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What is Muscle Invasive Bladder Cancer (MIBC)?

Muscle invasive bladder cancer (MIBC) is a cancer that spreads into the detrusor muscle of the bladder. The detrusor muscle is the thick muscle deep in the bladder wall. This cancer is more likely to spread to other parts of the body.

In the U.S., bladder cancer is the third most common cancer in men. Each year, there are more than 83,000 new cases diagnosed in men and women. About 25% of bladder cancers are MIBC. Bladder cancer is more common as a person grows older. It is found most often in the age group of 75-84. Caucasians are more likely to get bladder cancer than any other ethnicity. But there are more African-Americans who do not survive the disease.

What is Cancer?

Cancer is when your body cells grow out of control. When this happens, the body cannot work the way it should. Most cancers form a lump called a tumor or a growth. Some cancers grow and spread fast. Others grow more slowly. Not all lumps are cancers. Cancerous lumps are sometimes called malignant tumors.

What is Bladder Cancer?

When cells of the bladder grow abnormally, they can become bladder cancer. A person with bladder cancer will have one or more tumors in his/her bladder.

The bladder is where the body stores urine before it leaves the body. Urine is what we call the liquid waste made by the kidneys. The bladder is a hollow organ in the pelvis with flexible, muscular walls. The bladder can get bigger or smaller as it fills with urine. Urine is carried from the kidneys to the bladder through tubes called ureters. When you go to the bathroom, the muscles in your bladder contract. They then push urine out through a tube called the urethra.

How Does Bladder Cancer Develop and Spread?

The bladder wall has many layers, made up of different types of cells. Most bladder cancers start in the urothelium or transitional epithelium. This is the inside lining of the bladder. Transitional cell carcinoma (sometimes also called urothelial carcinoma) is cancer that forms in the cells of the urothelium.

Bladder cancer gets worse when it grows into or through other layers of the bladder wall. Over time, the cancer may grow outside the bladder into tissues close by. Bladder cancer may spread to lymph nodes nearby and farther away. The cancer may reach the bones, the lungs, or the liver and other parts of the body.

Symptoms

How do you know that you may have bladder cancer? Some people may have symptoms that suggest they have bladder cancer and others may feel nothing at all. Some symptoms should never be ignored. You may need to talk to a urologist about your symptoms. A urologist is a doctor who focuses on problems of the urinary system and male reproductive system.

Talk to your doctor if you have these symptoms:

  • Hematuria (blood in the urine) - the most common symptom, often without pain
  • Frequent and urgent need to pass urine
  • Pain when you pass urine
  • Pain in your lower abdomen
  • Back pain

Symptoms You Should Not Ignore

Blood in the urine is the most common symptom of bladder cancer. It is often painless. Often, you cannot see blood in your urine without a microscope. If you can see blood with your naked eye, you should tell your health care provider right away. Even if the blood goes away, you should still talk to your doctor about it.

Blood in the urine does not always mean that you have bladder cancer. There are a number of reasons why you may have blood in your urine. You may have an infection or kidney stones. Very small amounts of blood might be normal in some people.

Frequent urination and pain when you pass urine (dysuria) are less common symptoms of bladder cancer. If you have these symptoms, it is still important to see your health care provider. He/she may perform more tests to find out if you have something such as a urinary tract infection or something more serious, like bladder cancer.

Causes

People can get bladder cancer when they come into contact with tobacco or other cancer-causing agents. There also are some risks linked to genes and certain types of infections. One more known risk factor is treatment with radiation given to the pelvis.

Smoking is a Big Risk Factor

You are more likely to get bladder cancer if you smoke or breathe in tobacco smoke. Smoking tobacco may be the cause of half of all bladder tumors. If you smoke, you are more likely to get bladder cancer than those who have stopped.

Workplace Exposure is Another Known Cause

Some things in the workplace may put you at a greater risk for bladder cancer. Contact with chemicals used to make plastics, paints, textiles, leather and rubber may cause bladder cancer.

