Bladder Cancer

Overview
What are some of the symptoms and who is at the greatest risk?
How is Bladder Cancer Diagnosed?
What if a Tumor is Present?
What happens if Bladder Cancer is Found?
What are my treatment options?
What is a cystectomy?
Anatomy and Physiology of the Bladder

Overview
Bladder Cancer is the sixth most common cancer in the United States: about 53,200 Americans are diagnosed with bladder cancer each year. In recent years there has been a steady increase in the incidence of bladder cancer. However, doctors are making progress in the treatment and survival rates are improving.

What are some of the symptoms and who is at the greatest risk?
Early recognition of symptoms helps save lives. Early symptoms may include:

Blood in the urine
More frequent urination
Pain on urination
a sense of incomplete emptying of the bladder after urination

The symptoms above could also indicate problems (less serious) other than bladder cancer.
Individuals at the greatest risk are:

Those over 60 years of age
Cigarette smokers
Exposure to certain industrial chemicals (derivatives of arylamines)

How is Bladder Cancer Diagnosed?
Diagnostic tools to check for bladder cancer include various types of urinalysis. In one type, the urine is examined under a microscope to look for cancer cells that may have been shed into the urine from the bladder lining. Urine can also be tested for substances known to be closely associated with cancer cells.

Radiological diagnostics is also another excellent method used for diagnosis. An Intravenous pyelogram (IVP) is a conventional x-ray test using dye to examine the pelves of the kidneys (where urine collects within the kidneys),ureters, and bladder. This x-ray allows visualization of the upper and lower urinary tract to determine the presence of any abnormality. Computed Tomography (CT) scanning is essentially a detailed X-ray of the body. CT shows cross-sections of the body and allows your doctor to see details of the anatomy that would not be seen on regular x-ray. Magnetic Resonance Imaging (MRI) is more sensitive than CT scanning. CT and MRI have the added benefit of detecting enlarged lymph nodes near the tumors, which can suggest that a cancer has spread (metastasized) to the lymph nodes.

Another diagnostic tool is cystoscopy, which is a procedure that allows direct viewing of the inside of the bladder. This is most commonly performed as an office procedure under local anesthesia or light sedation. First a topical anesthetic gel is applied, so the person will feel little or no discomfort. The doctor then inserts a cystoscope through the urethra and into the bladder. Looking through the cystoscope the doctor is able to examine the bladder’s inner surfaces for signs of cancer.

What if a Tumor is Present?
If tumors are present, the doctor notes their appearance, number, location and size. As removal (resection) of the tumors cannot usually be done under local anesthesia, the person is then scheduled to return for a surgical procedure to remove the tumor under general anesthesia or regional anesthesia. In a manner as before, the doctor inserts an instrument called a resectoscope in to the bladder. This is a viewing instrument similar to the cystoscope, but contains a wire loop at the end for removing tissue. This procedure is done through the urethra and is called a transurethral resection of bladder tumors. The removed tissue is sent to a pathologist for examination.

In addition to removing visible tumors, the doctor may remove very small samples of tissue of any suspicious-looking areas of the bladder. A pathologist also examines this tissue.

What happens if Bladder Cancer is found?
If a biopsy is taken and bladder cancer is found, the pathologist who examines the tissue will grade the tumor according to how much cells differ in appearance from normal cells. The most widely used grading systems classify tumors into three main grades: low, intermediate, and high.

The cells of low- grade tumors have minimal abnormalities. In high-grade tumors, the cells have become disorganized and many abnormalities are apparent. The grade indicates the tumor’s “aggression level” – how fast it is likely to grow and spread. High-grade tumors are the most aggressive and the most likely to progress into the muscle.

Another grading scale uses numbers. Staging is an assessment of how far the tumor has spread.

STAGE 1:	The tumor has spread only into loose tissue beneath the lining (lamina propria) but not into the bladder’s muscular wall or beyond. No lymph nodes are involved.
STAGE 2:	Tumor has invaded into the muscle wall (muscularis propria) of the bladder but has not spread to lymph nodes or other sites in the body.
STAGE 3:	Tumor has invaded through the muscle wall (muscularis propria) of the bladder to involve the soft tissue around the bladder OR has invaded adjacent organs including the prostate, uterus or vagina. No lymph nodes or other distant sites in the body are involved at this stage.
STAGE 4:	Tumor has extended out of the bladder to invade the pelvic or abdominal wall, but does not involve lymph nodes or other distant sites in the body. OR Tumor has spread to involve lymph nodes and/or other distant sites in the body.

