Urine produced in the kidneys passes down the ureters and is stored in the bladder prior to voiding. The layers comprising the bladder from inside out are the urothelium, the lamina propria, and the detrusor muscle, covered on the outside by fat. Bladder cancer is one of the commonest urological cancers and its incidence seems to be increasing.
Causes Of Bladder Cancer
The commonest causes are smoking of cigarettes, bidis, hookah and exposure to chemicals in industries such as dyes, metal, paints, leather, textile and organic chemicals. More than 90 percent of all bladder cancers originate in the urothelium and then may invade the lamina propria and detrusor muscle.
Symptoms of bladder cancer: Painless hematuria with or without clots is the most common symptom. However, hematuria by itself does not confirm the presence of bladder cancer. A diagnostic investigation is necessary to determine whether bladder cancer is present. Other symptoms of bladder cancer may include frequency and dysuria and may also be due to renal failure and disseminated disease.
1) Urine exam 2) Urine cytology for malignant cells 3) Imaging studies like Ultrasound and CT scan 4) Cystoscopy and Transurethral resection of bladder tumor (TURBT). Material obtained from resection is sent to pathology to determine the grade and level of invasion of the tumor.
Treatment of Bladder Cancer:
This depends upon the grade and depth of invasion of the tumor (denoted by the TNM staging system).
Carcinoma In Situ(CIS): This is a high grade but non-invasive lesion seen as a reddish, velvety patch on the bladder lining. It is best treated with intravesical immunotherapy or chemotherapy. If untreated, CIS will likely progress to muscle-invasive disease.
Low Grade Lesions Confined To The Urothelium Or Lamina Propria: TURBT is the usual treatment method for these patients. Following removal, intravesical chemotherapy (thiotepa, doxorubicin, mitomycin C) or intravesical immunotherapy with BCG (bacillus Calmette-Guérin) may sometimes be indicated to try to prevent tumor recurrences. Each of these is superior to TURBT alone for preventing tumor recurrences. Both BCG and mitomycin C are superior to doxorubicin or thiotepa for reducing recurrence of superficial tumors. However, there is no absolute evidence that any intravesical therapy affects the progression to muscle-invasive disease although some studies with BCG suggest this may be the case. Each of the four agents produces some side effects. Recent studies have shown that maintenance therapy is useful for some patients receiving BCG, it is of less certain benefit for those receiving the other three drugs.
Muscle Invasive lesions or high-grade lesions involving lamina propria or lesions not controlled with TURBT and/or intravesical agents: Radical Cystectomy or Surgical removal of the bladder is the treatment of choice in such cases. This involves some form of urinary diversion such as ileal conduit, ureterosigmoidostomy or neobladder reconstruction. Alternatives to surgery include various types of bladder preservation protocols that include both systemic chemotherapy and external beam radiation.
Things to remember
Smoking and exposure to chemicals MUST stop immediately 2) Recurrence rates after TURBT for superficial cancer are about 70% and periodic check cystoscopy is mandatory for all such cases 3) Complications of TURBT include bleeding and bladder perforation 4) Mortality after radical cystectomy is less than 5% and complication rate is about 10-15% 5) Complications of cystectomy include heavy bleeding requiring blood transfusion, urine leak, bowel leak, abdominal and chest infections and septicemia. 5) Metastatic disease at presentation is treated with palliative measures and chemotherapy. 6) This is only a brief guide and cannot cover all aspects and eventualities.