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Bladder Cancer

Bladder Cancer: What You Need to Know

  • You can reduce your risk of bladder cancer by quitting smoking, avoiding occupational exposure to certain chemicals, drinking plenty of liquids and eating lots of fruits and vegetables.

  • Bladder cancer is three times more common in men than women.

  • Bladder cancer treatment is determined by your doctor based on the stage and grade of your tumor.

What is bladder cancer?

Illustration of the anatomy of the urinary system, front view
Click Image to Enlarge

Bladder cancer occurs when there are abnormal, cancerous cells growing in the bladder. The American Cancer Society (ACS) estimated 73,000 diagnosed cases of bladder cancer in 2013.

Bladder cancer affects men about 3 times more often than women, and it occurs in whites twice as often as in African-Americans. The risk of bladder cancer increases with age—over 90 percent of people who are diagnosed with it are older than 55.

The bladder is a triangle-shaped, hollow organ located in the lower abdomen. It is held in place by ligaments that are attached to other organs and the pelvic bones. The bladder's walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. The typical healthy adult bladder can store up to 2 cups of urine for 2 to 5 hours.

Urinary tract of male and female.
Click to Enlarge

Bladder Cancer Signs and Symptoms

Sign: something physical that can be observed (i.e., fever)
Symptom: what the patient experiences (i.e., pain)

For most people, the first symptom of bladder cancer is hematuria, blood in the urine. Hematuria is either gross (visible) or microscopic.

  • Gross/visible: can be seen with the naked eye

  • Microscopic: blood is only visible if a sample is examined under a microscope

Irritative urination symptoms are also associated with bladder cancer, including:

  • Pain

  • Burning

  • Frequent urination

  • Incomplete emptying of the bladder

  • Passage of tissue fragments in urine (less frequent than other symptoms)

The presence of one or all of these signs does not mean you have cancer but that you should be seen by a physician, as these are abnormal bodily functions. Sometimes those diagnosed with bladder cancer do not experience any bleeding or pain; therefore, routine screening and physicals are very important.

Bladder Cancer Screening and Diagnosis

There are several tests that can determine the diagnosis of bladder cancer.

While the exact causes of bladder cancer are not known, there are well-established risk factors for developing the disease. Risk factors for bladder cancer include the following:

  • The most efficient, noninvasive and inexpensive test is a urinalysis/cytology. Here, a sample of urine is taken from the patient and evaluated for red and white blood cells (which fight urinary tract infections) and microscopic hematuria or infection. Hematuria is also a sign of a possible tract infection.

  • If abnormalities are found, a biopsy will be performed in which a pathologist examines tissue for the presence of cancer cells. If a urine culture fails to turn up bacteria or other organisms in the urinary tract, additional testing may be needed.

There are also a series of imaging tests that can be done.

    IVP x-ray showing a bladder tumor contrast
  • An intravenous pyelogram (IVP) is when contrasting dye is injected into the patient and then looked at with an X-ray. This X-ray will look at the collecting system of the kidneys to determine the presence of any irregularities. This is good for seeing small cancer locations and the upper urinary tract and especially for detailing the kidneys, ureters and bladder.

  • Computer axial tomographic (CT or CAT) scans are another form of X-ray, which creates a more detailed image of the body and organs. This is used to locate kidney or bladder blockages, determine staging and therapy and whether cancer has metastasized.

  • Magnetic resonance imaging (MRI) is another imaging form that creates very high quality and detailed images of bladder tumors in addition to adjacent organs, such as the chest, pelvis and abdomen, to locate any metastasis.

  • Ultrasound imaging , without side effects or radiation, is noninvasive and looks primarily at the bladder and kidneys. It can locate small tract blocks and stones and also measure the bladder wall thickness.

  • The gold standard for the evaluation of the lower urinary tract is a direct visual examination called a cystoscopy. This is a routine outpatient procedure that examines the lower urinary tract and bladder lining using a specialized instrument called a cystoscope. Cystoscopes are either rigid or flexible. Fiber optics allow for images of the bladder lining to be created. If abnormalities, such as tumors, stones or patches of abnormal appearing tissue, are discovered during cystoscopy, a biopsy may be taken. The biopsy specimen will then be evaluated by a pathologist for the presence of cancerous cells.

  • Occasionally, the urologist will take a biopsy during a transurethral resection of bladder tumor (TURBT) procedure, which will be scheduled for a future appointment. This is an endoscopic or scope procedure that does not involve making an incision in the body. The entire removal of a bladder tumor can be accomplished through an operative scope, which passes through the urethra into the bladder.