Diagnosis

If your health care provider believes you have MIBC, you may be referred to a urologist. Your urologist may perform a full medical history and physical exam. Further tests may be needed to form a diagnosis. If you are diagnosed with bladder cancer, you may need more tests. These tests will find out the stage of your disease. It will also give your doctor an idea of what treatment is best for you.

Tests for MIBC

These tests may be done to see if you have bladder cancer:

  • Urine cytology: The color and content of your urine will be checked. This test will also look at body cells under a microscope.to test for cancer cells.
  • Blood tests: A comprehensive metabolic panel (CMP), which includes kidney and liver function tests, will be among the blood tests your doctor will order.
  • A Computerized tomography scan (also known as CT or CAT scans).
  • Cystoscopy: A doctor will use a thin tube that has a light and camera at the end of it (cystoscope) to pass through the urethra into the bladder. It allows your doctor to see inside the bladder. Your doctor will likely use a flexible cystoscope and a local anesthetic for your exam in the office to see if there is a growth in the bladder.

If any of these tests suggest you have bladder cancer, the next step is to do a transurethral resection of a bladder tumor (TURBT), as described below. You will likely be put to sleep for this procedure. The scope the doctor uses when you are put to sleep to perform a TURBT is not flexible like the one used in the office, but rigid. This means it is straight and does not bend. This cystoscope is bigger, has a light at the end, and surgical tools can pass through it. During a TURBT, the doctor will both try to remove all visible tumors and take tissue. The tissue sample will be sent to a lab where they will find out vital information about your cancer. They will also see whether the cancer has spread. This will help with choosing the right treatment.

  • Transurethral resection of bladder tumor (TURBT): This is a very important procedure for accurate tumor typing, staging and grading. Your doctor can look inside the bladder, take tumor samples and resect (cut away) what he/she sees of your tumor.
  • Blue light cystoscopy with TURBT: For this test, your doctor uses a catheter to place an imaging solution into your bladder through your urethra. The solution is left in the bladder for about an hour. The doctor then uses the cystoscope to check the bladder with a white light and then with blue light. Bladder cancer cells show up better with blue light.

Other Imaging Tests

These tests may help your doctor diagnose and stage bladder cancer.

  • Retrograde pyelogram: This test uses x-rays to look at your bladder, ureters and kidneys. The test is done during a cystoscopy.
  • Magnetic resonance imaging (MRI): These tests use a strong magnetic field, radio waves and a computer to make detailed pictures of the inside of your body.
  • Positron emission tomography (PET) scan: If your chest, abdomen or pelvic image results are not normal or if your doctor cannot get a lymph node biopsy, your doctor may order a PET scan. For this, you will be given a special drug (a tracer) through your vein or you may swallow the drug. Your cells will pick up the tracer as it passes through your body. When the scanner passes over the bladder, the tracer allows your doctor to better see where and how much the cancer is growing.

Grading and Staging

What are the Grades and Stages of Muscle Invasive Bladder Cancer?

Grade and stage are two vital ways to measure and describe how cancer develops. A tumor grade tells how aggressive the cancer cells are. A tumor stage tells how much the cancer has spread.

Tumor Grade

Grading is one of the ways to know if the cancer will return. It also tells us how quickly the cancer may grow and/or spread.

Tumors can be low or high grade. High-grade tumor cells are very abnormal, poorly organized and tend to be more serious. They are the most aggressive and more likely to grow into the bladder muscle.

Tumor Stage

The tumor stage tells how much of the bladder tissue has cancer. Doctors can tell the stage of bladder cancer by taking a small sample of the tumor. This is called a biopsy and is often done as part of a TURBT. A pathologist in a lab studies the sample under a microscope and decides the stage of the cancer. Additional tests (such as imaging studies) can also help with determining stage.

The stages of bladder cancer are:

  • Ta: Tumor on the bladder lining that does not enter the muscle
  • Tis: Carcinoma in situ - a high-grade cancer - looks like a reddish, velvety patch on the bladder lining
  • T1: Tumor goes through the bladder lining but does not reach the muscle layer 
  • T2: Tumor grows into the muscle layer of the bladder
  • T3: Tumor goes past the muscle layer into tissues around the bladder
  • T4: Tumor has spread to nearby structures such as lymph nodes and the prostate in men or the vagina in females.

