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Bladder Cancer

What is the bladder ?


The urinary bladder (referred to as ‘the bladder’) is the organ that collects and stores urine produced by the kidneys. It is a hollow stretchy bag made of muscle tissue that sits on the pelvic floor muscles. The blad- der expands as urine from the kidneys collects before being passed out of the body through the urethra.

What is bladder cancer ?

Bladder cancer is the growth of abnormal tissue (tu- mour) in the bladder. It is not contagious. A tumour that grows towards the centre of the bladder without growing into the muscle tissue of the bladder is non–muscle invasive. These tumours are superfi- cial and represent an early stage. This is the most common type of bladder cancer. In most cases, these tumours are benign and rarely spread to other or- gans, so they are not usually lethal.

As the cancer grows into the muscle of the bladder and spreads into the surrounding muscles, it be- comes muscle- invasive bladder cancer. This type of cancer has a higher chance of spreading to other parts of the body (metastatic) and is harder to treat. In some cases, it may be fatal.

If bladder cancer spreads to other parts of the body such as the lymph nodes or other organs, it is called locally advanced or metastatic bladder cancer. At this stage, cure is unlikely, and treatment is limited to con- trolling the spread of the disease and reducing the symptoms.

How can I prevent bladder cancer ?

Several biological factors and harmful substances can increase the risk of developing bladder cancer. A higher risk does not necessarily mean that someone gets cancer. Sometimes bladder cancer develops without any known cause.

Risk factors for bladder cancer :

  • Age: Bladder cancer develops slowly and is more common in older people (age 60 and older).
  • Tobacco use: Smoking contains many harmful substances and is responsible for almost half of bladder cancer cases.
  • Occupational chemical exposure: Chemicals used in the production of paint, dye, metal and petroleum have been associated with bladder cancer, although workplace safety guidelines have helped reduce this risk.
  • Infections: Certain viruses, bacteria, or parasites and chronic urinary tract infections increase risk of developing bladder cancer.

It is important to maintain a healthy lifestyle. If you smoke, try to stop. Follow workplace safety rules and avoid exposure to harmful chemicals. Some evidence suggests that drinking a lot of fluids, mainly water, might lower bladder cancer risk. Eating a balanced diet with lots of fruits and vegetables has health ben- efits and might protect against cancer. If you have questions or need support to maintain a healthy life- style, ask your health care team for assistance or re- ferrals.

What are the symptoms of bladder cancer?

Blood in the urine is the most common symptom when a bladder tumour is present. Tumours in the bladder lining (non–muscle-invasive) do not cause bladder pain and rarely present with lower urinary tract symp- toms (need to urinate, irritation).

If you have urinary tract symptoms such as blood in the urine, painful urination or need to urinate more often, a malignant tumour might be suspected, par- ticularly if treatment does not reduce the symptoms. Muscle-invasive bladder cancer can cause symptoms as it grows into the muscle of the bladder and spreads into the surrounding muscles.

If you have a more advanced tumour, you may experi ence additional symptoms like pelvic pain, pain in the flank, and weight loss, or you might be able to feel a mass in the lower abdomen.

What tests are done to diagnose bladder cancer?

Because blood in the urine is the most common symptom when a bladder tumour is present, your doctor will test your urine to look for cancer cells and to exclude other possibilities like urinary tract infec- tions. Your doctor will take a detailed medical history and ask questions about your symptoms.

Physical examination does not reveal non–muscle-in- vasive bladder cancer, but you might be able to feel a mass if cancer has advanced to the muscle-invasive stage. If muscle-invasive bladder cancer is suspect- ed, your doctor should perform rectal and, for women, vaginal examinations by hand (bimanual palpation).

In addition, your doctor will do a series of tests to make the diagnosis. Advanced diagnostic tools include:

  • CT urography
  • Intravenous urography
  • Transabdominal ultrasound
  • Cystoscopy
  • Transurethral resection (removal) of bladder tu-mours (TURBT)
  • Photodynamic diagnosis
  • Narrow-band imaging

CT and magnetic resonance imaging (MRI scan) are the techniques used for staging invasive bladder can- cer. A combination of positron emission tomography (PET scan; uses a radioactive tracer) and CT is in- creasingly being used at many centres in Europe to enhance the ability of detecting the spread of bladder cancer to the lymph nodes or other organs, mainly in difficult sites like bone.

Do these tests hurt ?

Most imaging tests are done from outside the body (noninvasive) and do not hurt. Some imaging tests use a contrast agent that is injected into a vein and can cause an allergic reaction. Tell your doctor about any allergies that you have. Tests that require the insertion of instruments inside the body (invasive) require local or general anaes- thesia and may cause some bleeding and infections. Drinking an additional 500 mL per day (eg, two extra glasses of water) will help dilute the urine and flush out the blood. You might also have painful urination or have to urinate more often or more urgently. These short-term effects will pass. If they persist for more than 2 days, you might have a urinary tract infection and should contact your doctor. Symptomatic infections are treated with antibiotics and rarely require hospitalization.

How are bladder cancer tumours classified?

Tumour stage and subtype are based on whether or not the cancer is limited to the bladder (localisation) and the degree to which the tumour has invaded the bladder wall. This information is important for deter- mining the risk of recurrence of the disease.

