What Is the bladder cancer?
Bladder cancer is a common type of cancer that begins in the cells of the bladder. The bladder is a hollow muscular organ in your lower abdomen that stores urine.
Bladder cancer most often begins in the cells (urothelial cells) that line the inside of your bladder. Urothelial cells are also found in your kidneys and the tubes (ureters) that connect the kidneys to the bladder. Urothelial cancer can happen in the kidneys and ureters, too, but it's much more common in the bladder.
Most bladder cancers are diagnosed at an early stage, when the cancer is highly treatable. But even early-stage bladder cancers can come back after successful treatment. For this reason, people with bladder cancer typically need follow-up tests for years after treatment to look for bladder cancer that recurs.
What are the risk factors for bladder cancer?
Some factors increase the risk of bladder cancer:
- Cigarette smokingis the biggest risk factor; it more than doubles the risk. Pipe and cigar smoking and exposure to second-hand smoking may also increase one's risk.
- Prior radiation exposure is the next most common risk factor (e.g., as treatment for cervical cancer, prostate cancer or rectal cancer).
- Certain chemotherapydrugs (e.g., cyclophosphamide) also increase the risk of bladder cancer.
- Environmental exposures increase the risk of bladder cancer. People who work with chemicals, such as aromatic amines (chemicals used in dyes) are at risk. Extensive exposure to rubber, leather, some textiles, paint, and hairdressing supplies, typically related to occupational exposure, also appears to increase the risk.
- Infection with a parasite known as Schistosoma haematobium, which is more common in developing countries and the Middle East. (This organism is not found in the United States.)
- People who have frequent infections of the bladder, bladder stones, or other diseases of the urinary tract, or who have chronic need for a catheter in the bladder, may be at higher risk of squamous cell carcinoma.
- Patients with a previous bladder cancer are at increased risk to form new or recurrent bladder tumors.
Other risk factors include diets high in fried meats and animal fats, and older age. In addition, men have a three-fold higher risk than women.
What is the symptoms of bladder cancer?
Blood in your urine is the most common symptom of bladder cancer.
The medical name for blood in your urine is haematuria and it's usually painless. You may notice streaks of blood in your urine or the blood may turn your urine brown. The blood isn't always noticeable and it may come and go.
Less common symptoms of bladder cancer include:
- a need to urinate on a more frequent basis
- sudden urges to urinate
- a burning sensation when passing urine
If bladder cancer reaches an advanced stage and has spread, symptoms can include:
- pelvic pain
- bone pain
- unintentional weight loss
- swelling of the legs
What are the types of bladder cancer?
Once diagnosed, bladder cancer can be classified by how far it has spread.
If the cancerous cells are contained inside the lining of the bladder, doctors describe it as non-muscle-invasive bladder cancer (early bladder cancer). This is the most common type of bladder cancer.
When the cancerous cells spread beyond the lining, into the surrounding bladder muscle, it's referred to as muscle-invasive bladder cancer (or invasive bladder cancer). This is less common, but has a higher chance of spreading to other parts of the body.
If bladder cancer has spread to other parts of the body, it's known as advanced or metastatic bladder cancer.
Urothelial carcinoma (transitional cell carcinoma)
Urothelial carcinoma, also known as transitional cell carcinoma (TCC), is by far the most common type of bladder cancer. In fact, if you have bladder cancer it's almost certain to be a urothelial carcinoma. These cancers start in the urothelial cells that line the inside of the bladder.
Urothelial cells also line other parts of the urinary tract, such as the part of the kidney that connects to the ureter (called the renal pelvis), the ureters, and the urethra. People with bladder cancer sometimes have tumors in these places, too, so all of the urinary tract needs to be checked for tumors.
Other types of bladder cancer
Other types of cancer can start in the bladder, but these are all much less common than urothelial (transitional cell) cancer.