What to Expect with MIBC

Muscle invasive bladder cancer is a serious and more advanced stage of bladder cancer. MIBC is when the cancer has grown far into the wall of the bladder (Stages T2 and beyond).

For patients with MIBC, the overall prognosis (how the disease may progress) is dependent on stage and treatment. In patients who have a cystectomy (removing part of or the whole bladder), the cancer return rate can be from 20-30% for stage T2. The cancer return rate can be 40% for T3, greater than 50% for T4 and often higher when lymph nodes are involved. If bladder cancer does come back, it most often will happen within the first two years after bladder surgery.

Treatment

Knowing you have cancer can be scary. Still, your doctor and health care team are there to help you. Your health care team will discuss what you must know about all the treatment choices. They will tell you about possible risks and the side effects of treatment on your quality of life.

Choices for Treatment

Treatments for muscle invasive bladder cancer include:

  • Bladder removal (cystectomy) with chemotherapy or without chemotherapy
  • Chemotherapy with radiation, in addition to TURBT

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. For MIBC, chemotherapy will most likely be given before radical (total) cystectomy. Bladder removal with chemotherapy raises survival rates for bladder cancer patients. Neoadjuvant chemotherapy (given before cystectomy) should include the drug cisplatin. Adjuvant chemotherapy means the drug is given after surgery. Your doctor may offer this treatment if it is right for you.

Chemotherapy drugs are mostly given by vein (intravenous). The drugs enter the bloodstream and travel throughout your body.

Most often, doctors offer chemotherapy before bladder removal for best survival rates. But not all people are able to have chemotherapy. You may not get chemotherapy if you have poor kidney function, hearing loss, heart problems or other health issues. Some patients may choose not to get chemotherapy before surgery. But some may still need to have it after surgery based on the tumor stage. You will likely have your bladder surgery about 6-8 weeks after you have finished chemotherapy.

You may have your chemotherapy treatment in an outpatient part of the hospital, at the doctor's office or at home. Rarely, you will need to stay overnight in the hospital. Chemotherapy is sometimes given in cycles. Each cycle often has a treatment period followed by a rest period.

There are side effects to chemotherapy. The side effects depend on which drugs are given and how much is given. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells, such as:

  • Blood cells: If chemotherapy drugs lower the levels of healthy blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. If your levels are low, you may need to stop the chemotherapy or reduce the dose of the drug. There are also medicines that can help your body make new blood cells.
  • Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back after treatment. But your hair color and texture may be different.
  • Cells that line the digestive system: Chemotherapy can cause a poor appetite, upset belly and vomiting, loose stools, or mouth and lip sores. Your health care team can give you medicines and suggest other ways to help with these problems. Symptoms most often go away when treatment ends.
  • Nerve cells: Some drugs used for bladder cancer may cause tingling or numbness in your hands and feet. Your healthcare team can suggest ways to control these side effects.

Surgery to Remove the Bladder (Cystectomy)

FFor MIBC, because the cancer has grown into the muscle, in most cases the whole bladder is removed (in some cases only part of the bladder is removed). As mentioned, before your bladder is removed, you will most likely be given neoadjuvant cisplatin-based chemotherapy. Bladder cancer can spread to the lymph nodes. When the bladder is removed, a pelvic lymph node dissection is also done to remove the fatty tissue surrounding the pelvic blood vessels. A pelvic lymph node dissection is thought of as standard of care. Standard of care means that this is the usual treatment.

What happens during surgery?

Your bladder can be removed by an open or a robotic approach. In the open approach, the doctor makes one larger cut in the middle of the belly to remove the bladder. Open surgery may have a shorter operative time.

In a "robotic" procedure, a few smaller cuts are made in the belly. Your surgeon puts small tools through the openings to reach the bladder. Often people have less pain and less blood loss with robotic surgery.

