Bladder Cancer Information
Frequently Asked Questions, General Information, and Example Mock Patients
What is bladder cancer?
Most bladder cancers arise from the bladder lining. The lining of the bladder is called urotheliumand it is made up of elastic cells called transitional cells. The current medical term for bladder cancer is urothelial carcinoma. The older term is transitional cell carcinoma is sometimes still used. Since urothelium lines the entire urinary tract, urothelial carcinomas can appear in the bladder, either ureter, or in the lining of the kidneys. Less common bladder cancers includeadenocarcinomas, squamous cell carcinomas, rhabdomyosarcomas, and melanoma. These tumors generally originate from the urinary system. In other cases, tumors from the colon, cervix, uterus, or lymph nodes might invade into the bladder.
In the United States, bladder cancer is the fourth most common type of cancer in men and the ninth most common cancer in women. More than 50,000 men and 16,000 women are diagnosed with bladder cancer each year.
What are the usual bladder cancer symptons?
Bladder cancer is most commonly diagnosed after the appearance of blood in the urine. The medical term for blood in the urine is hematuria. In the case of bladder cancer, the bleeding is usually painless, and unfortunately this can cause patients to delay a medical examination. In the earliest stage, the blood in the urine is not visible. This is termed microscopic hematuria. Some patients will experience frequent urination or frequent urinary tract infections as the first sign of bladder cancer. I advise a workup to rule out bladder cancer in patients who have experienced three or more infections in a twelve month period. In more advanced stages, major hemorrhage, inability to urinate, kidney failure, and bone pain can be the presenting symptoms. When bladder cancer gets out of the bladder and into the body, it is not considered curable.
What causes bladder cancer?
Tobacco smoking is the main known risk factor that increases the risk of bladder cancer. Smoking is associated with over half of bladder cancer cases in men and one-third of cases among women. Quitting smoking reduces the risk. Passive smoking may also be involved. Authors have proposed that bladder cancer might partly be caused by the bladder directly contacting carcinogens that are excreted in urine, although this has not yet been confirmed in other studies. Occupational exposure may also be a risk. Occupations at risk are bus drivers, rubber workers, motor mechanics, leather workers, blacksmiths, machine setters and mechanics. Hairdressers are thought to be at risk as well because of their frequent exposure to permanent hair dyes – and are advised to wear gloves at work.
How is bladder cancer diagnosed?
Patients with suspicious symptoms are evaluated by three categories of tests. These are; urine tests, upper tract imaging, and cystoscopy. In addition to ruling out bladder cancer, these tests can find kidney stones, undiagnosed infections, and other diseases associated with blood in the urine.
Urine Testing. So far, there is no urine test that can reliably diagnose bladder cancer. However, urine testing is important to monitor the status of bladder cancer, help detect tumors that are hard to see by other means, and rule out other causes of blood in the urine. Urine tests that come in to play are listed here.
Dipstick. This is a fast and cheap test to see if there MIGHT be blood in the urine. It involves exposure of the urine to chemicals, that change color in the presence of absence of various substances in the urine.
Microscopy. By looking at urine under the microscope, one can actually see blood cells, bacteria, crystals, that help interpret the meaning of an abnormal dipstick.
Cytology. Cytology is a more detailed examination of the urine by a specially trained pathologist. In this case, we are looking for free floating bladder cancer cells. I order this test routinely in patients suspected of having bladder cancer. Sometimes the results are indeterminate.
NMP-22. (Matritech, Inc.) This is a urine dipstick test specifically designed to detect cancer. It is quick and inexpensive, but, false results (caused by stones and infections) limit its usefulness in my practice.
FISH. UroVysion test (Vysis, subsidiary of Abbott Laboratories). FISH stands for fluorescence in situ hybridization. This is a biochemical technique used to find certain gene sequences. In the case of bladder cancer, a DNA probe is used that detects genetic mutations that are strongly associated with bladder cancer. The results are reported as positive or negative. In my practice, I primarily use FISH to help interpret the significance of an equivocal cytology test. This can avoid the need for more invasive testing, like biopsies, etc… Due to the cost of the equipment and reagents involved, this is a very expensive urine test and the use is selective. Some authors suggest that a positive FISH test in the absence of tumor can predict the later appearance of bladder cancer.
