Can bladder be preserved in the elderly with bladder cancer?

Question

Hello doctor,

My husband, who is 71, was just diagnosed with bladder cancer after ignoring blood in his urine for three months, thinking it was a UTI (urinary tract infection). The urologist did a cystoscopy last week and found a three-centimeter tumor, then performed a TURBT (transurethral resection of bladder tumor) procedure.

We got the pathology report yesterday, saying it is high-grade urothelial carcinoma invading the muscle layer (T2). His CT (computed tomography) scan showed some enlarged lymph nodes in the pelvic area (1.2 centimeters), which the doctor says is concerning.

He is a retired construction worker who smoked two packs a day for 50 years until quitting two years ago. Since the procedure, he has had terrible urinary frequency, going every 30 minutes, and the pain is unbearable. The burning sensation has not improved despite taking Phenazopyridine.

The doctor mentioned neoadjuvant Cisplatin-based chemotherapy before radical cystectomy, but my husband is worried about losing his bladder and wearing a bag. His kidney function tests show a creatinine level of 1.7, which complicates treatment options. He gets very tired walking from the bedroom to the bathroom and has lost 22 pounds without trying.

Yesterday, he had a fever of 101.3°F (Fahrenheit), but it went down with Tylenol (Acetaminophen). Is bladder preservation with radiation therapy a realistic option for muscle-invasive bladder cancer, or is removal the only way? What questions should we ask the oncology team when we see them next week?

Kindly advise.

Thank you

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

You are doing the right thing by advocating early and asking important questions. Your husband’s diagnosis of muscle-invasive bladder cancer (MIBC) is serious, but it is important to know that there are options. Every treatment decision should aim to balance effectiveness with quality of life, especially in older patients with other health concerns, such as borderline kidney function.

The burning, pain, fever, and frequent urination may suggest post-transurethral resection of bladder tumor (post-TURBT) inflammation, which is common and can last one to two weeks. However, these bladder cancer symptoms could also indicate a secondary urinary tract infection (UTI).

Please speak with your urologist about performing a urine culture (if not already done), reassessing kidney function, and possibly conducting a bladder ultrasound or computed tomography (CT) scan to rule out retained clots or bladder wall injury. If pain or fever persists, do not delay seeking urgent care. Infections after TURBT can escalate quickly in high-risk patients.

Radical cystectomy remains the standard treatment for T2 bladder cancer. However, bladder preservation is a viable alternative for selected patients. Candidates for this approach typically meet the following criteria: good tolerance for combined radiation and chemotherapy, absence of extensive carcinoma in situ (CIS) or hydronephrosis, a unifocal tumor, and no visible residual tumor after TURBT.

This approach, known as trimodal therapy (TMT) (trimodal therapy), involves maximal TURBT, followed by radiation therapy and concurrent low-dose chemotherapy. In properly selected patients, TMT can offer five-year survival outcomes similar to radical cystectomy.

Cisplatin-based chemotherapy before surgery is the standard of care, improving survival outcomes. However, it requires relatively good kidney function, ideally a creatinine level below 1.5. Given your husband's elevated creatinine (1.7), a full dose of Cisplatin may be too risky.

In such cases, doctors might consider split-dose or dose-reduced regimens. Some centers are exploring immunotherapy (such as Atezolizumab) in clinical trials as an alternative. If chemotherapy is not an option, radiation therapy alone or with radiosensitizers may be considered.

How risky is surgery for someone with his current level of fatigue and recent weight loss? (In my opinion, the mortality risk is around 2 percent.)

Your husband needs immediate symptom management, possibly for infection or inflammation. He also needs a comprehensive discussion about bladder-sparing versus surgical treatment options. If surgery is likely, a nutrition and rehabilitation plan will be essential. Most importantly, he needs a medical team that tailors treatment to his individual needs rather than relying solely on standard protocols.

Bladder cancer is challenging, particularly in older patients with complex health issues. Yet many individuals live full and meaningful lives after treatment, whether with their bladder or without it. Your role in asking the right questions and supporting him through this process is invaluable.

Let me know if you would like help reviewing his pathology report in more detail. You are doing an exceptional job, and your husband is fortunate to have you by his side.

I hope you are satisfied with my answer.

For further queries, you can consult me at iCliniq.

Thank you.