Bladder Cancer Treatments

The majority of bladder cancers arise from the lining of the bladder. Over 75 percent of these tumors remain confined to the linin layer and do not invade the bladder wall.

These tumors are called superficial transitional cell cancers. Advanced bladder cancer is cancer that has invaded the bladder wall or outside of the bladder.

Advanced cancer treatment options are different than those for superficial bladder cancer. Bladder cancer treatment is determined due to the stage and grade of the tumor(s).There are several tests that can determine the diagnosis of bladder cancer.

Treatment for Superficial Bladder Cancer

Cystoscopy with Cautery Destruction of the Tumor

Most modern cytoscopes are equipped with channels that permit small instruments to be passed into the bladder for the purpose of removing tissue, stopping bleeding with a special electrical device called an electrocautery or even performing laser treatment. If the bladder cancer tumor is small enough, this cautery may be used to remove cancer.

Transurethral Resection

This is when the tumor is removed via electrical force from the urinary tract through the urethra. Transurethral resection (TUR) is an endoscopic or scope procedure that does not involve making an incision in the body. The entire removal of the bladder tumor can be accomplished through an operative scope, which is passed through the urethra into the bladder.

Drug therapy after TUR is commonly prescribed for patients with large, multiple or high-grade tumors.

Intravesical Drug Therapy/Immunotherapy

Here medicines are placed directly into the bladder (intravesical) via a urethral catheter in order to lower the recurrence rate of bladder tumors. This is usually used for multiple CIS large in size (5 cm plus), high grade in stage tumors. About 50 percent to 68 percent of patients with superficial bladder cancer have a very good response to intravesical therapy.

Commonly used intravesical drugs are:

  • Mitomycin C, which kills the normal DNA function in cancer cells and is easily absorbed into the bloodstream through the bladder's lining

  • Bacille Calmette–Guerin (BCG) forces the immune system to respond to the BCG drug in the lining of the bladder, thus forcing the body's immune system to help fight off the cancer

Treatment for Advanced Bladder Cancer

Partial or Radical (Complete) Cystectomy Surgery

This is performed when tumors completely invade the bladder's muscular wall.

Partial bladder removal is rare because the requirements are that the tumor(s) is easily accessible and small in size and that there are no tumors in the rest of the bladder. This is usually used only if the cancer has not left its site of origin. Additionally, if all other treatments fail for superficial cancer, this could be used as an alternative.

Types of Surgical Reconstruction to Replace the Removed Bladder

Ileal Conduit

Ileal conduit diagram

This procedure has been routinely performed since the 1950s. The internal pouch that holds the urine is made from a small portion of intestinal tract. One end is closed with sutures while the other end is attached to skin on the front side of the abdomen. A stoma is the open end of the conduit attached to the skin. An external appliance (ostomy bag) covers the stoma to collect urine. The ureters are implanted into the back of the ileal conduit.

Catheterizable Continent Diversion Pouch

This is a reservoir of bowel with a stoma that is catheterizable for emptying the bladder. The urine is siphoned out of the urinary reservoir with a small catheter every four to six hours. The catheterizable pouch may require surgical repair at some point after surgery due to the wear and tear of frequent catheterization. This type of reconstruction is not performed on patients with a history of bowel disease.

Neobladder

A neobladder is a new bladder made of intestines. This internal, new bladder is connected to the urethra and ureters. After this reconstruction, the patient needs to relearn how to void. Some disadvantages of this type of reconstruction are the possibility of incontinence and scar tissue formation at the connection of the urethra and new bladder.

Radiation Therapy

The type of radiation, which is used to treat cancer, is actually a special high-energy X-ray that is more powerful than the X-rays used for imaging studies. Radiation therapy is planned and executed in a way to kill cancer cells or alter their ability to reproduce while the surrounding healthy cells are minimally affected. Historically, radiation therapy has been used for muscle-invasive bladder cancer, but current treatment can involve a combined approach of both radiation and chemotherapy. The role of radiation therapy in combination with chemoradiation therapy (combined chemotherapy and radiation therapy) is to kill the bladder cancer cells both in the bladder and outside the bladder. Local lymph nodes are frequently radiated as part of the therapy to treat the microscopic cancer cells that may be in the nodes.

Chemotherapy

Chemotherapy is the use of chemical agents that interfere with the replication and other normal functions of cells and results in tumor shrinkage or cancer cell death. The use of two or more chemotherapy drugs together has been found to be more effective than a single drug alone. There are several types of chemotherapy. The most common chemotherapeutic drug used in bladder cancer is cisplatin.

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