Bladder Cancer (cont.)
Charles Patrick Davis, MD, PhD
Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.
In this Article
- What is the bladder?
- What are the layers of the bladder?
- What is bladder cancer?
- What is the burden of bladder cancer in the U.S.?
- What are the types of bladder cancer?
- What are bladder cancer causes and risk factors?
- What are bladder cancer symptoms and signs?
- How is bladder cancer diagnosed?
- How is bladder cancer staging determined?
- What is bladder cancer grading?
- What is transurethral surgery or "TURBT" for bladder cancer?
- What is the treatment for superficial bladder cancer?
- What is surveillance for bladder cancer?
- What is the treatment for muscle-invasive bladder cancer?
- What is chemotherapy for bladder cancer?
- What is the prognosis for bladder cancer?
- Can bladder cancer be prevented?
- Where can people find more information on bladder cancer?
- What research is being done on bladder cancer?
- Bladder Cancer At A glance
- Find a local Oncologist in your town
What is surveillance for bladder cancer?
Patients diagnosed and treated with superficial bladder cancer need to be followed up regularly to detect recurrences and treat them effectively. The following is a typical follow-up protocol:
- Cystoscopy and urine cytology every three months for two years, every six months for the next two to three years and annually thereafter
- Imaging study (CT scan/intravenous urogram) of the kidneys and ureters once every year (especially for high-grade tumors/those associated with CIS)
Cystoscopy and cytology detects recurrence in the bladder itself while CT/IVU is used to detect a tumor in the kidneys and ureters. Patients with bladder cancer are more likely to get upper-tract tumors which arise from the inner lining of these organs and share a common origin with bladder tumors. The risk of upper-tract recurrence depends on the stage and grade of the initial disease and the response of the tumor to BCG. Individuals with recurrent high-grade bladder tumors can have up to a 20% risk of developing a tumor in the upper tracts and need to be followed closely in this regard.
Commercially available tumor markers which are used to test urine samples for evidence of bladder tumor recurrence are also being used in follow-up protocols. However, their exact role is undefined as of now and they are not considered an adequate substitute for cystoscopy and cytology. Some of these markers are NMP 22, BTA Stat, BTA Trak, and UroVysion.
What is the treatment of muscle-invasive bladder cancer?
Muscle invasive bladder cancer generally requires a more aggressive treatment plan than superficial bladder cancer. The standard and most effective treatment is the surgical removal of the bladder and diversion of the urinary stream using intestinal segments. This procedure, known as radical cystectomy, is a major operation and a thorough discussion and counselling of the risks, complications, and benefits is warranted prior to this surgical procedure.
In short, the procedure entails removal of the bladder, prostate, seminal vesicles, and the fatty tissue around the bladder through an incision made in the abdomen. The surgery also includes removal of lymph nodes in the pelvis on both sides of the bladder to detect their involvement with the cancer. This helps in deciding further management after surgery including the need for chemotherapy. It has been shown that patients who undergo a thorough lymph node dissection have a better chance of cure as compared to patients who either do not receive one or undergo a less extensive dissection.
Radical cystectomy can be performed via open surgery, laparoscopy, or with robotic assistance. It has been shown that the outcomes in terms of cancer control and cure rates do not differ between these different approaches. However, the use of laparoscopic and robotic approaches significantly decreases blood loss during the surgery, decreases the need for blood transfusions, and may help in early recovery by decreasing postoperative pain at the surgical site. An additional advantage of the robot is that it permits an enhanced magnification of the surgical field with three-dimensional vision which helps to enhance surgical precision. It is very important to note that all these approaches can achieve comparable results in terms of cancer control in the hands of surgeons skilled and experienced in a particular modality. So, the comfort factor and experience of an individual surgeon in a particular approach should play a major role in the patient's decision regarding selection of the approach for surgery.
Once the bladder has been removed, the urine needs to be diverted. There are three popular ways of doing that. All of them require the use of segments of the intestine which are still connected to their blood supply but have been disconnected from the gastrointestinal tract.
- Ileal conduit is the most extensively used form of urinary diversion. It is also the simplest and the least time-consuming form of diversion and has the least chances of complications in the short and long term. This entails the use of an intestinal segment, one end of which is connected inside the body to the ureters that drain urine into it from the kidneys, while the other end is brought out to the level of the skin and is covered by an external appliance (a "urostomy bag"). The urine from the kidneys continuously drains into the bag through the ureters and the "ileal conduit." The bag can be emptied at regular intervals or when it is nearly full by opening a tap-like attachment at the lower end of the bag. The major advantage of this procedure is that is relatively straightforward to perform with the least chances of complications. The disadvantages include the need to wear a bag all the time and the resultant negative impact that may occur on body image.
- Orthotopic neobladder entails the creation of a new bladder ("neobladder") with the help of an intestinal segment and connecting it to the natural urinary passage so that a person may be able to pass urine "more normally." The major advantage of this procedure is that it avoids the need to wear a bag, and the patient can pass urine in a more natural fashion. However, this is a more difficult procedure with a longer recovery period and may lead to some short-term and long-term complications, including persistent urinary leakage and inability to pass urine requiring the use of self-intermittent catheterization (passage of a tube into the urinary passage to empty the bladder). Some senior patients and those with certain medical conditions that affect the function of the kidneys or impair their ability to self-catheterize may be best served by the ileal conduit rather than the neobladder.
- Continent catheterizable pouch (for example, "Indiana pouch") is a form of neobladder which is not connected to the normal urinary passage but instead has an opening or a "stoma" at the level of the skin on the abdomen through which a catheter can be passed to empty it periodically. This has a valve-like mechanism which prevents the leakage of urine through this opening thereby precluding the need to wear a bag. It is used it patients desirous of and fit for a continent urinary system while being unsuitable for an orthotopic neobladder due to certain circumstances such as cancer at the point where the bladder joins the urethra.
Radical cystectomy (open, laparoscopic, or robot assisted) combined with one of the three urinary diversion methods is the gold standard for the treatment of muscle invasive and selected cases of high-grade superficial bladder cancer. Certain patients, however, may be unfit or unwilling to undergo this surgery. These patients can often undergo a combination of extensive TURBT, chemotherapy, and radiation in an attempt to cure or control the disease without the need to remove the urinary bladder surgically. Most experts believe that this regime may not be as effective as a radical cystectomy but can be used as an option in unfit/unwilling patients. Radiation to the bladder can, however, lead to its own set of problems and complications, including radiation damage to the bladder and rectum which give rise to bleeding and irritative symptoms ("radiation cystitis" and "radiation proctitis").
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