I was just fortunate to have this option, which was part of saving my life. So perspectives matter.

Dr. Robert Svatek:

Yeah. I love that perspective that you described there. And it reminds me of this patient who, we were on the fence about whether he would be able to undergo a cystectomy because he had evidence of nodal metastasis. The cancer had already spread to his lymph nodes and we were treating him with chemotherapy. And it was one of those situations where he may or may not benefit from bladder removal. And he knew the disease really well, he had studied. And when we completed the chemotherapy and he had a great response, the lymph nodes shrunk, he came to me and he was, he’s like, “Oh, I’m ready. I’m ready for my bladder removal.” And he kind of, he understood that this was an opportunity because he was now eligible for bladder removal because his cancer had responded so well to chemo. And it was a nice kind of way to look at things.

Rick Bangs:

Oh yeah. Yeah. All right. So suppose I’ve been diagnosed and I know I need the surgery, but I want to find the absolute best surgeon I can. And we all know that there’s a lot of complication and a lot of life changing aspects to this. So what should I look for in a surgeon and how do I find that person?

Dr. Robert Svatek:

Well, that’s a great question. I mean, I think there are a lot of factors to consider and I think there is pretty good data that high volume centers tend to have better outcomes. If you look at population based data, high volume centers, centers that are doing this once a week, as opposed to once a month are going to have infrastructure in place and techniques in place to kind of mitigate complications. That said, none of us are immune to complications, even the best surgeons out there. This particular operation has a very high complication rate, even among those high volume centers where there’s outstanding surgeons. And what I love about this community is that we’re very honest. We publish our results. We say these are our complication rates and they all tend to be above 30%. But a lot of those are very minor complications and things that are very easily managed.

Dr. Robert Svatek:

So in addition to, let’s say a high volume center, I think access what’s feasible for you. Okay, sure, driving to this city does get me a surgeon with much higher volume, but is it worth it for me to drive this distance rather than going with a surgeon who’s been taking care of me? So I think those are important questions that need to be considered. And I think the other important factor is the relationship you’ve developed with the urologist, because some things are out of our control, they’re out of the surgeon’s control, the patient’s situation. And do you have a good relationship, do you have confidence in the relationship that the surgeon will take care of you after the procedure? And if a complication does arise that you have confidence in that relationship for that surgeon to get you through it. So it’s not all about volume.

Dr. Robert Svatek:

It’s also about the relationship that you have and do you feel like you’re being taken care of. I think that’s an important factor. The other thing too, there are some specific things that you can ask your surgeon that are not offensive to us and they shouldn’t be. How many of these do you do? Do you have a partner that does more of these that you would recommend me for a second opinion? Keep in mind that asking for a second opinion is not offensive. It is something that is encouraged. And so seeking a second opinion is okay. But questions that you might want to ask, how many do you do or how many of these have you done? Do you prefer to do this open or robotically? And not that it should change your opinion about whether you’ll get it done there, but I think it’s important for you to know what you’re going into. Is this going to be an open surgery or a robotic surgery? Yeah. So those are the kind of things in the top of my head.

Rick Bangs:

Let’s talk a little bit about this robotic versus open. So I hear some patients say, I absolutely want to have robotic, and it’s typically, that’s what they say rather than open. I always suggest, really you want the best surgeon and let the surgeon decide. So where do you sit on this kind of, as a criteria for searching for a surgeon, should I include the robotic versus open? Or how should I approach that?

Dr. Robert Svatek:

Great question, Rick. So some patients don’t have the resources, let’s say, the capacity to search and to, they’re just kind of in a city where they have one surgeon that can do this and that’s who they have to go with. And so I think it’s important to point that out that we don’t always have that option. We did do a large randomized control trial. Dr. Dipen Parekh actually deserves credit for this trial. I mean, he initiated it in San Antonio and then did a larger trial nationwide where he compared open versus robotic. And so the surgeons that participated could do both and they did a randomized trial of open versus robotic. And what we found was that largely the outcomes are similar. The main benefits of robotic surgery are decreased blood loss. There’s clear evidence that there’s decreased blood loss with robotic surgery.

