Bladder Cancer

Overview

The bladder is a balloon-shaped organ that stores urine. Bladder cancer is one of the most common cancers, with about 75,000 new cases diagnosed nationwide each year. It is more prevalent in men - 75 percent of new cases are men. It typically occurs in older individuals, with nine out of 10 people diagnosed over the age of 55.

Most patients, about 70 percent, develop a non-muscle-invasive or superficial type of bladder cancer and can be treated by just removing the tumor and leaving the remaining portion of the bladder intact.

Symptoms

• Blood in urine that may be bright red or dark, or microscopic so it's not visible at all but detected through lab analysis
• Frequent urination
• Painful urination
• Back or pelvic pain

Risk Factors

• Smoking - chemicals from smoke are excreted into the bladder, which may damage the lining of the bladder and increase the risk for cancer.
• Age - individuals over the age of 40 are most likely to develop bladder cancer.
• Race - Caucasians develop bladder cancer more often than people of other races.
• Gender - Men are more likely to have bladder cancer than women.
• Previous cancer treatment - Individuals who have been treated for cancer with the drug cyclophosphamide or received radiation treatment aimed at the pelvis have an increased risk of developing the disease.
• Diabetes drugs - Diabetic medications taken for more than a year that contain pioglitazone may raise the risk of getting bladder cancer.
• Chronic bladder inflammation - Repeated urinary tract infections that can inflame the bladder may increase the risk of a specific type of bladder cancer, known as squamous cell.
• Personal or family history - Individuals who have already had bladder cancer and those with close family members diagnosed with the disease are more likely to develop it again.

Types of Bladder Cancer

• Transitional cell carcinoma - is the most common form of bladder cancer. It occurs in the cells that line the inside of the bladder.
• Squamous cell carcinoma appears in the bladder in response to irritation and frequent infections. It is common in areas where the parasitic infection schistosomiasis is prevalent but rare in the U.S.
• Adenocarcinoma is a very rare type of bladder cancer, occurring in cells that are part of the mucus-secreting glands in the bladder.

Tests

Cystoscopy

A cystoscopy is a procedure used to see inside the bladder and urethra - the organ that carries urine from the bladder to the outside of the body. It is used for diagnosing and treatment.

Procedure

A tube with a live camera (cystoscope) is inserted into the urethra and advanced into the bladder. It helps physicians identify problems such as early signs of cancer, infection, narrowing of the urethra, obstruction and bleeding. During this procedure, the physician is also able to use surgical instruments for biopsy and removal of stones.

Why have a Cystoscopy?

A cystoscopy can be used to learn the cause of symptoms such as blood in the urine, frequent urinary tract infections and painful urination. It can help diagnose bladder stones, inflammation (cystitis) and cancer. It can also reveal an enlarged prostate.

Small tumors may be removed during the procedure.

Recovery

When done in an outpatient setting and no sedation is given, the procedure takes less than five minutes. Patients can resume daily activities almost immediately.

If a local or general anesthetic is used in a hospital setting, it can take between 10 and 30 minutes. Patients will need to stay in a recovery area until the effects of the sedation have dissipated.

Some side-effects that may occur include bleeding from the urethra, which can appear bright pink in urine or on toilet tissue,a burning sensation during urination and more frequent urination over the next couple of days. Patients are encouraged to drink water to flush out the bladder after the procedure.

Treatment

Surgery

Transurethral resection of bladder tumor (TURBT)

A transurethral resection of a bladder tumor is used for diagnosis as well as treatment of early stage bladder cancers. It is done through the urethra, very similar to a cystoscopy, so no incision is required.

Patients are given either general anesthesia or have the lower half of their body numbed before a physician guides a scope through the urethra into the bladder and removes the tumor. After surgery, patients may experience some bleeding and pain during urination but these side effects diminish quickly. Patients can usually leave the hospital the same day or stay one night and resume normal activities within two weeks.

Partial cystectomy

If the cancer has invaded the muscle of the bladder in one place but is not very large, only a part of the bladder wall may need to be removed. This is called a partial cystectomy. Lymph nodes from the area are also taken out.

Patients who have this procedure can still urinate normally. Only a small number of patients with invasive bladder cancer are eligible for this procedure and there is a chance the cancer may recur in another area of the bladder.

Radical Cystectomy and Reconstruction

A radical cystectomy is the removal of the entire bladder and nearby lymph nodes. In men it also includes the prostate and seminal vesicles and in women, the ovaries, fallopian tubes, uterus, cervix and a small section of the vagina are also taken out.

For years, a cystectomy was done as an open surgery through a cut made in the abdomen. Today, cystectomies are increasingly being done with robotic surgery. A radical robotic cystectomy results in less pain and reduced recovery time.

When the entire bladder is removed, reconstruction is needed to create another place to store and remove urine. Depending on the patient's condition and the type and stage of the cancer, there are three options for reconstructive surgery, all using a section of the patient's intestine.

• An incontinent diversion requires a passageway, called an ileal conduit, to be made with the small intestine. The conduit carries urine from the ureters to the outside of the body through an opening called a stoma or urostomy to a bag placed on the outside of the abdomen. Urine comes out continuously and the bag needs to be emptied once it is full.
• A continent diversion requires using a piece of the large intestine, this time to create a pouch located inside the body. Like an incontinent diversion, a stoma or opening is also created. Urine travels through the ureters to the pouch but when it becomes full, a catheter must be inserted through the stoma to drain it several times a day.
• One option - a neobladder enables patients to urinate normally without a bag outside the body or the need to remove urine through a catheter. Only a select number of urologic oncologists perform this complex surgery, which requires using part of the small intestine to create a pouch. This newly reconstructed bladder is inside the abdomen, connected to the ureters and urethra, so urine flows through it and out the body as it did before the cystectomy. Patients must train their bodies to recognize the need to urinate - it feels differently than with a normal bladder - and may experience some incontinence at night for a while.

Immunotherapy

Immunotherapy, also known as biological therapy, triggers the body's immune system to fight cancer cells.It consists of substances made by the body or in a lab that rev up the immune system and is typically used for early, superficial bladder cancers.

Immunotherapy is usually administered through the urethra directly into the bladder. The most common biological therapy drug is bacilli Calmette-Guerin (BCG) - a bacterium used in tuberculosis vaccines. The success rate for this drug is above 70 percent. Other drugs are also available and clinical trials for different immunotherapies are held in select sites nationwide.

Chemotherapy

Chemotherapy treatment may involve using a combination of two or more drugs. It can be administered through a vein in the arm or directly into the bladder via the urethra. It can be used before or after surgery or paired with radiation when surgery isn't an option.