Clinical Specialties : Oncology and Robotics

Bladder Cancer

General Information

Your kidneys are 2 bean shaped organs that help filter your blood to create urine. The urine drains through 2 small tubes, called ureters, which connect the kidney to the bladder. The bladder is a muscular organ located in the pelvis. It is designed to hold urine and expel it at a convenient time. When you are ready to pee, your bladder squeezes and empties the urine into your urethra, at which point you are peeing. The bladder contains many layers of cells, creating a thick wall. The bladder can expand to hold 400-500 milliliters of urine. Since the bladder contains muscle, when you feel the need to urinate, it will powerfully contract to expel the urine in order to empty.

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Bladder Cancer is the fourth leading cause of death in the US. The most common type of bladder cancer in adults in the US is called Urothelial Carcinoma (transitional cell carcinoma), which makes up for over 90% of bladder cancer cases. Other types include squamous cell carcinoma (5%), adenocarcinoma (1%), and small cell carcinoma.

Risk Factors

The #1 identified cause of bladder cancer has been linked to smoking. Smoking increases the risk of developing bladder cancer by 50% according to the NIH. You do not have to be an active smoker to have bladder cancer. Rather, it is often seen in long-term exposure tto smoking, even if you have quit a while ago. Other causes include: chronic inflammation of the bladder due to chronic urinary tract infections or indwelling catheter, bacteria found in other parts of the world (uncommon in the US), or chronic bladder stones. Links to occupational chemical exposures have also been found. Textile workers, hairdressers, dry cleaners, dye workers, or rubber workers can be at increased risk.

Signs and Symptoms

Bladder cancer typically presents itself as hematuria, or blood in the urine. Individuals with bladder cancer do not typically have pain associated with hematuria. This blood can either be visible to the naked eye, or microscopic. Other symptoms may include pain with urination, urgency to urinate, or increased frequency to urinate. In advanced disease, bone pain or back pain can occur.

Diagnosis

A thorough history and physical exam is pivotal in developing a diagnosis. There are additional diagnostic tests available:
There are three major tests involved in diagnosing bladder cancer.

1. Urine cytology. This involves looking at urine cells through a microscope. This test is good at picking up high grade cancer and moderately good at picking up low grade cancer.

2. CT Scan – A Special CT scan will be ordered to assess for bladder cancer. This can detect large cancers in the bladder, but not small cancers. This scan is good at looking at the kidneys, ureters, and lymph nodes to see if there is any spread of your cancer or cancer in other locations.

3. Cystoscopy – This is a procedure where a small scope is passed through your urethra and into your bladder. This is one of the most important tests to characterize your bladder tumors. This test is performed in the office and does not require anesthesia or sedation. It is uncomfortable, but typically not very painful.

If bladder cancer is suspected, a biopsy or resection is scheduled in the operating room. The biopsy is known as a trans-urethral resection (TURBT). A cystoscope is inserted through the urethra and into the bladder in order to scrape the cancer from the bladder. A pathologist then analyzes this tissue under a microscope and determines if cancer cells are present. The pathologist will also determine whether or not the cancer has invaded the muscle surrounding the bladder. If muscle-invasive bladder cancer is suspected, you may be ordered additional tests such as a chest or bone imaging or blood tests to determine if the cancer has spread to other parts of the body, mainly, the chest, liver, and bone.

Tumor type, grade, and stage based on the pathology report will determine the treatment course of bladder cancer.

Treatment

Treatment for bladder cancer depends largely on how far the bladder cancer penetrates into the layers of the bladder.

Fortunately, 70% of bladder cancer does not penetrate into the muscle layer. This is called non-muscle invasive bladder cancer and most often can be treated by resecting/scraping the tumor off the bladder (TURBT) using the cystoscope. Sometimes, treatment may also require placing some medications into your bladder (BCG or Mitomycin C) to help treat the cancer and prevent recurrence. Bear in mind, this type of bladder cancer tends to recur and surveillance is critical to make sure we address recurrent cancer.

For cancer that has invaded into the muscle layer of the bladder, the recommended treatment involves removing the whole bladder. This is because once the cancer gets into the muscle layer, it has access to blood vessels and lymphatic vessels and can spread to other locations of the body. If the cancer spreads outside the bladder, curing the cancer becomes very difficult. The procedure to remove the bladder is called a radical cystectomy and is a major operation, but is the best chance to cure the cancer. Sometimes, chemotherapy is used before for after this type of surgery to help increase chances of success. Part of this surgery involves creating a new way for the urine to leave your body. This is called a urinary diversion. There are 2 major types of urinary diversion: ileal conduit and neobladder.

1. Ileal conduit — This involves using about 15cm of your bowel (intestine) which becomes a separate tube to drain urine from the kidneys to the skin on your belly. The part of the bowel that comes up to the skin is called a stoma. With this type of diversion, you will be required to wear a small bag to collect the urine. Usually, this bag can be kept hidden well under clothes. The recovery from this type of diversion is much quicker and has less complications. This is, by far, the most common option for urinary diversion.

2. Neobladder – This involves using about 60cm of your intestines to fashion a new bladder for your urine to collect in. This will be reconnected to your urethra so that you will not need an external bag. However, since it is made of intestine, it does not function quite like a bladder and there are several problems that we will have to overcome in the long term. If this option is selected, it is important that you are willing to catheterize yourself, as mucous may often build up in the neobladder. As mentioned, the complication rate is significantly higher for this surgery. This option is usually reserved for younger, healthy patients, who are motivated and willing to catheterize.