Squamous cell carcinoma
In the US, only about 1% to 2% of bladder cancers are squamous cell carcinomas. Seen with a microscope, the cells look much like the flat cells that are found on the surface of the skin. Nearly all squamous cell carcinomas of the bladder are invasive.
Only about 1% of bladder cancers are adenocarcinomas. These cancer cells have a lot in common with gland-forming cells of colon cancers . Nearly all adenocarcinomas of the bladder are invasive.
Small cell carcinoma
Less than 1% of bladder cancers are small-cell carcinomas. They start in nerve-like cells called neuroendocrine cells. These cancers often grow quickly and usually need to be treated with chemotherapy like that used for small cell carcinoma of the lung.
Sarcomas start in the muscle cells of the bladder, but they are very rare. More information can be found in Soft Tissue Sarcoma and Rhabdomyosarcoma.
These less common types of bladder cancer (other than sarcoma) are treated a lot like TCCs, especially early-stage tumors, but if chemotherapy is needed, different drugs might be used.
Invasive vs. non-invasive bladder cancer
Bladder cancers are often described based on how far they have spread into the wall of the bladder:
- Non-invasivecancers are only in the inner layer of cells (the transitional epithelium). They have not grown into the deeper layers.
- Invasivecancers have grown into deeper layers of the bladder wall. These cancers are more likely to spread and are harder to treat.
A bladder cancer can also be described as superficial or non-muscle invasive. These terms include both non-invasive tumors as well as any invasive tumors that have not grown into the main muscle layer of the bladder.
Papillary vs. flat cancer
Bladder cancers are also divided into 2 subtypes, papillary and flat, based on how they grow (see the image above).
- Papillary carcinomasgrow in slender, finger-like projections from the inner surface of the bladder toward the hollow center. Papillary tumors often grow toward the center of the bladder without growing into the deeper bladder layers. These tumors are called non-invasive papillary cancers. Very low-grade (slow growing), non-invasive papillary cancer is sometimes called papillary urothelial neoplasm of low-malignant potential (PUNLMP) and tends to have a very good outcome.
- Flat carcinomasdo not grow toward the hollow part of the bladder at all. If a flat tumor is only in the inner layer of bladder cells, it's known as a non-invasive flat carcinoma or a flat carcinoma in situ (CIS).
If either a papillary or flat tumor grows into deeper layers of the bladder, it's called an invasive urothelial (or transitional cell) carcinoma.
What examinations should I undergo if I suspect bladder cancer?
Your doctor will do a urine analysis (urinalysis) to see whether an infection is the source of your symptoms. A cytology examination of the urine will check for cancer cells under a microscope.
The primary method for detecting and diagnosing bladder cancer is a cystoscopy. A lighted telescope (cystoscope) is introduced into the bladder from the urethra to observe the interior of the bladder and, if done under anesthesia, collect tissue samples (biopsy) to be studied under a microscope for symptoms of cancer. To reduce pain during this treatment in the doctor's office, local anesthetic gel is injected into the urethra prior to the procedure.
A CT scan of the abdomen and pelvis could be the next step for some individuals with invasive cancer to see whether the illness has gone beyond the bladder.
Magnetic resonance imaging, which makes detailed pictures using a magnet, radio waves, and a computer, may also be done and aids in the planning of subsequent therapy.
A chest X-ray may be used to determine if the cancer has progressed to the lungs. A bone scan may be conducted to check for cancer metastases (spread) to the bone. The majority of these tests are utilized selectively, that is, only in individuals who have similar symptoms.
The tests outlined above are used to stage bladder cancer after it has been diagnosed. The treatment plan will be determined by the stage of the illness.
What are the treatment options for bladder cancer?
There are four types of treatment for patients with bladder cancer. These include:
- Intravesical chemotherapy or immunotherapyfor superficial cancers
- Radiation therapy
Sometimes, combinations of these treatments will be used.