Upper Tract Imaging. The goal of upper tract imaging is to rule out urothelial cell carcinoma in the lining of the kidneys and ureters.
Ultrasound. Ultrasound is cheap. There is no radiation. It does a reasonable job of screening for signs of cancer in the kidneys. It is also the least sensitive of the available upper tract tests for urothelial tumors. I prefer ultrasound in younger patients, especially women of childbearing age, due to a lower risk harboring serious disease in these patients and greater worry about the effects of diagnostic radiation later (much later) in life. We can perform ultrasound right in the office.
Intravenous Pyelogram (IVP). In this test, a substance called contrast is injected into a vein in the arm. This substance is rapidly cleared from the blood by the kidneys, becomes urine, and is visible on Xray. A series of X-rays films taken after the infusion of the contrast creates a picture of the kidneys and the ureters. This test produces excellent images of the ureters, but, can be limited by the presence of bowel gas, poor kidney function, and large patients. IVP uses radiation to produce images. Unfortunately, IVP tests take a long time (up to one hour). Since they are ordered less frequently than in previous decades, I have concerns that the quality of films and interpretation is less consistent than in years past.
Retrograde Pyleogram. This is a test done in the operating room under anesthesia. Contrast is injected by a Urologist directly into the ureters through a cystoscope. It produces images like an IVP, but, I have better control of the contrast and timing and a real-time “motion picture” type of image. I can usually produce superior images to those of IVP. Once the patient is asleep, it takes about 15 minutes to perform this test. It uses radiation to produce images.
CT Urogram. CT Urogram is the most accurate test available at this time. It is the least likely test to miss a urothelial carcinoma, renal cell carcinoma, or stone and also can detect tumors from other organs that might be contributing to blood in the urine. It is fast, convenient, and accurate. CT Urogram uses radiation to produce the images. We can perform CT right in our office. Our board certified / board eligible Urologists are trained to read your films while you are here. The images are also double-checked by board certified radiologists. While a CT can be performed at most hospitals, we prefer to do them in-house to ensure the right test is done to answer the question. In-house testing also gives our Urologists the best opportunity to personally review the films during the patient visit – this enhances our decision making ability. It should be noted that Advanced Urology OWNS this equipment – thus it is also financially advantageous to our practice to perform in house studies. CD copies of films brought in from outside do not contain high resolution images and limits our ability to “double check” the interpretation of the radiologist.
MRI. Magnetic Resonace Imaging uses strong magnets to “spin” the electrons in your body. When they return to normal orientation, an energy wave is released that can be detected by a computer. There is no radiation. MRI images are blurred by motion in organs like the kidneys that move with breathing, we rarely can produce clear enough images to rule out bladder or kidney cancer with MRI. MRI is very useful in determining if cancer has spread to the bones.
PET scan. These are occasionally used to check for bladder cancer outside of the bladder. We reserve this test for patients who are high risk to have cancer outside the bladder.
Cystoscopy. The majority of bladder cancers are diagnosed by cystoscopy. This involves using a small flexible scope inserted through the urethra and into the bladder. In about 3 minutes, we can inspect the entire surface of the bladder under magnification to detect even small bladder cancers. Most patients describe the test as moderately uncomfortable. Anesthesia or sedation is not usually recommended. Once a tumor is visualized, we schedule another procedure called cystoscopy with TURBT.
The following stages are used to classify the location, size, and spread of the cancer, according to the TNM (tumor, lymph node, and metastasis) staging system:
- Stage 0: Cancer cells are found only on the inner lining of the bladder (This stage is also often called Stage Ta).
- Stage I: Cancer cells have proliferated to the layer beyond the inner lining of the urinary bladder but not to the muscles of the urinary bladder.
