Bladder Cancer

Bladder Cancer Symptoms

The most common symptom of bladder cancer is painless haematuria (blood in the urine). Blood in the urine may be visible to the naked eye (gross haematuria) or invisible to the naked eye but detected on a microscopic urine examination (microscopic haematuria), often done during health screenings or checkups for people wit high blood pressure or diabetes.


It is very important to note that haematuria associated with bladder cancer may be intermittent. That is, days, weeks, or even months may pass after an episode of haematuria during which no blood is seen in the urine. It is therefore very important that any episode of gross haematuria is reported to your doctor even if it occurred days, weeks or even months ago.
Other symptoms sometimes associated with bladder cancer include:

  1. A change in urination habit (unexplained urinary frequency or urgency)
    2. A recent history of difficulty passing urine


Bladder cancer rarely causes pain in until it has reached an advanced stage.


Diagnostic tests

Bladder cancer is diagnosed by looking for abnormalities inside the bladder endoscopic examination of the bladder (Flexible cystoscopy). Flexible cystoscopy can be done in the comfort and convenience of our clinic. If there is a tumour seen in the bladder, endoscopic surgery is required to remove the tumour and check if it is cancerous.

Cystoscopic view of a bladder cancer

Cystoscopic view of a bladder cancer

CT Urography (this is a CT scan in which intravenous contrast is injected in order to accurately assess the kidneys, the inner lining of the kidneys, the ureters and the bladder). This will 1) assess the rest of the urinary for causes of haematuria, and 2) in the case of patients found to have a bladder tumour, determine if the bladder cancer has spread to other organs in the body.


Treatment 

Endoscopic removal of the bladder tumour

TURBT (Transurethral resection of bladder tumour) is the current standard procedure to diagnose bladder cancer and to remove cancers confined to the inner layers of the bladder. During the procedure, a surgeon passes an electric wire loop through a cystoscope and into the bladder. The electric current in the wire is used to cut away or burn away the cancer. This is done in a piecemeal fashion until the entire tumour is removed.

This procedure is performed through the natural opening of the urethra, so you won't have any cuts (incisions) on your abdomen.

Transurethral resection of bladder tumour

ERBT –En-Bloc Resection of Bladder Tumour – a better way to remove bladder tumours

TURBT has been the gold standard in managing non-muscle invasive bladder cancer (NMIBC). However, this technique violates the usual cancer control principle of removing tumours intact in a single piece. “Piecemeal resection” may cause scattering and spread of exfoliated tumours cells leading to increased recurrence rate. Other pitfalls of the traditional TURBT include difficulty in ensuring complete resection around the edges and depth of the tumour (to include the deeper muscle layers). Poor quality of resection can directly affect accuracy of staging and cancer control outcomes in early bladder cancer.

ERBT aims to remove the tumour in a “one-piece” fashion. This is performed endoscopically by making a circular cut around the margin beyond the edges of the tumour, followed by removal of the tumour with underlying bladder (detrusor) muscle. TUERBT specimens can maintain the 3D architecture of the tumour, thus allowing more accurate staging of bladder cancer with proper assessment of the resection margins (edges of tumour). A good assessment of the depth of invasion can reduce the need for a second look TURBT.

Dr Lincoln Tan helps train young urologists in the region on this technique through his work with AUSTEG- Asian Urological Surgery Training & Education Group

En-bloc resection of bladder tumour(EBRT) – the entire tumour is removed in a single piece including sufficient margin from the edges and depth of the tumour

En-bloc resection of bladder tumour(EBRT) – the entire tumour is removed in a single piece including sufficient margin from the edges and depth of the tumour

Grading and Staging

Grading 

During analysis of the tumour specimen under a microscope by the Pathologist, the grade of the cancer is determined. High grade cancers behave more aggressively with higher risk of distant spread and cancer death. Low grade cancers are less likely to grow into the wall of the bladder or to spread beyond the bladder, and have better prognosis compared to high grade disease.

Staging

The stage or extent of the disease is assessed by the results of the bladder biopsy. The specimen is examined by a Pathologist who is able to accurately determine how deeply the tumour has grown into the wall of the bladder. To determine whether the cancer has spread beyond the bladder, information from the CT urography is used.

Stage

Description

Carcinoma in situ

High grade cancer cells filling the inner lining of the bladder

Ta

Cancer cells occupying part of the inner lining

T1

Cancer cells have broken through the inner lining into lamina propria

T2

Cancer cells have invaded the muscle of the bladder

T3

Cancer has grown through the muscle into fat around the bladder

T4

Cancer has grown into surrounding organs (eg rectum)


Bladder Cancer Treatment

Treatment depends on the stage and grade of the bladder cancer

Treatment of Non Muscle Invasive Bladder Cancer (Stages Ta, T1 and CIS)

The treatment of non muscle invasive bladder cancer will combine some or all of the following procedures

  1. TURBT/ EBRT
  2. Intravesical chemotherapy (Mitomycin C)
  3. Intravesical immunotherapy (Intravesical BCG)


Endoscopic surgery - TURBT/EBRT

Whilst a cystoscopy and endoscopic removal of the tumour are always required to accurately stage bladder cancer, it may also be the only surgical treatment required for some bladder cancers. This is particularly the case for small low grade, non invasive bladder cancers.

