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Bladder: It is part of the urinary tract which lies in the pelvis. It stores urine made by the kidneys till the time we pass urine. The cells that line the inside of the bladder are called transitional cells or urothelial cells. The outer part of the bladder wall contains a layer of muscle fibers (Detrusor) which contract at the time of urination and pushes the urine out.

Bladder Cancer: Cancer developing from the lining (transitional cells) of the bladder wall. This type of cancer is called ‘transitional cell cancer’ (TCC). Transitional cell cancer of the bladder can be divided into two groups. The treatment and outlook of these groups are different.

Tumors still confined to bladder wall
  • Superficial tumors - This is the most common type of tumor (4 out of 5 confined cases). These tumors are confined to the inner lining of the bladder. At this stage the tumors rarely spread outside bladder and can usually be cured. However, if left untreated, they can develop into muscle invasive tumors.
  • Muscle invasive tumor - These occur in about 1 in 5 cases. These tumors have involved the muscle (outer layer) of the bladder wall. Muscle invasive tumors have a high chance of spreading to other parts of the body (metastases).

Tumors beyond the confines of bladder wall
  • Locally advanced tumors- In this situation the tumor has already spread through the wall of the bladder involving the surrounding tissues and organs. The treatment has lesser chance of being curative in these cases.
  • Metastatic tumors- In this situation the spread has occurred to other parts of the body including lymph nodes, liver, lungs, spine etc.

What causes Bladder Cancer?
The cancerous tumor starts from one abnormal cell. The exact reason why a cell becomes cancerous is not known. It is thought that something damages or alters certain genes and normal repairing mechanisms in the cell, making the cell multiply ‘out of control’. Most of the people develop cancer for no apparent reason but certain risk factors increases the chances of developing bladder cancer. These include:

  • Smoking - Bladder cancer is 4 times more common in smokers than non-smokers. Some of the chemicals from tobacco are passed into urine which may be the inciting cause for bladder cancer. It is estimated that about 1/3rd bladder cancers are related to smoking. The risk correlates with the number of cigarettes smoked, the duration of smoking, and the degree of inhalation of smoke. Former cigarette smokers have a reduced incidence of bladder cancer compared with active smokers. However, the reduction of the risk to baseline takes nearly 20 years after cessation.
  • Other Chemical - Certain environmental chemicals and industrial compounds are also carcinogenic. Exposure of ‘Aromatic amines’ in certain occupations like dry cleaning, paper manufacture, rope and twine making, leather worker , autoworker, painter etc increases the risk of cancer.
  • Pelvic Irradiation - Women treated with radiation for cancer of the cervix or ovary have a 2-4 fold increased risk of developing bladder cancer compared to those who underwent surgery only. The incidence rises further if chemotherapy was also administered. The risk continues to rise even after 10 years.
  • Chronic Cystitis and other infections - Chronic cystitis in the presence of indwelling catheters or calculi is associated with an increased risk for Squamous cell cancer of the bladder. Similarly Schistosoma haematobium (a parasite) cystitis is also related to the development of bladder cancer.

Symptoms of bladder cancer

  • Blood in urine- In most cases, the first symptom is passage of blood in urine (hematuria). It is usually painless. The blood in the urine may ‘come and go’ as the tumor bleeds from time to time. You should always see your doctor if you pass blood in urine.
  • Other symptoms- Symptoms similar to a urine infection such as going to toilet frequently or pain on passing urine may be observed in some tumors.
To Confirm the diagnosis

  • Urine cytology- A fresh urine sample is examined under the microscope to see if any cancerous cell are present
  • Cystoscopy and Biopsy- This is the most important test to confirm a bladder tumor. A Cystoscopy is where the doctor looks into the bladder using a thin endoscopic instrument called ‘Cystoscope’. The Cystoscope is passed into the bladder via the urethra. During cystoscopy, biopsy is taken from the suspicious area and then examined under the microscope.