- Stage II: Cancer cells have proliferated to the muscles in the bladder wall but not to the fatty tissue that surrounds the urinary bladder.
- Stage III: Cancer cells have proliferated to the fatty tissue surrounding the urinary bladder and to the prostate gland, vagina, or uterus, but not to the lymph nodes or other organs.
- Stage IV: Cancer cells have proliferated to the lymph nodes, pelvic or abdominal wall, and/or other organs.
- Recurrent: Cancer has recurred in the urinary bladder or in another nearby organ after having been treated.
How is bladder cancer treated?:
At presentation, in the United States, about 75% of bladder cancers are superficial (just on the bladder surface), 20% are invasive (growing deeply into the bladder wall), and 5% have metastases (found outside the bladder in lymph nodes, bone, liver, lung etc…). Although superficial tumors respond favorably to localized treatment, the recurrence rate varies from 30% to 70% and the risk of progression to an invasive malignancy is 10% to 30%.
Cystoscopy and TURBT. Trans Urethral Resection of Bladder Tumor is the initial treatment for bladder cancer. This is done under spinal or general anesthesia. Using a scope inserted into the bladder through the penis or urethra, we are able to scrape the tumor off the wall of the bladder. This can remove the tumor entirely in most cases. It will usually stop any significant bleeding and allows us to get a specimen and a pathology report. For some patients, this is the only treatment necessary to “cure” them of bladder cancer. Certain tumors may require two resections to verify complete removal of the tumor.
Radical Cystectomy – This is the removal of the entire bladder and the surrounding pelvic lymph nodes. In men, this also includes removal of the prostate. In women, this sometimes includes hysterectomy. For patients with disease that cannot be treated by TURBT, the radical cystectomy procedure is considered the “Gold Standard” to prevent the spread of the cancer to the rest of the body. In 2010, Advanced Urology began using the DaVinci Robot to remove the bladder. So far, we have noted much shorter hospitalization times and faster recovery with this technique. Once the bladder is removed we must devise a way for the body to handle the urine produced by the kidneys. See the information on urinary diversion below.
Pelvic Lymph Node Dissection – The role of removing the lymph nodes around the bladder has been controversial. For most of our patients, we include this dissection during radical or partial cystectomy. Finding cancer in the lymph nodes is a poor prognostic finding, but, occasionally patients realize cure even when small amounts of cancer are found in the lymph nodes.
Partial Cystectomy – In very select cases, we can remove only part of the bladder when TURBT cannot control the tumor. This does allow preservation of the bladder, but, this comes at a price. Namely, there is a higher likely-hood of cancer coming back in the bladder or pelvis.
Intravesical Treatment – Certain medications, when put directly in to the bladder via a catheter can eradicate bladder cancer and prevent or delay bladder cancer recurrence.
BCG – The most common agent used is BCG. BCG stands for Bacillus Calmette-Guerin. BCG is actually a vaccine, made from live TB bacteria. It causes an intense inflammatory reaction that by coincidence has a strong anti cancer effect. BCG is the most common agent used to prevent tumor from coming back after TURBT. It is also used to irradiate thin sheets of tumor (called Carcinoma in Situ). Usually, it will be given in six, once per week treatments. This is called induction therapy. Additional anti-cancer benefit can be realized by continuing treatments for up to three years. This is called BCG maintenance. Treatments are given roughly every six months as three weekly treatments.
Interferon – Interferon is an agent that can “supercharge” the effect of BCG. If BCG fails to prevent tumors from coming back, I prefer to use BCG plus interferon to prevent tumor recurrence.
Mitomycin – Mitomycin is effective against superficial bladder cancer. The treatments can be given as an alternative to BCG. It is also sometimes used in combination with TURBT with the goal of reducing the likelihood of recurrence.
Valstar – Valstar is a drug that can be placed in the bladder for patients who have failed to respond to BCG. It is an alternative to BCG plus IFN.
