| Bladder
Cancer |
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Incidence
Bladder cancer (transitional cell carcinoma
of the bladder) is the second most common urological
cancer in adults. It occurs more commonly in
men and is often associated with cigarette smoking.
Other risk factors include exposure to certain
industrial chemicals, namely aromatic amines,
often used in the printing and rubber industry.
Symptoms and
signs
Haematuria (blood in the urine) is the most
common presenting symptom in patients with bladder
cancer. The bleeding may be seen with the naked
eye or only found when the urine is examined
under the microscope. Irritative voiding symptoms
such as burning, frequent and urgent urination
can also result from bladder cancer.
Diagnosis
If you complain of any of these symptoms your
doctor may ask you to have a number of investigations
to determine a cause for the symptoms. Such
tests may include:
- Urine microscopy and culture - to confirm the presence of blood and to exclude an underlying urinary tract infection.
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- Urine cytology - this involves the microscopic evaluation of the urine looking specifically for any cancer cells.
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- Intravenous pyelogram (IVP) - this is a dye study, that is very good at looking at the inside of the kidneys, at the tubes that drain urine from the kidney to the bladder (called the ureters), and at the bladder itself.
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- Cystoscopy - this involves a very small fibre-optic scope being passed through the urethra into the bladder. This very simple test can be done as an outpatient using a local anaesthetic gel injected into the urethra. This test is essential in any patient with blood in the urine in order to thoroughly evaluate the bladder.
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- Bladder biopsy - if any abnormality is seen in the bladder a small piece of tissue can be taken and sent to the pathologist for examination.
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- Transurethral resection (TUR) - if the urologist sees a tumour on cystoscopy it can be removed via the cystoscope. Usually, this can only be done under a general anaesthetic. Once again the tissue is sent to the pathologist. For many patients this is the only treatment their cancer will need.
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TCC completely removed with an
electro-catery loop (TURBT)
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Typical appearance of low grade superficial TCC |
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Staging
Once the diagnosis of bladder cancer is made,
your doctor will order a number of investigations
to ensure that the cancer has not spread to
anywhere else in the body. These may include
a CT scan of the abdomen and pelvis, a chest
Xray or CT scan of the chest, liver function
tests and rarely an MRI scan.
TNM Classification of Bladder Cancer
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Treatment
The vast majority of bladder cancers arise form
the transitional cells lining the inside of
the bladder wall and are called transitional
cell cancers (TCC). Most of the cancers are
confined to this lining and are called superficial
TCCs. When the cancer invades into the muscle
of the bladder wall they are called advanced
or muscle invasive bladder cancers. The treatment
options for each of these types of bladder cancers
are very different.
A. Treatment options for superficial
bladder cancer:
a. Cystoscopy and diathermy of the tumour
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b. Transurethral resection of the bladder tumour (TURBT)
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c. Intravesical therapy
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Small tumours can easily be destroyed by heat
delivered by either an electro-cautery device
or laser fibre, similar to many superficial
skin cancers. These instruments are passed into
the bladder through a tiny channel within the
cystoscope.
Larger tumours are usually completely resected
using a curved endoscopic loop passed through
the cystoscope. The tissue is removed from the
bladder and sent to the pathologist for diagnosis.
Often a urethral catheter is placed into the
bladder for a time, to ensure there is no significant
bleeding.
Certain drugs can be placed into the bladder
via a catheter to coat the lining of the bladder
and help reduce the risk of recurrence of the
tumour and its progression. The most commonly
used drugs include Bacille Calmette-Guerin (BCG)
and Mitomycin C. The drugs delivered this way
are not associated with the side effects commonly
seen with chemotherapy.
Unfortunately, for those patients who have had
one bladder cancer, up to 70% of them will develop
a recurrent tumour. Therefore, it is imperative
that these patients are diligently followed-up
with regular check cystoscopies. These can be
done under local anaesthetic and are usually
performed at 3 monthly intervals in the first
year, 4 monthly intervals in the second year,
6 monthly for the third and once a year thereafter.
B. Treatment options for advanced bladder
cancer:
a. Cystectomy
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b. Radiotherapy
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c. Combination chemotherapy and radiotherapy
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Cystectomy involves the complete removal of
the bladder and in the male patient removal
of the prostate and seminal vesicles as well.
In the female the uterus and tubes are also
removed. Obviously once the bladder is removed,
the drainage of urine needs to be addressed.
Reconstructive techniques used include:
1. Ileal conduit
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2. Continent cutaneous reservoir
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3. Orthotopic bladder substitution
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Essentially, in these operations a segment of
bowel is harvested and isolated from the intetsine.
The ureters are connected to one end and the
other drains to the skin (stoma) and empties
into a bag, in the case of an ileal conduit,
into a reservoir of bowel with a stoma that
is catheterizable, in the case of the continent
cutaneous reservoir and finally into a new bladder
fashioned out of the bowel and is connected
to the patients own urethra allowing normal
micturition in the case of bladder substitution.
Orthotopic Bladder Substitution
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(a) Segment of bowel harvested
from the intestine
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(b) Ureters implanted into proximal limb
of the isolated segment
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(c) Distal limb fashioned into the neobladder |
(d) Neobladder attached to patient's own urethra |
Radiation therapy can be used to treat muscle
invasive bladder cancer as well, either in isolation
or more commonly nowadays in combination with
chemotherapy. Multiple chemotherapeutic agents
are used together with the radiation therapy.
This prolonged treatment course can give results
approaching those of surgery in terms of curing
the cancer.
All treatment options are associated with differing
risks and benefits, and patients with bladder
cancer are best served being managed in units
where multidisciplinary clinics are available
to offer each individual patient the best treatment
option for both their cancer and themselves.
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