Bladder Cancer
Bladder cancer is the fourth most common cancer that affects men and the twelfth most common cancer of women in the United States and Europe. The patient and societal costs of treating bladder cancer are significant, with bladder cancer accounting for one of the most expensive malignancies to treat.[i] The most common type of bladder cancer is one that arises from the lining of the bladder, termed urothelial carcinoma.
Diagnosis
It is important to detect bladder cancer as soon as possible. Most of the time the initial presentation is hematuria, whether it be gross or microscopic. Other presentations can include irritative voiding symptoms and pain with urination. Sometimes blood in the urine can be incorrectly attributed to a simple urinary tract infection, which can lead to a delay in diagnosis. It is important if a patient has gross or microscopic hematuria, that he or is she is referred to a urologist.
The blood in the urine could arise from the lining of the kidneys, ureter, or bladder. The upper urinary system is evaluated using CT imaging with contrast to evaluate for any filling defects and the bladder is evaluated using a small cystoscope to visualize the inside of the bladder to detect any abnormalities.
Treatment
If a bladder cancer is detected, the first step is to stage the cancer. In the operating room, a transurethral resection of the bladder tumor (TURBT) is performed using a scope in order to obtain a tissue diagnosis of the bladder tumor and to clear out all visible tumor. At the end of the procedure a catheter may be left in place to allow the bladder to heal.
For low-grade superficial tumors, an intravesical chemotherapy agent Mitomycin C may be left to instill in the bladder for about an hour after surgery. This agent is used to help prevent tumor implantation at other sites of the bladder after resection.
A pathologist will examine the resected tissue to determine the histology of the tumor and to see how deeply into the wall of the bladder the cancer has penetrated.
Because bladder cancer is a cancer that has a propensity to recur, the bladder is surveilled closely in clinic to ensure it doesn’t come back. High grade cancers are monitored more stringently in clinic follow up than low grade disease, but each patient’s surveillance schedule is tailored the individual’s cancer characteristics.
For high grade cancers, an agent called Bacillus Calmette-Guerin (BCG) may be instilled weekly into the bladder for 6 weeks starting about a month after the TURBT. BCG is an attenuated vaccine that promotes the body’s own immune system to attack the bladder cancer. It is particularly useful for carcinoma in situ of the bladder and to reduce the chance of recurrence of high grade Ta or T1 bladder cancer after complete resection.
Imaging tests including a CT of the abdomen and pelvis, CXR and blood tests are performed as part of the initial work up of bladder cancer to see if the cancer has spread or if the cancer is confined.
More aggressive treatments
Once the disease burden reaches a critical state that cannot be treated with endoscopic techniques, more aggressive measures are needed to control the cancer. Because the mortality of metastatic bladder cancer is so high, radical cystectomy with pelvic lymph node dissection and urinary diversion remains a staple treatment for patients with aggressive disease. In men, the complete operation includes removal of the bladder, prostate, seminal vesicles, and pelvic lymph nodes. In women, the bladder, ovaries, uterus, anterior vagina, and pelvic lymph nodes are removed. The urinary system is then reconstructed with the following options for diversion:
Ileal conduit
This is an incontinent diversion where urine passes from the kidneys to a small segment of bowel and exits the body through the abdominal wall and skin via a stoma. Advantages include a shorter operation and less postoperative complications. Patients can still swim, bathe, and perform their usual daily activities. Disadvantages include the need to change a stoma bag on the skin surface and cosmetic appearance.
Orthotopic Neobladder
This is a continent diversion where a new bladder is constructed using a longer segment of small bowel than that which is used for an ileal conduit. The kidneys are hooked up to the new bladder and the new bladder is then attached to the urethra. Advantages include continence (controlling when a patient goes to the restroom) and not having any external stoma. Disadvantages include longer operation, higher risk of postoperative complications, need to self catheterize if the neobladder does not empty well, and nocturnal incontinence when the sphincter is relaxed. The patient will have to learn how to manage and utilize the neobladder over time. A neobladder cannot be performed if intra operative frozen section of the urethra shows evidence of cancer or if the blood supply to the bowel cannot reach down to the urethra.
Continent Cutaneous
The right colon and small bowel is used to construct a reservoir for urine storage, and a small channel is brought up to the abdominal wall skin. The patient externally catheterizes the channel through the skin to empty the reservoir regularly. Advantages include maintenance of continence and the external channel is quite small and hardly visible. Disadvantages include more complex operation and difficulties post operatively with the channel including stenosis and leakage that may require surgical revision in the future.
[i] Botteman, M. F., et al. (2003). “The health economics of bladder cancer: a comprehensive review of the published literature.” Pharmacoeconomics 21(18): 1315-1330.