# Treatment methods for bladder cancer
The treatment of bladder cancer depends greatly on the stage and type of tumor. Doctors distinguish two major groups: non-muscle invasive bladder cancer (NMIBC) — tumors that have not yet grown through the muscle layer of the bladder wall — and muscle invasive bladder cancer (MIBC) — tumors that have grown through that muscle. For each stage, various treatments are available, often in combination.
Transurethral resection (TUR)
This is a minimally invasive procedure in which a thin tube is inserted through the urethra into the bladder wall. At the end is a loop with which the tumor is cut away and at the same time the wound is cauterized (with electric current). This is done under general anesthesia.
ProveniIncluded in official guidelines, or approved by EMA or FDA
TUR is the standard treatment for non-muscle invasive tumors. It serves both as a diagnostic tool (the removed tissues are examined) and as a treatment. The procedure can be repeated multiple times if there is recurrence or insufficient initial removal. Known side effects are temporary pain during urination, blood in the urine and, very rarely, perforation of the bladder wall.
A recent variant is blue-light cystoscopy, in which special dye and blue light are used to make tumors more visible. This can help detect and completely remove more tumor.
Intravesical therapy (intra-bladder treatment)
After TUR, non-muscle invasive cancer is often treated directly in the bladder wall, via a catheter inserted through the urethra. The most commonly used form is bacillus Calmette-Guérin (BCG).
BCG therapy
ProveniIncluded in official guidelines, or approved by EMA or FDA
BCG is a weakened bacterial strain that activates the immune system against cancer cells in the bladder wall. It is administered in weekly sessions, usually for several weeks. This can be repeated for months or years to prevent recurrence.
BCG therapy reduces the risk of cancer returning or progressing. Side effects are mostly local: painful, frequent urination, blood in the urine and irritation. In approximately one in ten patients, a flu-like feeling occurs. Very rarely, BCG can work systemically and cause serious infection. A small proportion of patients do not respond to BCG; for them, alternative strategies are needed.
Other intravesical agents
Besides BCG, there are chemotherapy drugs (such as mitomycin C) that are administered directly into the bladder wall. These are used less frequently than BCG, but may be an option for certain tumor types or after BCG failure.
ProveniIncluded in official guidelines, or approved by EMA or FDA
These agents work by directly attacking cancer cells. Side effects are similar to BCG: local irritation, blood in the urine and pain. Systemic side effects are rare because the substance mostly remains in the bladder wall.
New intravesical approaches
Research is ongoing into new agents that work via intravesical administration, including modified immunotherapies. These are not yet standard available.
ResearchediPositive results in clinical studies, not yet standard treatment
Radical cystectomy (complete bladder removal)
This is major surgery in which the entire bladder wall is removed. In men, the prostate and seminal vesicles are also removed; in women, the uterus and the front of the vagina are also removed. At the same time, lymph nodes in the pelvis are usually removed.
ProveniIncluded in official guidelines, or approved by EMA or FDA
Radical cystectomy is the standard treatment for muscle invasive cancer and for non-muscle invasive tumors that do not respond to BCG, are very large, or are located in multiple places.
After removal of the bladder, a new way must be found to collect and excrete urine. This can be done by creating a **pouch** (a small bag made from bowel tissue), after which patients must regularly use a catheter to empty it. Another option is a **urostoma** (an opening in the abdomen to which a bag is attached). The surgeon discusses these options beforehand with the patient.
The operation can be performed open (traditional incision) or with robotic assistance. Both approaches have advantages and disadvantages in terms of recovery and ultimate oncological outcomes; studies show comparable results.
Complications can include blood loss, infection, bowel obstruction, and in rare cases damage to surrounding organs. Recovery takes weeks to months.
Chemotherapy
Neoadjuvant chemotherapy (before surgery)
When muscle invasive cancer is diagnosed, some patients receive chemotherapy before surgery takes place. This aims to shrink the tumor and address any hidden metastases.
ProveniIncluded in official guidelines, or approved by EMA or FDA
The combination of gemcitabine and cisplatin is the standard. This is given in cycles (usually one to four treatments) before radical cystectomy takes place. Chemotherapy is burdensome; side effects include nausea, fatigue, decrease in blood cells (which increases infection risk) and neuropathy (nerve damage, especially in feet and hands).
Adjuvant chemotherapy (after surgery)
Patients in whom cancer is found to have spread further after cystectomy, or has very aggressive features, may receive chemotherapy after surgery.
ProveniIncluded in official guidelines, or approved by EMA or FDA
Radiation therapy
Radiotherapy can be used when the bladder wall cannot or should not be removed, for example due to age, other serious illnesses, or patient preference. External radiation targets the pelvis and bladder wall.
ProveniIncluded in official guidelines, or approved by EMA or FDA
Radiation is often combined with chemotherapy to increase effectiveness. Side effects include fatigue, diarrhea, bladder wall irritation (dysuria) and in the long term a small risk of second cancer types. In older patients or those with severe blood loss, radiation can also be used to stop bleeding.
Immunotherapy
Checkpoint inhibitors (immune checkpoint blockers)
Tumors hide from the immune system by activating certain 'brakes'. Medicines such as pembrolizumab and atezolizumab block these brakes, allowing the immune system to recognize cancer cells again.
ProveniIncluded in official guidelines, or approved by EMA or FDA
These agents are used in advanced and metastatic bladder cancer, both alone and in combination with chemotherapy. Side effects are immune-related and can be serious: inflammation of the lungs, heart, kidneys or other organs. The same side effects can occur later.
Combinations of immunotherapy
Studies are testing combinations of different checkpoint inhibitors or checkpoint inhibitors with chemotherapy.
ResearchediPositive results in clinical studies, not yet standard treatment
Targeted therapy and antibody-drug conjugates
New agents target specific protein mutations on the cancer cell surface. An example is sacituzumab govitecan, an antibody-drug conjugate (ADC) that attacks a cancer cell and simultaneously delivers chemotherapy.
ResearchediPositive results in clinical studies, not yet standard treatment
ADCs show promising results in advanced bladder cancer. They can be used when previous treatment no longer works or as an alternative to chemotherapy. Side effects are similar to chemotherapy: fatigue, nausea and reduced blood cell function.
Research is ongoing into more targeted agents, including NPTXR-targeted therapy.
Treatment of metastases
When cancer has spread to bone, lung or other locations, local radiation (stereotactic radiation) of bone metastases can help relieve pain and prevent bleeding, alongside systemic treatment.
ProveniIncluded in official guidelines, or approved by EMA or FDA
Supportive care and clinical trials
All patients receive guidance on managing side effects, recovery and psychosocial support. Many hospitals like to put patients in contact with clinical trials should standard treatment no longer work or to improve existing options.
---
_This information never replaces a doctor's judgment. Always discuss your situation with your own healthcare provider._