Assessment of the extent and spread

If Cystoscopy and biopsy confirms, the presence of superficial tumor (involving the inner lining only) then no further tests may be necessary. Superficial bladder tumors have a low risk of spread to other parts of the body. In case of muscle invasive or advanced tumors, further tests are necessary to assess the extent of spread. This assessment is called ‘Staging of the Cancer’. The test includes Computed tomography (CT scan) or MRI, Bone scan and blood investigations

What are the treatment options for superficial bladder tumors?

Most superficial tumors are removed by a urologist endoscopically thorough the urethra. This procedure is called ‘Transurethral resection of bladder tumor (TURBT)’. This does not involve any open incision. The pieces of tumor tissue are removed at the end of the procedure and sent for examination under the microscope (Histopathology). Histopathological examination provide with complete information about the type of cancer and the need for any further treatment.

Immunotherapy (BCG) or Chemotherapy

Depending upon the stage and number of tumors in the bladder, the doctor may advise you to have a course of ‘intravesical’ immunotherapy or chemotherapy. The purpose of additional therapy is to reduce the chance of recurrence of tumor. The most common immunotherapy drug is called BCG. This is actually a vaccine which is used to prevent TB. Intravesical BCG has been found to be effective in treating some kinds superficial tumors (Carcinoma in situ) and decreasing the incidence of recurrence in others.

Repeat ‘Check’ cystosocpy

Bladder tumors are notorious for coming back again. Therefore, after a superficial tumor is removed, you need cystoscopy at regular intervals (initially every 3 monthly). This is done to detect recurrences (if any) at an early stage and treat accordingly. The interval between check cystoscopies may be increased if you are free of tumor for 2 years.

What are the treatment options for muscle invasive bladder tumors?

The treatment of advanced cases of bladder tumors depends upon various factors such as the stage of cancer, location and size of cancer and health status of the patient. Treatment options which may be considered include radical surgery, radiotherapy and chemotherapy (alone or in combinations).
  • Radical Cystectomy- This is the most effective form of treatment for localized muscle invasive bladder tumors. This is a major surgery where complete urinary bladder is removed along with surrounding lymph nodes. Since, the bladder is removed; you will need an alternative way of passing urine. This can be in the form of Ileal conduit or Neobladder
  • Ileal Conduit- Here the surgeon makes a small urine reservoir using a small segment of intestine. One end of the segment of small intestine opens on to the skin of the abdomen. Urine draining through this collects into a bag which the patient wears on the outside of the abdomen.
  • Continent diversion and Neobladder – For continent cutaneous diversion, a pouch is constructed out of portions of the small and large intestine; the ureters are connected to the pouch and a stoma is created through the abdominal wall. Urine is removed intermittently by the patient by inserting a thin tube (catheter) into the stoma. Alternatively, a similar pouch using the intestine is created and attached to the urethra; in an attempt to preserve the functions as close to normal bladder functions as possible.
Discuss with your doctor about the suitable urinary diversion technique for you.

Radical surgery for bladder cancer can be performed by open surgical techniques or by newer advancements like Robotic surgery. Robotic radical cystectomy is the latest advancement in technique of surgical removal of bladder and pelvic lymph nodes which achieves comparable results while minimizing morbidity. For most patients, robotic surgery can offer numerous potential benefits over open surgery including: Less pain, less blood loss and rate of transfusion, faster recovery and quicker return to normal activities.

  • Radiotherapy- It is used sometimes instead of surgery (for patient unsuitable for surgery or advanced disease) or after the surgery (as a booster treatment). Radiotherapy is a treatment which uses high energy beams focused on the cancer tissue. This kill cancer cell or stop cancer cell from multiplying.
  • Chemotherapy- It is the treatment of cancer by using anti-cancer drugs which kill cancer cells or stop them from multiplying. This may be used alone or in combination with surgery or radiation depending upon the suitability of the case.
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