Bladder Cancer
by E. Davillas, M.D., Urologist

Etiology-Epidemiology

The bladder is a hollow muscular organ that serves as reservoir for urine.

Bladder cancer is the 4th most common cancer in men and 9th most common in women, with 250,000 cases diagnosed globally every year. Smoking cigarettes, occupational causes as well as frequent use of pain killers may increase the risk of bladder cancer. Multiple bladder infections are also risk factors.

 

Symptoms

The main symptom of bladder cancer is hematuria. It can be gross macroscopic hematuria or microscopic hematuria, usually is painless and it can appear just once, symptom which should be enough to get referred to a urologist.

Other possible symptoms include pain during urination, high frequency, feeling to urinate without being able to do, overactive bladder. Also, many other symptoms not specific to bladder cancer can be related to other pathological conditions from the urinary tract system.

 

Diagnosis

The following tests are useful to make the diagnosis of bladder cancer.

  • Urine cytology is a PAP test of urine in which we examine urine for abnormal cells. Negative urine cytology does not mean that we do not have bladder cancer. Usually we need two or three samples of urine at the cytology department.
  • Ultrasound is the easiest way to check any hematuria. Using ultrasound technology, we investigate the bladder’s walls for any tumor(s), and examine whether they appear superficial or invasive. A single ultrasound can be enough to allow us to proceed to transurethral resection. Other tests include intravenous pyelography and CT scan pyelography which focus on the upper urinary track ureters and bladder.
  • Finally, cystoscopy is a procedure aiming to look inside the bladder and the urethra to check the abnormal areas, and take biopsies if necessary.

 

Transurethral resection of bladder cancer

Surgeon resect tumor transurethrally from the bladder wall, trying to resect as deep as possible in the bladder wall. The goal is to identify the pathological classification of this bladder cancer, and also determine the extent to which the tumor has invaded the bladder wall. Therefore, through such an operation it can be determined whether this is a superficial or invasive cancer (pathological stage). In case of a superficial cancer, this procedure may be the only surgical step required for cure.

 

Pathological classification

Most of bladder cancer cases are transitional cell carcinomas, while a minority corresponds to adenocarcinomas or squamous cell carcinomas.

For superficial bladder cancer, transurethral resection is usually the only treatment. After the pathology report, when it becomes known that the tumor has not invaded the muscle wall of the bladder, we have the option of bladder installations (local chemotherapy or immunotherapy) in order to prevent recurrence and progression.

Most of the superficial bladder cancers will recur (about 70% of them), so the most important part of their treatment after surgery is the patient’s follow-up with cystoscopies and usually biopsies at random. Many protocols exist, but we suggest every 3-4 months during the first year, every 6 months during the second and third year, and annually until the fifth year.

Surgical treatment, bladder installations and proper follow-up can cure superficial bladder cancer.

 

Prognosis

Prognosis of bladder cancer depends on:

  • Clinical and pathological stage of cancer: superficial or invasive, local or metastatic
  • The type of bladder cancer cells

 

Invasive Bladder Cancer

Invasive bladder cancer has invaded the muscle wall of the bladder. Following such a diagnosis, the next step is to clarify whether it is local or has spread to other parts of the body (cancer staging).

The following tests are used for staging bladder cancer:

  • CT scan
  • MRI
  • Chest X-ray
  • Bone scan

Through these procedures, the main and most important question can be addressed: if the tumor is confined within the bladder wall, or it has spread through the bladder wall to the abdomen or pelvis-lymph nodes and other parts of the body.

 

Treatment of invasive bladder cancer

Early stage cancer can be cured so the most important and crucial point of treating bladder cancer is to take the right treatment decision at the right time.

Radical cystectomy and, rarely, partial cystectomy are the surgical options to treat bladder cancer. Through radical cystectomy the bladder is removed and all the nearby organs: prostate-seminal vessels for men; uterus, ovaries and part of the vagina for women, plus a good lymph node dissection.

A very important step of radical cystectomy is urinary diversion, during which surgeons create a new bladder to collect and pass the urine. The small bowel is often used, and urologists create a reservoir with a stoma on the belly of the patient or a reservoir which is connected to the urethra and ideally allows the patient to pass urine normally as before (continent reservoir). Finally another option is the continent diversion with stoma.

A further treatment option for early stage bladder cancer is the combination of surgery and chemotherapy. In particular, if after surgery the cancer is found to be at higher risk (penetration of bladder wall) compared to the risk assessment during clinical staging, chemotherapy is administered in order to reduce the risk of recurrence. This option is called adjuvant therapy.

In very high risk cancers, especially those that have penetrated the bladder wall (preoperative diagnosis), chemotherapy is often administered before surgery in order to reduce the risk of recurrence after surgery. This kind of chemotherapy is called neoadjuvant chemotherapy.

The option of Cystectomy causes the patient understandable anxiety. It is common for patients to ask for other options instead. Usually patients get used to their new neobladder, and as time passes and they remain recurrence-free, they adopt quite well.

Adjuvant or neoadjuvant chemotherapy play a major role in treating early stage invasive bladder cancer.

 

Organ preservation

If cystectomy is not a viable option for any reason, a combination of chemotherapy and radiotherapy can be instituted in order to try to save the bladder and cure the cancer.

Following such a treatment course, very close follow up with cystoscopies and biopsies is required, which can detect any recurrence of the tumor early on. Patients adhering to these procedures can have long survival and good quality of life.

 

Metastatic bladder cancer

For metastatic bladder cancer, the patient usually undergoes chemotherapy alone, or chemotherapy in combination with cystectomy and radiotherapy. Urinary diversion even without cystectomy in combination with chemotherapy are treatment options that try to offer longer and great quality of life. On the other hand, the cancer cannot be considered completely cured.

 

Conclusions

Bladder cancer is a major health problem. Surgery often offers the best possibility for a cure. Chemotherapy and radiotherapy play a major part in bladder cancer treatment. Finally, new types of treatment are being tested in clinical trials.

 

Content on this site is not a substitute for professional medical advice. You should always consult your doctor.