Stage 3 bladder cancer is a locally advanced form of the disease where the tumor has grown through the muscle layer of the bladder wall and has spread to the surrounding fatty tissue or neighboring reproductive organs. Treatment requires a complex, multimodal strategy aimed at eradicating the local tumor and any microscopic spread. Therapy necessitates a combination of surgery and systemic treatments, often involving a carefully sequenced plan tailored to the individual patient.
Radical Surgery and Urinary Diversion
The standard surgical intervention for Stage 3 bladder cancer is a radical cystectomy, which involves the complete removal of the urinary bladder and a pelvic lymph node dissection. In men, this procedure also includes the removal of the prostate and seminal vesicles. In women, the uterus, ovaries, fallopian tubes, and a section of the anterior vaginal wall are typically removed. Removing the local lymph nodes is important for assessing the extent of cancer spread and providing therapeutic benefit.
Since the bladder is removed, urinary diversion is required to create a new way for the body to store and pass urine. The most common method is the ileal conduit, which uses a segment of the small intestine to route urine to a stoma on the abdominal wall, where it drains continuously into an external bag. Other options are continent diversions, which eliminate the need for a continuously draining external bag.
One type of continent diversion is the continent cutaneous reservoir, where an internal pouch is created, requiring a catheter to be periodically inserted into a stoma to drain the urine. The orthotopic neobladder is the most complex option, using intestine to create a bladder-like pouch connected to the urethra. This allows the patient to void naturally, but requires careful selection and training to achieve continence. The choice of diversion depends on the patient’s overall health, manual dexterity, and personal preference.
Systemic Treatment Timing: Chemotherapy and Immunotherapy
Systemic therapy treats the entire body and plays an important role alongside surgery due to the cancer’s potential for microscopic spread. This treatment is administered in the perioperative setting, meaning it is given either before (neoadjuvant) or after (adjuvant) the radical cystectomy. Neoadjuvant therapy is primarily used to shrink the tumor and treat undetectable micrometastases before surgery.
The standard neoadjuvant approach for healthy patients is a combination of chemotherapy drugs that includes cisplatin. Giving this platinum-based chemotherapy before surgery improves overall survival compared to surgery alone. Patients who achieve a complete response to neoadjuvant therapy often experience the best long-term outcomes.
For patients who cannot tolerate cisplatin or who have residual disease after surgery, adjuvant therapy is used to reduce the risk of the cancer returning. Immunotherapy agents, such as checkpoint inhibitors like nivolumab, have become standard adjuvant options for high-risk patients. Immunotherapy works by activating the patient’s own immune system to recognize and attack cancer cells.
Bladder Preservation Through Trimodal Therapy
For certain patients, Trimodal Therapy (TMT) offers a bladder-sparing alternative to radical surgery. This strategy is designed for those who are not suitable candidates for major surgery or who wish to keep their native bladder. TMT combines three distinct treatments: maximal transurethral resection of bladder tumor (TURBT), followed by concurrent chemotherapy and radiation therapy.
The process begins with an aggressive TURBT to remove as much of the visible tumor as safely possible. This is followed by chemoradiation, where the patient receives radiation to the bladder and pelvis while simultaneously receiving chemotherapy. The chemotherapy acts as a radiosensitizer, increasing the treatment’s effectiveness.
This combined-modality approach offers long-term survival rates comparable to those achieved with radical cystectomy in selected patients. Successful TMT allows 75% to 80% of long-term survivors to maintain a functional native bladder. However, this intensive treatment requires close monitoring, and if the cancer recurs, a salvage cystectomy may be necessary.
Long-Term Monitoring and Follow-Up Care
After completing treatment, long-term monitoring is necessary to check for recurrence or delayed side effects. For patients who underwent radical cystectomy, follow-up involves CT scans of the chest, abdomen, and pelvis at regular intervals, such as every six months for the first few years. Blood tests are performed annually to monitor kidney function and check for potential metabolic issues, like vitamin B12 deficiency, related to the use of intestinal segments in the diversion.
Patients who received bladder preservation therapy require rigorous surveillance of the preserved organ. This monitoring includes regular cystoscopy, often scheduled every three to four months initially. The frequency of these check-ups gradually decreases if the patient remains disease-free, but lifelong surveillance is recommended. Survivorship planning, which involves outlining the schedule of tests and managing potential long-term issues, is an important part of post-treatment care.