If a stage T1 tumour is discovered on the initial biopsy, a repeat biopsy is important to ensure that deeper invasion of cancer cells into the muscle of the bladder has not been missed. There is a well-recognised risk of underestimation of depth of cancer invasion in T1 tumours. This is particularly true when certain pathological features are present.

As these cancers have varying risks of recurring, surveillance with repeat cystoscopies are necessary.

High risk tumours will need addition treatments with BCG/chemotherapy to reduce the chances of recurrence or progression to more aggressive cancer.

Intravesical therapy

With intravesical therapy, the doctor puts a liquid drug into your bladder rather than giving it by mouth or injecting it into your blood. The drug is put in through a soft tube (catheter) into your bladder through your urethra. The drug stays in your bladder for up to 2 hours. This way, the drug can affect the cells lining the inside of your bladder without having major effects on other parts of your body.

Intravesical Chemotherapy (Mitomycin C)

Following the diagnosis of a non muscle invasive bladder cancer, a single dose of chemotherapy is often instilled into the bladder within 24 hours of tumour resection. This reduces the risk of tumour recurrence by approximately 40%. Sometimes a single dose is inadequate and a full course (six to eight weekly instillations) is required to reduce the risk of cancer recurrence.

Intravesical immunotherapy (BCG)

Immunotherapy causes the body’s own immune system to attack the cancer cells. Bacillus Calmette-Guerin or BCG is the most common intravesical immunotherapy for treating early-stage bladder cancer. BCG is a bacteria that's related to the one that causes tuberculosis (TB), but it doesn’t usually cause serious disease.

BCG must come in contact with the cancer cells to work, which is why BCG is put right into the bladder through a catheter. After it reaches the cancer cells, it activates the immune system. The immune system cells are attracted to the bladder and attack the bladder cancer cells – helping to keep the cancer from growing and keeping it from coming back.

For higher grade, non muscle invasive bladder cancers (eg stages CIS and T1), intravesical chemotherapy may not be adequate treatment. In these cases, intravesical BCG is administered. This usually takes the form of six weekly instillations. After this course has been completed, a follow-up cystoscopy is performed to determine whether the cancer has been eradicated. A further three week course may be required. Sometimes prolonged course, (maintenance BCG therapy) is used. There is evidence that if a patient can tolerate maintenance BCG, this can reduce the risk of cancer recurrence and progression to more aggressive disease.

If a high grade, non muscle invasive bladder cancer recurs despite intravesical BCG therapy, more radical treatment may be recommended, consisting of removal of the entire bladder (radical cystectomy).


Treatment of Muscle Invasive Bladder Cancer (stages T2-4)

When bladder cancer invades into the deep muscle of the bladder wall or through the entire thickness of the bladder, it becomes a life threatening cancer. In this case, more aggressive treatment is required. The choice of treatment depends on a number of factors including the position of the cancer within the bladder, whether there are associated abnormal areas in the bladder, the age and general state of health of patient.


Partial Cystectomy

In approximately 5% of cases of muscle invasive bladder cancer, the tumour is localised to one, small, accessible portion of the bladder, usually at the dome of the bladder. In this case, it may be possible to remove only the cancerous portion of the bladder, leaving the remainder of the bladder intact.

Radical Cystectomy

In most cases of muscle invasive bladder cancer, the treatment of choice is removal of the entire bladder (radical cystectomy). In the male patient, this involves removal of the bladder and prostate gland together with draining lymph nodes. In the female patient, the operation consists of removal of the bladder, a portion of the front wall of the vagina, the uterus and ovaries, together with draining lymph nodes.

Following removal of the urinary bladder, the urinary stream must be diverted. There are two main ways in which this can be achieved:

1.Ileal conduit urinary diversion.

This is the most common form of urinary diversion. A short segment of small bowel is separated from the rest of the bowel, and one end of the is brought out to the skin, usually on the right side. The ureters, which drain urine from each kidney are then joined onto this small segment of bowel and the urine is collected by means of an external collection device placed onto the skin.

Ileal conduit (Attribution - Cancer Research UK, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons)



2.Ileal neobladder formation. 

This is a more complicated procedure and not every patient is suitable for this type of urinary diversion. In this procedure, a segment of small bowel is isolated and fashioned into a spherical shape. One end of the spherical pouch is joined to the urethra and the ureters are joined onto another portion of the spherical pouch. Therefore, there is no external drainage of urine and the body appearance is normal.


Radiation Therapy

In selected cases, where patients are either not fit for a radical cystectomy or when the cancer cannot be removed by radical cystectomy, radiation therapy possibly in conjunction with chemotherapy may provide good control of the cancer. Radiation treatment alone is usually reserved for palliative treatment of bladder cancer in patients who are not fit for surgery.

Chemotherapy

When bladder cancer has spread beyond the bladder to other sites within the body, it is no longer curable by surgery/radiation. In this case, chemotherapy is the standard treatment.

Early detection can save your life.

Most conditions can be treated effectively if detected early.

Make an appointment with us to get an accurate diagnosis and a treatment plan.