Bladder Cancer: The things you should know

What is bladder Cancer?

In simple terms, it is the cancer affecting the bladder which is an integral part of the urinary tract. The human urinary tract is made of two kidneys and ureters (right and left), a bladder, prostate in males and urethra. Bladder is a bag which stores the urine and is located in the pelvis .The cancer disease can affect all these elements of urinary tract- bladder cancer and prostate cancer are the commonest urologic cancers.

What are the symptoms of the bladder cancer?

The commonest presentation of bladder cancer is painless hematuria (blood in the urine) with or without clots. Patients may have irritative urinary symptoms like increased frequency of micturation, urgency and can also have pain in the lower part of the abdomen. Many times these symptoms are put down as a simple infection, stone disease or even as a prostate problem by the patients (and even by the family physicians at times) and are treated by conservative measures without further investigations. This can lead to delay in the diagnosis of bladder cancer which in turn can have adverse effect on the treatment outcomes and prognosis.

What are the risk factors in developing the bladder cancer?

Smoking, use of tobacco, recurrent stone disease, recurrent urinary tract infections and aging are the main etiological factors for developing the bladder cancer. Some parasitic infections such as Bilharziasis (common in Egypt) can also lead to the development of bladder cancer. It affects males and females and the peak incidence is in the 4th and 5th decade of life. Bladder cancer in elderly can be a challenging situation, rarely children can also get bladder cancer which is entirely a different entity than the adult bladder cancer, but still can have excellent prognosis if treated correctly.

What are the modalities used in the diagnosis of bladder cancer?

The patient needs to undergo routine blood tests, kidney function tests, urine microscopy and a test called as urine cytology. Ultrasonography of the urinary tract is mandatory and if need be, a CT scan of the abdomen and pelvis is performed at this stage. These imaging modalities are helpful in delineating the growth in the bladder and give a rough idea about the stage and spread of the cancer disease.

The urologic cancer specialist will then perform an endoscopic procedure called Cystoscopy (looking inside the bladder through a telescope) under anesthesia to assess the exact location of this cancer and its extent. TURBT (Transurethral resection of bladder tumor) is then performed under the same anesthesia where the tumor is completely resected with endoscopy techniques and at the end of operation a deeper biopsy of the muscle bed is taken to stage the disease. This operation is the most crucial step in deciding the further treatment of the bladder cancer. I always feel that the battle of the bladder cancer is won or lost in this first assessment. If this surgery is incomplete/inadequate then the entire treatment can go haywire and the outcome may change.

There are some new advances in the endoscopy such as Blue light cystoscopy, Narrow band imaging (NBI), OCT which can enhance the optical diagnosis of bladder cancer at this first assessment.

What happens after TURBT?

The tumor which is resected through endoscopic route (TURBT with deep muscle) is examined by an expert uro-pathologist under the microscope. Bladder cancer is of mainly two types – non muscle invasive bladder cancer (NMIBC) and Muscle invasive bladder cancer (MIBC). If the growth is not involving the bladder muscle, it’s called as NMIBC and if it invades the muscle it’s called as MIBC. This distinction is extremely important.

If the patient has NMIBC, then depending on the grade (low grade or high grade), he/she receives an intravesical therapy (instillation of chemotherapy drug or immunotherapy with BCG in to the bladder) weekly for six weeks as an induction course and thereafter monthly for a year or two as a maintenance therapy. This results into a cure rate of nearly 70-80% at five years. About 20-30% of these NMIBC may progress into MIBC and therefore need to closely observed for the period of 5-7 years with imaging and cystoscopies.

If the patient has MIBC, then the bladder needs to be removed completely along with the pelvic lymph nodes (Radical cystectomy with pelvic lymph node dissection). Once the bladder is removed, we configurate a new bladder from the patient’s own small intestine, a procedure called construction of a neobladder. The ureters are inserted in to this neobladder at the dome and the outlet is connected to the patient’s native urethra. This is a highly complex and challenging operation. If the conditions inside the abdomen are not favorable, then the bladder is constructed in the form of pouch or a conduit which is brought to the exterior called as urostomy where patient has to use an external appliance.

Is there a role of chemotherapy and radiotherapy in the bladder cancer?

In the past, the chemotherapy was given after the radical cystectomy in case of advanced disease and if it had spread to the lymph nodes. With the advent of higher success rate with newer chemotherapy drugs, we nowadays offer chemotherapy prior to cystectomy (neoadjuvant chemotherapy -NACT) in patients who have high chance of relapse and then perform surgery. There have been good studies where a combination of radiotherapy and chemotherapy is used as an alternative to cystectomy with good outcomes, but the patient selection is the key and few of them subsequently may need bladder removal.

The outcome of MIBC is also good if it is diagnosed and treated by an expert urologic oncologist who has large experience in doing these surgeries. Patients after radical cystectomy and with neobladder construction or ileal conduit /pouch can lead to perfect normal and healthy life.

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