Bladder Cancer

How common is bladder cancer?

Bladder cancer is a disease of elderly but in recent times, younger people are also presenting with bladder cancer in advanced stage. Median age at presentation is 60 years (range: 18- 90 years). World over, males are more commonly detected to have bladder cancer with male to female ratio of 4:1. Unfortunately in Indians, bladder cancer predominantly is the disease of male population with male to female ratio of 8.6:1. 

What is the function of urinary bladder?

Urinary system consists of kidneys, ureters, bladder, prostate and urethra. The bladder is the organ in the center of the lower abdomen that function as temporary storage system for urine, which is produced by 2 kidneys and drain into the bladder via ureters. The most common type of bladder cancer originates from the cells, lining the inside of the bladder and is called transitional cell carcinoma (also called as urothelial cell carcinoma). Bladder cancer is second most common cancer of urinary system after the prostate. It has two specific features, which are different from other tumors i.e. multi-focal character, which means tumor arising at more than one site and another is the higher rate of recurrence. Almost 70% of the tumors would recur after initial removal by endoscopy.

What causes Bladder cancer?

Bladder cancer is an outcome of multi-factorial process influenced by exogenous exposure of carcinogens (chemical producing cancers) and molecular changes leading to DNA instability and DNA damage (damage to genes). Cigarette smoking is thought to be responsible for 50-66% of all bladder cancers in men and 35% in women. In India, the incidence of smoking amongst the patients with bladder cancer is much higher in males than females (74% vs. 22%). {Source: Indian J Urol 2009; 25:207-10} Occupational exposure to aromatic amines (petrochemical, textile, printing industries), and other chemicals in the professions like hairdressing, fire fighting, truck driving and plumbing, may increase the risk of developing bladder cancer. Other known risk factors include chronic use of drugs like Phenacetin, Cyclophosphamide and Arsenic and radiation exposure. Alcohol, coffee and artificial sweeteners have not been found to be direct risk factors for the bladder cancer.

How do we diagnose it?

The gold standard of diagnosing bladder cancer is endoscopic visualization (cystoscopy) of inside the bladder. Once urologist sees any doubtful area or obvious tumor then he takes it out using an endoscope for biopsy. This procedure is called Trans Urethral Resection of the Bladder Tumor, TURBT. Bladder tumor can be seen in various forms likes papillary, solid or as carcinoma in situ (CIS), which is flat velvet like lesion.

What tests will my doctor recommend?

Ultrasonography is the most common imaging done, which could pick up a small papillary lesion in the bladder. It can also pick up mild degree of swelling of kidneys, resulting from the pressure on ureteric opening into the bladder. CT scan of the abdomen is useful to assess the local extent of involvement by bladder tumor and also to know the status of lymph nodes; glands, which drain lymph from the bladder. As they are the second station of involvement by cancer before it goes to other sites in the body.

What is the initial treatment and how do we confirm the diagnosis?

Once urologist suspects bladder cancer in you, then with the help of endoscope called resectoscope, a piece of a tumor or the whole tumor is removed for biopsy. We have described and popularized a technique of en-bloc resection, where the whole tumor is detached from the bladder and then removed in 2 to 3 pieces. This has better chance of removing the tumor completely. (Sureka S et al. Indian J Urol. 2014 Apr; 30:144-9).

What is the best treatment after the diagnosis?Once we have pathology report on the biopsy taken or tumor removed, then further treatment is planned according to the stage classification of the tumor. Bladder tumors are broadly classified into muscle invasive (MIBC) and non-muscle invasive bladder tumor (NMIBC).What is the treatment of choice for non-muscle invasive bladder cancer (NMIBC)?For Non muscle invasive tumor you will be given Mitomycin C or BCG therapy, wherein chemotherapeutic drug (Mitomycin C) or live bacteria ( BCG) will be instilled inside the bladder at regular interval. This would kill the unseen cancer cell directly or by boosting local immunity to fight against the cancer cells in rest of the bladder lining. After this kind of treatment, you may have to have a cystoscopic examination at regular interval to pick up an early recurrence of the tumor. Such bladder tumors are notorious for recurrence.What are the options for muscle invasive bladder cancers (MIBC)?The gold standard of treatment for MIBC is removal of the bladder. Once the bladder is removed, urine has to be diverted by using a small piece of intestine to be used as a conduit (ileal conduit diversion), which opens in front of your belly and a bag is worn for life to collect the urine. (Click to See Video ) Another way in younger patients with good kidney function to divert urine is to make a new pouch or a neo bladder to replace the natural bladder. In this process you may still pass urine naturally but it comes with side effects, which could be managed if you understand the process well. Neo bladder formation is a demanding surgery and involves 20-30% major complications. Patients should understand the gravity of the surgery after proper discussion with the Urologist as your role is more important in long run. In select situations, one can opt for radiotherapy and chemotherapy to preserve the natural bladder. But in due course of time about 50percent of the patients have to get their bladder removed.

How does Robot help in managing bladder cancer?For MIBC, bladder can also be removed with the help of robot. Robot provides a comfortable platform to the surgeon to finish the surgery with less blood loss and pain. Unfortunately it has not changed the overall outcome of the surgery in terms of hospital stay and complications.What is the new bladder made from!Once the bladder is removed, new bladder is formed with the help of patient’s own small gut. Gut is cut open and folded in a shape of a pouch or bladder and fixed to the remaining urethra, so that patient could pass urine normally.How do I choose from the options of urinary diversion?Neo bladder is an option, which can be chosen from after a thorough discussion of pros and cons. Other factors, which are required for neobladder, are normal kidney functions, absence of comorbidity like Diabetes and manual dexterity to do self-catheterization. Self-catheterization is putting a catheter through urethra into the neobladder by you only to wash the mucus out. Mucus is normal secretion of the intestine, which may cause obstruction to the flow of your urine.

What is continent cutaneous pouch?

This is the 3rd type of diversion where you don’t have to wear a bag but you need to empty the pouch though a continent conduit ( this does not leak on its own so you don't have to wear a bag continuously). The intestine pouch is made from the intestine similar to the neobladder but instead of attaching it to the urethral it is taken out through your belly via a continent conduit.

How will be my life after neobladder?

You will have to eat some medicine for long time and at times put in a catheter to wash the bladder of mucus. You need to come for follow up at a regular interval so that the side effects are picked up early and managed. You will regain your continence and don't leak urine during the daytime but about 30 % of patients may leak very little amount of urine at night during sleep.

New bladder with new hope! Rebuilding confidence to urinate normally.