Dr. Robert Svatek:

And why is that? Well, when you do it robotically, you fill the abdomen up with gas at a pressure. And that pressure is applied to the very small vessels and so it really prevents those small vessels from bleeding. So there’s clearly a difference in blood loss. And that means then that there’s a difference in transfusion rate. So if you get it done robotically, there’s less likelihood or possibility of a transfusion, a blood transfusion.

Rick Bangs:

And isn’t there less incision with a robotic or is there the same amount cumulatively? I always imagine there’s less.

Dr. Robert Svatek:

Good question. So it depends. It depends on, the open approach can be done with a fairly small incision nowadays. I mean, it’s done below, often below the belly button. And even if you do it robotically, you have to make an incision to get the bladder out of the abdomen. And so you still have an incision when it’s done robotically, although it is smaller, generally a little bit smaller. But then ask, Rick, ask yourself, well, what does that matter? What does that mean? Because for most of these patients, they’re not really worried about whether the incision is four centimeters or six centimeters.

Dr. Robert Svatek:

But I do think blood loss is important. And the other thing is there’s a slightly decrease in hospital stay if you do it robotically. So your recovery might be a little bit faster with the robotic. I do both. There are challenges, when I first started operating, robotic took longer and there’s downside with duration of surgery. So the advantage of open is that it’s a little bit faster. The other thing is that some people feel like the open is better for continent diversions like a neobladder, just because it’s difficult to do a neobladder robotically. And so some surgeons are offering robotic if they do the incontinent, ileal conduit, the one with the bag, whereas they’ll do an open if they do a neobladder, for example. So it’s kind of influx and it’s moving around a little bit. I wouldn’t say, I kind of agree with you, Rick, if you have a good relationship with a surgeon, the surgeon has high volume. I think that matters more than whether they do it robotic or open. I think you’re right on that measure.

Rick Bangs:

To me, it’s like the car versus the driver. I want the great driver. If they get the fancy car, that’s one thing, but I want the driver. So that seems to be an analogy there for me.

Dr. Robert Svatek:

Yeah. I mean, the only thing I would say to that is that most of us now are doing or moving toward robotic surgery. And so I think the training of robotic training is a reflection of their surgical training. So those surgeons that are offering robotic is because they got good training. And so it’s uncommon nowadays to not have robotic training in your residency program. So I guess what I’m kind of getting at is that there are certainly some open surgeons out there that are outstanding, no question. But as time moves on and moving forward, I think we’ll see more and more adoption of robotic practices into the vast majority of urologists that are offering cystectomys.

Rick Bangs:

Yeah. And you mentioned Dr. Parekh and so he is going to be an invited guest to talk about this very subject in the future. Talk to me about, from your point of view as a surgeon, what do you consider when you present the choices? And you talked earlier about choices. So when you’re presenting these choices, what are the considerations that go into your offering A versus B, versus C?

Dr. Robert Svatek:

First I’m thinking about the patient, their stated age, other medical conditions that they may have, their degree of cognitive impairment, degenerative neurologic disease if they have any of that, frailty, things that might affect their dexterity and attention. I’m also thinking about their social system. Where do they live at, in reference to a big city? Do they have family members caretakers that are involved in their care? So these social determinants of health are very important as we’re kind of creating a message to give to them. And there are certain patients that have, let’s say, chronic kidney disease or chronic liver disease that make them not a candidate at all for neobladder. So those are the things I’m thinking about before I kind of plan to talk. But hopefully, hopefully we get to a situation where I can provide them choice, because I think it’s important for them to be able to have a choice.

Dr. Robert Svatek:

But there are, obviously in some situations there are patients that really cannot have a continent diversion, and I really can only offer them an ileal conduit. But let’s say for the majority of patients we can offer all three diversions. And so I kind of start with the simplest concept of the ileal conduit because it’s a smaller piece of intestine. It’s a straightforward flow. Because a lot of times automatically kind of their mind shuts down when they hear the appliance and the bag, if they haven’t been prepared for that. And so I say, “Well, wait, we don’t have to do that. There is an alternative.” And so that’s a great feeling like, okay, great, there’s an alternative. And so then we go through the neobladder and the Indiana pouch and we talk about the pros and cons.

