Diagnosis and classification
Various types of cancers can arise in the urinary bladder, of which one particular variety, known as urothelial carcinoma, is the commonest. This type of cancer is associated with cigarette smoking and various chemicals which affect the bladder, but may also occur in people without these risk factors.
Bladder cancer is often diagnosed as a result of bleeding in the urine or irritable symptoms such as painful, urgent or frequent urination. Such symptoms should always be taken seriously and assessed medically. On occasion, bladder cancer may be found incidentally on scans performed for other reasons. Definitive diagnosis requires visualization by cystoscopy, with biopsies which are assessed by a pathologist.
Bladder cancer is classified according to its stage and grade. Stage measures the extent of cancer spread through the bladder wall and beyond, as assessed by the pathologist and on scans. In broad terms, bladder cancer can be characterized as non-invasive (if it is restricted to the lining or the epithelium of the bladder) or invasive (if it has grown beyond the lining) or metastatic (if spread to other parts of the body). Grade is reported by the pathologist, and can be divided into high grade (more aggressive) or low grade (less aggressive) cancers.
Treatment of bladder cancer is dependant on its classification.
Low-grade, non-invasive cancers can be completely removed by cystoscopic surgery. They have a very low likelihood of spread, although they frequently recur within the bladder. Thus, periodic check-ups including cystoscopic examination of the bladder, are required.
Non-invasive cancers which are high grade, large or multiple, or keep recurring frequently, require additional treatment in the form of medications put into the bladder on a weekly basis for a six or eight week course. Various medications, including some chemotherapy drugs are available for this purpose, but the most effective treatment uses the tuberculosis vaccine (BCG). More information on this treatment is available from your urologist.
Invasive cancers which do not extend into the bladder muscle may also be treated using BCG treatments, although this may fail in a proportion of cases. In such cases, or if a more definitive early treatment is desired, surgery to remove the bladder (cystectomy) is required.
Cancers that extend into or through the bladder muscle are generally treated by surgical removal of the bladder and lymph glands draining the bladder (cystectomy), which offers a high rate of cure. Surgical reconstruction of the urinary system is carried out using parts of the small intestine, either with the formation of a stoma or a pouch (neobladder) that replaces the bladder. If pathologic findings indicate, chemotherapy may be considered. As an alternative to surgery, radiation with or without chemotherapy may be considered, as it provides the advantage of preserving the bladder. However, in some cases, bladder symptoms persist or worsen following radiation, and may even necessitate removal of the bladder.
Metastatic bladder cancer is usually treated by chemotherapy, with bladder treatments reserved to control local symptoms. (top)
This is a minor surgical procedure in which the interior of the bladder is examined using an endoscope passed through the eye of the penis (for men) or the external urinary opening (for women). The instrument used may be small and flexible, in which case local anaesthetic is sufficient. In many instances, a larger, rigid instrument may be used (under anaesthesia), since this allows additional procedures to be performed as necessary.
Additional procedures that may be carried out during cystoscopy include biopsy or removal of abnormal areas, such as bladder tumours (which is often the first step in treating bladder tumours). If required and planned, cystoscopy may lead onto a TURP. The kidneys can be assessed using x-rays by injecting dye up to them through the cystoscope (retrograde pyelogram). If required, retrograde pyelograms may lead onto further procedures, for example the placement of an internal tube to drain the kidneys (known as a ureteric stent). Foreign material, such as a bladder stone or a previously placed stent, may be removed during cystoscopy. (top)
This is a major surgical procedure in which the bladder is removed, along with the prostate, seminal vesicles and vas (in men) and the uterus and part of the vagina (in women). Usually cystectomy is performed to treat suitable bladder cancers, most often with an intention to cure, but occasionally to relieve symptoms even if the cancer is incurable. Removal of draining lymph glands is usually carried out at the same time.
Once the bladder is removed, the rest of the surgery reconstructs the urinary system in order to allow the urine being produced by the kidneys to drain effectively. This can be done in one of two main ways, both utilizing a portion of the bowel (usually the small intestines), as outlined below.
An ileal conduit is made by connecting a small segment of bowel to the ureters on the inside, with the other end brought out to the skin to drain into a stoma bag. In contrast, a neobladder is made by re-configuring a longer length of bowel to form a pouch that is then positioned where the bladder used to be. Therefore, there is no external drainage of urine, and patients with a neobladder can pass urine through the normal channel, known as the urethra. (top)