There are many things to think about before choosing open or robotic bladder removal:

  • Your body weight
  • History of prior surgery
  • History of prior radiation
  • Where to go for surgery. There is some evidence that complex surgery (such as bladder removal) has better outcomes when performed at Centers of Excellence facilities rather than hospitals, etc.
  • Surgeon's experience: ask your surgeon about his/her familiarity with this type of surgery. If you have concerns, get a second point of view.

For more information on bladder removal, view our Bladder Removal Surgery video.

Radical Cystectomy (removal of the whole bladder)

For MIBC, the most common type of surgery is radical cystectomy. The surgeon removes the whole bladder, nearby lymph nodes and part of the urethra. In men, the surgeon also may remove the prostate. In females, the surgeon may remove the uterus, fallopian tubes, ovaries and vaginal wall. Other nearby tissues may also be removed.

When the whole bladder is removed, the surgeon makes another way for urine to be collected from the kidneys and stored before passing from your body. This is called urinary diversion. Your doctor will talk over the risks of cystectomy and the different methods of urinary diversion.

Partial Cystectomy (removal of part of the bladder)

For MIBC, partial cystectomy is a less likely choice as the cancer may be more advanced. Partial cystectomy may be thought about in select cases of bladder cancer in which the tumor is found in a specific part of the bladder and does not involve more than one spot in the bladder. Ask your surgeon whether you are a candidate for this type of surgery.

Urinary Diversion after Bladder Removal

When your bladder is removed or partly removed, your urine will be stored and made to leave your body by a different route (urinary diversion). If you have a radical cystectomy, you will need to know about urinary diversion options.

Because the surgeon uses tissue from your intestines for bladder reconstruction, you must have enough bowel tissue for a urinary diversion. Before surgery, your surgeon will go over the procedure and the changes you will need to make.

Here are some of the urinary diversion choices your surgeon may offer:

  • Ileal conduit: To make an ileal conduit, the surgeon will take a piece of your upper intestine and use it to make an opening (stoma) on the surface of your stomach. The ureters are joined so that the urine leaves your body by the opening. A bag will be attached to collect the urine and you will "dump" the bag many times a day. This is the most simple and most often used diversion after bladder surgery.
  • Continent cutaneous reservoir: Your surgeon makes a pouch inside your body and you will learn to use a catheter to remove your urine.
  • Orthotopic neobladder: Your surgeon makes an internal pouch, much like your bladder, to store urine. Your ureters are joined to this new "bladder" and you are able to empty through your urethra the same way you did before surgery. In some instances, you may need to use a catheter to remove the urine.

Talk with your doctor about your choices for a urinary diversion. Having a urinary diversion will greatly impact your quality of life.

For more information on urinary diversion, visit our Urinary Diversion article or view our Urinary Diversion video.

Chemotherapy with radiation

Bladder Preservation

Chemotherapy with radiation may be used for bladder preservation (keeping the bladder or parts of it). Bladder preservation may be suggested for select patients where radical cystectomy is not an option or is undesired. The right health circumstances must be present for bladder preservation.

Your surgeon (urologist) will repeat a TURBT as described above to remove all visible tumor. Chemotherapy and radiation will then be given by medical oncologists and radiation oncologists (doctors that specialize in giving chemotherapy and radiation). This is called a multi-modal (many methods) approach. Radiation alone for MIBC is not a choice to control the spread of bladder tumors. Some chemotherapy drugs that may be used along with radiation are cisplatin, 5-FU and Mitomycin-C. Once treatment is complete, follow up includes ongoing cystoscopy exams, cross-sectional imaging (e.g. CT scan) and other procedures to check to make sure the cancer has not come back.

For patients who use the multi-modal approach to bladder preservation, 30% of the time MIBC will return. Thus it is very important for you to be watched closely by your health care team in case the tumor progresses and cystectomy becomes needed.

For more information on bladder preservation, view our Bladder Preservation Therapy video.Radiation as a single form of treatment is not given for MIBC. It is most often done along with chemotherapy and rarely after surgery. Radiation therapy uses high-energy rays to kill cancer cells.