Radiation Treatment – Radiation therapy for bladder cancer, when combined with TURBT and Chemotherapy can be effective in selected cases as an alternative to radical cystectomy. This is generally done in patients who refuse to have cystectomy or who are too frail for major surgery.
Systemic Chemotherapy – Systemic chemotherapy is given by an IV and is designed to attack cancer cells that may be outside of the bladder. These drugs have shown to increase the chance of cure when combined with radical cystectomy but only when given before the operation. Because the medications have significant side effects – some patients are not deemed healthy enough to withstand the side effects just before a major operation. Systemic chemotherapy is used selectively with coordinated efforts by the Urologist and Oncologist. It is the final option in patients with cancer outside the bladder and can slow down progression of tumor.
What happens to urine of the bladder is surgically removed?
There are many solutions for this. Generally, a segment of small or large bowel (or both) is connected to the ureters. This bowel segment is separated from the digestive system and used to bring urine out of the body, or store urine for later evacuation.
Ileal Conduit: The most common diversion involves creating and ileo conduit. This is made of a small piece of small intestine (ileum). The ureter tubes from the kidneys are sewed to one end, the other end is brought to the skin creating a stoma. The stoma is raised over the skin by about 2 or 3 cm and is about the size of a quarter in diameter. The action of the bowel continuously expels urine out of the body. The patient then wears an appliance to collect the urine. The advantage of this diversion is easy maintenance. The stoma drains automatically, it does not require help to do its job.
Neobladder: For some patients, we are able to build a new bladder using a larger segment of small intestine. I personally use a Studer Pouch type of construction. This pouch will store urine without leakage. The bottom of the pouch is sewed to the urethra. With training and patience, patients are able to learn to urinate through the natural urethra. The disadvantage of this diversion is that there is a requirement for the patient to irrigate the pouch and make sure it empties. This is done by placing a tube (catheter) into the urethra up to four times per day. Patients who fail to do this are in danger of rupturing the pouch. Sometimes the pouch will absorb certain electrolytes from the urine and patients can take bicarbonate or sodium chloride tablets to correct this. No appliance (bag) is needed.
Indiana Pouch: This is another continent diversion. A large pouch is made with a segment of large and small bowel. One “limb” is brought to the skin creating a catheterizable stoma. This is a tiny stoma at the skin, covered with a band-aid when not in use. To empty the pouch, the patient MUST pass a catheter. Patients who fail to do this are in danger of rupturing the pouch. Also, when the pouch gets too full, it can be difficult to pass the catheter into the pouch. No appliance (bag) is needed.
Stoma Nurse: We are lucky to have specially trained hospital based nurses who help patients with stoma appliances. Getting the right appliance (compatible with a patient’s body habitus and life-style) can take some time and training. A stoma nurse is usually consulted before we create an ileal conduit to mark the patient with a marker at the optimal sight for the stoma. This helps make sure the stoma is placed away from skin folds, belt-lines, and other areas that can make it harder to maintain a urinary appliance.
Follow-up for patients treated with TURBT
Fortunately, about 70% of patients diagnosed with bladder cancer present in early stages and the tumors can be removed entirely with TURBT. Unfortunately, about 50% of these patients will experience new tumors in the bladder, kidneys, or ureters during later follow-up. Therefore, it is very important to continue surveillance of the bladder, kidneys and ureters so that new tumors can be removed quickly. The good news is that the majority of patients who stick to a follow up-schedule will not progress to invasive tumors. I typically follow patients with office cystoscopy every 3 months for two years, every 6 months for years 3 and 4, and annual cystoscopy after that. We also check cytology and occasionally redo upper tract imaging.
What can I do to help prevent tumors from coming back in my bladder?
The most important factor is to stop exposure to chemicals that promote bladder cancer. For many bladder cancer patients, this means smoking cessation. Being smoke free for just four years reduces the likelihood of new tumors. For patients with high grade tumors or tumors that have shown a pattern of coming back, we use intravesical treatments to prevent recurrences (see BCG and mitomycin above).