During examination of tissue under a microscope (histological analysis), the pathologist will grade the tumours according to their potential to grow (aggres- siveness). High-grade tumours are more aggressive, and tissue is greatly altered in appearance. Low- grade tumours are less aggressive, and tissue is mildly altered in appearance.

Based on your personal characteristics, your disease stage and grade, and study-based data from bladder cancer risk tables, you will be assigned to one of three risk groups—low, intermediate, or high risk—based on your risk of recurrence and progression. This risk stratification is used to determine the treatment op- tions that can be offered and the follow-up that will be needed.

How should I prepare for a consultation ?

Preparing for a consultation can be very useful. It will help you and your doctor better address your ques- tions and concerns. It can also help you prepare for treatment and the possible side effects.

Here are some ways to prepare:

  • Write down the questions you would like to ask the doctor. This will help you remember things that you want to ask. Writing down questions can also help organize your thoughts.
  • If you can, take someone with you to the visit. It is good to have someone to discuss what the doc- tor said, and you’ll probably remember different things.
  • Ask for information about your specific type of bladder cancer.
  • If the doctor uses words you do not understand, ask for an explanation.
  • Tell your doctor what medicines you take, including any nonprescription medicine and supple- ments. Some of these medicines can affect your treatment.

Questions about treatment

How is bladder cancer treated ?

Bladder cancer treatment is based on your risk of re- currence and progression. This risk is determined by your personal characteristics, your disease stage and grade, and your risk group. Non–muscle-invasive bladder cancer is treated by complete removal of all visible tumours with TURBT, often followed by washing of the bladder with drugs to prevent the growth or spread of cancer cells (che- motherapy). For patients with increased risk of recur- rence, additional chemotherapy or immunotherapy may be used. The mainstay of treatment for muscle-invasive blad- der cancer is surgical removal of the bladder (radical cystectomy), followed by construction of a new way to store and regulate the flow of urine (urinary diver- sion). Bladder-sparing treatments are available for patients who are not candidates for surgery or who do not want surgery, but they have side effects and require a high level of patient compliance with treat- ment and follow-up. About a third of patients under- go bladder removal after failure of a bladder-sparing treatment.

What is TURBT ?

TURBT is the surgical removal of bladder tumours. It used to take tissue samples for diagnosis and, if appropriate, to treat non–muscle-invasive disease. TURBT is performed by the insertion of a rigid en- doscope through the urethra into the bladder, with the patient under general anaesthesia (combination of intravenous drugs and inhaled gasses; you are ‘asleep’). TURBT usually takes no longer than 1 hour and requires a short hospital stay. After the operation,in some cases, a transurethral catheter is placed for a few days. As with any surgical procedure, there are risks of complications. Complications after TURBT include bleeding, infection, perforation of the bladder wall (rare but can happen when the tumour is removed from deep within the bladder), blood in the urine, and blockage of the urethra due to blood clots.

What is radical cystectomy ?

Radical cystectomy is the surgical removal of the whole bladder and is used to treat muscle-invasive bladder cancer. It includes removal of the bladder, the endings of the ureters, the pelvic lymph nodes, and adjacent gender-specific organs (the prostate and seminal vesicles in men; the entire urethra, adjacent vagina, and uterus in women). Radical cystectomy is done in tandem with urinary diversion to construct a new way of storing and regulating the flow of urine.

Your doctor has several reasons for recommending removal of the whole bladder:

  • Presence of a muscle-invasive tumour
  • Presence of a tumour that grows aggressively (high grade), that has multiple cancerous areas (multifocal), or that is superficial but recurs after chemotherapy or immunotherapy
  • Failure of or recurrence after a bladder-sparing approach or the occurrence of major side effects
  • Symptoms like bleeding or pain in patients whose tumours cannot be removed

Before undergoing this procedure, your biological age (performance status), other diseases, and eligi- bility for chemotherapy before surgery should be as- sessed. Chemotherapy is administered before blad- der removal to potentially shrink the tumour and kill cells that have already entered the blood or lymph nodes. In addition, if a tumour is large (>3 cm) or if cancer has spread to the lymph nodes (determined by the pathologist), chemotherapy after bladder re- moval is recommended.

As with any surgical procedure, there are risks of complications including bleeding and infection. In addition, functioning must be observed and con- trolled. Functional complications after bladder remov- al include vitamin B12 deficiency, high acid levels in the blood (metabolic acidosis), worsening kidney function, urinary infections, urinary stone formation, tightening of stoma openings, stoma complications in patients with ileal conduit diversions, neobladder continence problems, and emptying dysfunction. Ask your doctor for information about the major symptoms of these complications and their prevention.

What is urinary diversion ?

Urinary diversion is the surgical construction of a new way of storing and regulating the flow of urine. This can be achieved with several techniques.

Continent urinary diversions store urine inside the body:

  • Creating a pouch or reservoir inside the body (cu- taneous urinary diversion)
  • Attaching the ureters to the rectum (ureterocolon- ic diversion)
  • Forming a new bladder from small intestine (or- thotopic neobladder)

Incontinent urinary diversions collect urine outside the body through a new opening in the abdomen (urostomy):

  • Rerouting ureters through the skin (ureterocuta- neostomy)
  • Placing a piece of small intestine between the ureters and the skin (ileal conduit)

During recovery in the hospital, you will learn how to manage your urinary diversion. Once you have learned how to use and empty the urostomy or inter- nal urine pouch, a date for your discharge will be set.

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