Dr. Robert Svatek:

And I love it when I’m able to say at the end of it, okay, these are the pros and cons for all three. How do you feel? I feel like I can do any of these for your case. Where do you stand? And it’s a little bit of kind of back and forth. What are your concerns about this? What are your thoughts on this approach? And I’ll be honest, a lot of times I don’t like for them to have to make a decision right away. I say, “Listen, I want you to just mull this over. Talk about it with your family. Let’s just revisit this in a week or two.” And a lot of times what I’ll do, honestly, Rick, is I’ll talk about it before we give chemotherapy so that we can come back to that discussion later on after chemotherapy’s been started, so we can have it again. So it’s not such a … It’s hard because they’re dealing with the diagnosis of cancer and losing the bladder, and now they’ve got to make this decision about the diversion. It’s just so many things.

Rick Bangs:

Yeah. Let’s kind of flip this conversation around and talk about, what are patients considering, based on your experience, what are patients considering when they’re making their choice?

Dr. Robert Svatek:

Rick, let me throw this back to you and say, okay, how was it for you? Did you feel like it was a lot of information at one time and you had to absorb the information about the cancer and then make a decision on the diversion quickly? Or did you feel like you had time to really digest it and think about it?

Rick Bangs:

Well, so I was 2006 mile here, and in 2022 and as years have gone by, the information that would be available would be significantly better because of BCAN and the way the urologic community has kind of advanced. So I didn’t have a lot of information. The information I would’ve gotten at that time, because I looked, I mean, I was fairly web savvy back in 2006, but the information I would’ve gotten, would’ve been more from the technical side. It was like, well, this is how it’s constructed. But there was no, I didn’t have the opportunity like I would today to reach out to BCAN and say, hey, can you connect me with a survivor? I want to talk to somebody who’s had one of these or maybe I want to talk to somebody who’s had each of these. I couldn’t do that. I couldn’t go onto the web and really find great information.

Rick Bangs:

So I had to rely on the information I could get from my surgeon. And I think there was, at that point, still a tendency to think about it from the technical point of view. It’s like, okay, well, here is, I’m going to take two feet of small intestine versus a foot here and you’re going to have to wear the pouch. And today would be a different thing. Today I could go on the BCAN Inspire site and I can, there’s 50,000 plus members out there. And this is probably one of the more common questions that are out there. People post on this question all the time. I could go out to the BCAN site. I can find webinars and tips and tip sheets, and all kinds of things. So I have all these different opportunities today. So I would’ve been able to kind of take a lot of input, churn on it. But my decision today would be the same as I made. Not that it’s a perfect solution. It’s like I say, original equipment is always better than an aftermarket part. So that’s kind of where I come from.

Dr. Robert Svatek:

Yeah. I want to get your take on having a discussion with one person. I guess, and you’ve done this for me before. I mean, I think I’ve put you in touch with one of my patients and it can be incredibly impactful to have a discussion with somebody that has a great outcome from a neobladder. But is that the right way that we should do it? I mean, because I almost, it’s almost like I want to say, okay, here’s a patient that had a great outcome, here’s a patient that has struggled with catheterizing. I just want to present a fair balanced picture and sometimes I just worry about the one off. What are your thoughts on that? Is it-

Rick Bangs:

Yeah. So when I do it, I try to be balanced about it. I know enough from talking to folks like yourself that I know some of the balance. So I note, if I go to Inspire, everybody is going to tell the person that’s posting and asking the question that their choice of diversion is the best because, in part, because that’s the choice they made. And I don’t say that. I will tell people, look, the satisfaction levels are pretty similar for each of the diversions and it’s really about trade offs. And so back to the choices, how important is it for me to sleep through the night with no interruption? If that is incredibly important, not that it isn’t important to everybody by the way, but if that’s absolutely one of your fundamentals in life, don’t get the neobladder. You should go with ileal conduit.

Rick Bangs:

And so it’s things like that. It’s like, it’s all about trade offs and making sure people understand, if you have this, here’s some trade offs. Here’s the good points, here’s the bad points and try to help people have the balanced information they need to make a decision. That’s all the time we have today for part one of my two part conversation with Dr. Robert Svatek on choosing a urinary diversion. Stay tuned for part two of this podcast. It will be released soon. Never miss an episode by subscribing to Bladder Cancer Matters wherever you get your podcasts. Just a reminder, if you’d like more information about bladder cancer, you can contact the Bladder Cancer Advocacy Network at 1888-901-2226. Thank you for listening and we’ll be back soon with another interesting episode of Bladder Cancer Matters.

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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.