[Column] ‘I've already had surgery for bladder cancer. You say I need another one?’

According to data from the Korea Central Cancer Registry released in 2023, there were 5,169 cases of bladder cancer in Korea in 2021, including both men and women, accounting for 1.9 percent of all cancer cases.

The sex ratio was 4.3:1, with more cases in men, and the number of cases in men was 4,201, ranking ninth among male cancers. When looking at age groups for men and women combined, it was reported to be most common in the 70s.

The bladder is an organ involved in the storage and excretion of urine and is composed of four layers -- mucosal, submucosal, muscular, and serosa layers.

Bladder cancer originates from urothelial cells that make up the mucosal layer of the bladder and is divided into non-muscle-invasive bladder cancer and muscle-invasive bladder cancer, depending on whether the cancer cells invade the muscle layer.

Non-muscle-invasive bladder cancer accounts for about 75 percent of bladder cancer diagnoses, and transurethral resection of bladder tumor (TUR-BT) and postoperative intravesical drug infusion are the standard treatment methods.

Transurethral cystectomy is a surgical treatment that involves the physical excision and removal of all visible tumors using a resectoscope inserted through the urethra. The removed specimen is then biopsied to confirm the diagnosis of bladder cancer and its postoperative staging, the extent to which the disease has progressed. The patient will then receive further treatment based on the stage identified.

If physicians diagnose you with non-muscle invasive bladder cancer, they may offer you a second surgery (second TUR-BT or repeat TUR-BT) between two and six weeks after the first surgery, unlike other types of cancer. Patients are often surprised and worried when they are offered a second surgery, saying “Why do I need another surgery?” “Was the first surgery wrong?” or “Is the cancer still in my bladder?”

From the patient's point of view, this is a natural reaction.

Why would a patient need to undergo surgery again so soon afterward? Let's look at the internationally recognized guidelines of the European Association of Urology and the American Urological Association.

These international guidelines recommend a second transurethral cystectomy if 1) the tumor was not completely removed during transurethral cystectomy, 2) high-grade cancer is identified in high-risk patients, 3) the muscle layer of the bladder is not identified in the biopsy specimen, or 4) cancer cells have invaded the submucosal layer.

Transurethral cystectomy usually requires a short surgery and a short hospital stay. However, if tumors in the bladder are multiple or large, the surgery can take a very long time, and removing them completely may be impossible with a single operation. If the first surgery does not completely remove the tumor, a second surgery is required. Even if the tumor is completely removed visually during the first transurethral cystectomy, the patient will be advised to undergo a second surgery if your case fits the international standard of care guidelines.

Even if all visible tumor is removed at the time of surgery, microscopic cancerous tissue may remain in the bladder. This residual cancer can cause bladder cancer to recur and progress.

Based on an analysis of large studies, the risk of residual cancer is identified in about 50 percent of patients with non-muscle-invasive bladder cancer who undergo a second transurethral cystectomy for high-grade cancer. In addition, in T1-stage cancer with submucosal invasion, the risk of finding residual and invasive cancer is still high even if the first surgery is performed at sufficient depth to identify the muscle layer of the tissue.

In addition to detecting and further removing residual cancer, a second transurethral cystectomy can reduce the risk of bladder cancer recurrence and positively impact patient survival.

In a study of patients with bladder cancer who received postoperative intravesical drug infusion therapy, it was found that patients whose bladder muscle tissue was not identified during the first surgery were less likely to have recurrence or progression of bladder cancer and had a higher overall survival rate if they underwent a second transurethral cystectomy. This improved overall survival has been confirmed in other studies involving patients with T1-stage disease.

Based on these findings, a second transurethral cystectomy is a treatment procedure that can help remove unseen residual cancer and improve patient survival.

Surgery is physically, psychologically, and economically demanding for patients. Therefore, most patients hope that a single surgery will cure them of their disease. It's understandably difficult for patients to accept the idea of a second surgery when they've just had one.

However, for some patients with non-muscle-invasive bladder cancer, a second transurethral cystectomy can be a valuable opportunity to detect and remove residual cancer, reduce recurrence rates, and improve overall survival.