What are my treatment options?
Transurethral resection of the bladder, or TURBT, is the usual treatment method for people who, when examined with a cystoscope, are found to have abnormal growths on the urothelium (stage Ta) and/or in the lamina propria (stage T1).

Alternative methods, such as laser therapy, compare favorably with TURBT in terms of treatment results. However, TURBT has a major advantage in that it can provide tissue suitable for a pathologist to use in determining a tumor’s grade and stage. The tumor structure is left too distorted for this purpose after the alternative treatment methods, so biopsies of the tumor must be taken before the treatment.

Following removal, intravesical chemotherapy or intravesical immunotherapy may be used to try to prevent tumor recurrences. Intravesical means “within the bladder.” These therapeutic agents are put directly into the bladder through a catheter in the urethra, are retained for one to two hours and are then urinated out.

Surgical removal of the bladder may be an option for people with CIS or high-grade T1 cancers that have persisted or recurred after initial intravesical treatment There is a substantial risk of progression to muscle-invasion cancer in such cases, and some people may want to consider a partial or full cystectomy as a first choice of treatment. The risks of cystectomy and the methods of urinary reconstruction should be discussed with your doctor.

What is a cystectomy?
A cystectomy is either partial or complete surgical removal of the bladder. Cystectomy is indicated when bladder cancer is invasive into the muscle wall of the bladder or when patients with superficial tumors have frequent recurrences that are not responsive to intravesical therapy. When the cancer has spread outside the bladder wall, cystectomy is not usually done. The benefits of surgically removing the bladder are disease control, eradication of symptoms associated with bladder cancer, and long-term survival. When the bladder is surgically removed, a replacement for the bladder needs to be constructed. The types of bladder reconstruction currently available for patients are ileal conduit, catheterizable pouch and neobladder. The urologist is best qualified to assess whether surgery is a possible option, and if a cystectomy is performed, which type of reconstruction is the best.

Anatomy and Physiology of the Bladder
The bladder is a sac-like organ in the pelvis that stores the urine produced by the kidneys. There are two tubular structures called ureters (one from each kidney) that drain the urine into the bladder. The urethra is the outflow tract of the bladder and connects the bladder to the exterior.

Anatomically, the bladder is the most anterior (closest to the front) organ in the pelvis, located just behind the pelvic bone. Organs closest to the bladder include the rectum (the last part of the colon), which is the most posterior (closest to the back) organ in the pelvis, the prostate gland and seminal vesicles (in males), and the uterus, ovaries and fallopian tubes (in females). In males, the prostate gland and seminal vesicles (organs that contribute secretions in semen) are situated below the bladder and in front of the rectum. In females, the uterus (the womb), ovaries and fallopian tubes are located posterior the bladder and anterior to the rectum.

The bladder itself is made up of four layers. These layers are important landmarks in determining how deeply the tumor has invaded and the ultimate stage of the cancer.

Epithelium: The epithelium, which lines the bladder and is in contact with the urine, is referred as transitional epithelium or urothelium. Most bladder cancers originate from the cells of this transitional epithelium. The urethra, ureters and the pelvis of the kidney are also lined by this transitional epithelium, therefore, the same types of cancers seen in the bladder can also occur in these sites.
Lamina propria: Under the epithelium is the lamina propria, a layer of connective tissue and blood vessels. Within the lamina propria, there is a thin and often discontinuous layer of smooth muscle called the muscularis mucosae. This superficial layer of smooth muscle is not to be confused with the true muscular layer of the bladder called the muscularis propria or detrusor muscle.
Muscularis propria or detrusor muscle: This deep muscle layer consists of thick smooth muscle bundles that form the wall of the bladder. For purposes of staging bladder cancer, the muscularis propria has been divided into a superficial (inner) half and a deep (outer) half.
Perivesical soft tissue: This outermost layer consists of fat, fibrous tissue and blood vessels. When the tumor reaches this layer, it is considered out of the bladder.