Radiation therapy

Radiation as a single form of treatment is not given for MIBC. It is most often done along with chemotherapy and rarely after surgery. Radiation therapy uses high-energy rays to kill cancer cells.

The radiation comes from a large machine that aims beams of radiation at the bladder area in the abdomen. You may go to a hospital or clinic five days a week for many weeks to get radiation therapy. Each treatment session takes about 30 minutes.

Radiation therapy is painless, but it may cause other side effects. Problems with radiation include upset belly, vomiting or loose stools. Also, you may feel very tired during radiation therapy. Your health care team can suggest ways to treat or control these side effects.

Bladder Cancer Clinical Trials

What about Clinical Trials?

You may hear about clinical trials for your bladder cancer. Clinical trials are research studies that test if a new treatment or procedure is safe and effective.

Through clinical trials, doctors find new ways to improve treatments and the quality of life for people with disease. Trials are available for all stages of cancer. The results of a clinical trial can make a major difference to patients and their families. Please visit our clinical trials research webpage to learn more.

After Treatment

Make sure that you stay in touch with your health care provider. You should expect to return to your doctor for quite some time after treatment and surgery.

Follow-up is not the same for all people. However, continuous observation may include some or all of the following:

  • Imaging (e.g. CT scan) about every 3-6 months for 2-3 years; and then once a year.
  • Laboratory tests may be every 3-6 months for 2-3 years; and then once a year. Kidney and liver function tests will be a part of these tests.
  • Assessment for quality of life issues, such as urinary symptoms and sexual function.

If you had bladder removal surgery, it takes time to heal. The time needed to recover is different for each person. It is common to feel weak or tired for a while. Like any other major surgery, bladder surgery may have complications. Older patients and women are more likely to get complications after cystectomy.

There are some things you can do before surgery to help your recovery. If you smoke, try to get help so you can quit before surgery. You also need to make sure you eat right so that your body can heal and can cope with the changes.

Here are some possible problems you may have after treatment:

  • Gastrointestinal (GI) problems. You may have problems with your bowel function right after surgery. This often happens after abdominal surgery. Your health care provider will take steps to check bowel function and avoid GI problems.
  • Urinary diversion. Urinary diversion after bladder surgery may present challenges for which you should prepare yourself. You may need to learn how to remove urine from your body with a catheter. There also is the chance for leakage from the stoma (opening) that is made to take away urine. Infections linked to urinary diversion may happen, as may infections linked to the kidneys. It is of great value to learn as much as you can about the urinary diversion method you will use, and how to manage changes to your body. Also, before you leave the hospital, your health care providers will make sure you get the education you need so you can manage your new way of life.
  • Hormonal changes. For females who are not yet menopausal, you may have hot flashes after your ovaries are removed.
  • Reproductive health. When the prostate is removed, a man can no longer father a child. Also, a man may be unable to have sex after surgery. When the uterus is removed, a woman can no longer get pregnant. If the surgeon removes part of a woman's vagina, then sex may be difficult.
  • Sexual dysfunction: Bladder cancer surgery is likely to change your sex life. If you have a partner, you may be worried about sexual intimacy and your relationship. It may help you and your partner if you talk about your feelings. You can find other ways to be intimate after you had treatment.
    If you do not have a partner, you may want to explore how to manage your dating life after bladder cancer surgery. Either way, you (and your partner) may benefit from the help of a counselor who specializes in talking about sexual issues.
    Your healthcare provider may be able to refer you to medical professionals and counselors who specialize in sexual issues after cancer treatment. You can also find a certified sex therapist near you on the website of the American Association of Sexuality Educators, Counselors and Therapists.
  • Managing Pain: You may have pain or discomfort for the first few days after bladder surgery. Medicine can help control your pain. Before surgery, talk with your doctor about how to manage your pain. After surgery, your doctor can change the plan if you need more control.

Each person is different and each body may respond differently to therapy. It is vital that you take care of yourself and stay in touch with your health care provider. Try to adopt healthy lifestyle habits including exercise, a well-balanced diet and no smoking. Your health care provider may suggest a cancer support group or individual counseling.

Updated December 2020

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