Bladder Cancer Surgery
Surgery is part of the treatment for most bladder cancers . The type of surgery done depends on the stage (extent) of the cancer. It also depends on your choices based on the long-term side effects of some kinds of surgery.
Transurethral resection of bladder tumor (TURBT)
A transurethral resection of bladder tumor (TURBT) or a transurethral resection (TUR) is often used to find out if someone has bladder cancer and, if so, whether the cancer has spread into (invaded) the muscle layer of the bladder wall.
TURBT is also the most common treatment for early-stage or superficial (non-muscle invasive) bladder cancers. Most patients have superficial cancer when they're first diagnosed, so this is usually their first treatment. Sometimes, a second, more extensive TURBT is done to better ensure that all the cancer has been removed. The goal is to take out the cancer cells and nearby tissues down to the muscle layer of the bladder wall.
How TURBT is done
This surgery is done using an instrument put in through your urethra, so there's no cutting into the abdomen (belly). You'll get either general anesthesia (drugs are used to make you sleep) or regional anesthesia (the lower part of your body is numbed).
A type of thin, rigid cystoscope called a resectoscope is put into your bladder through your urethra. The resectoscope has a wire loop at the end that's used to remove any abnormal tissues or tumors. The removed tissue is sent to a lab for testing.
After the tumor is removed, more steps may be taken to try to ensure that the cancer has been completely destroyed. For instance, the tissue in the area where the tumor was may be burned while looking at it with the resectoscope. This is called fulguration. Cancer cells can also be destroyed using a high-energy laser through the resectoscope.
Possible side effects
The side effects of TURBT are generally mild and don't usually last long. Right after TURBT you might have some bleeding and pain when you urinate. You can usually go home the same day or the next day and can return to your usual activities within a week or two.
Even if the TURBT removes the tumor completely, bladder cancer often comes back (recurs) in other parts of the bladder. This might be treated with another TURBT. But if TURBT needs to be repeated many times, the bladder can become scarred and not be able to hold much urine. This can lead to side effects like frequent urination, or even incontinence (loss of control of urine).
In patients with a long history of recurrent, non-invasive low-grade tumors (slow-growing tumors that keep coming back), the surgeon may just use fulguration to burn small tumors that are seen during cystoscopy (rather than removing them). This can often be done using local anesthesia (numbing medicine) in the doctor’s office. It's safe but can be mildly uncomfortable.
When bladder cancer is invasive, all or part of the bladder may need to be removed. This operation is called a cystectomy. Most of the time, chemotherapy is given before cystectomy is done. General anesthesia (where you are in a deep sleep) is used for either type of cystectomy.
If the cancer has invaded the muscle layer of the bladder wall but is not very large and is only in one place, it can sometimes be removed along with part of the bladder wall without taking out the whole bladder. The hole in the bladder wall is then closed with stitches. Nearby lymph nodes are also removed and tested for cancer spread. Only a small portion of people with cancer that has invaded the muscle can have this surgery. The main advantage of this surgery is that the person keeps their bladder and doesn’t need reconstructive surgery (see below). But the remaining bladder may not hold as much urine, which means they'll have to urinate more often. With this type of surgery, the main concern is that bladder cancer can still come back (recur) in another part of the bladder wall.
If the cancer is larger or is in more than one part of the bladder, a radical cystectomy will be needed. This operation removes the entire bladder and nearby lymph nodes. In men, the prostate and seminal vesicles are also removed. In women, the ovaries, fallopian tubes (tubes that connect the ovaries and uterus), the uterus (womb), cervix, and a small part of the vagina are removed too.
Most of the time, cystectomy is done through a cut (incision) in the belly (abdomen). You'll need to stay in the hospital for about a week after the surgery. You can usually go back to your normal activities after several weeks.
In some cases, the surgeon may operate through many smaller incisions using special long, thin instruments, one of which has a tiny video camera on the end to see inside your body. This is called laparoscopic, or “keyhole” surgery. The surgeon may either hold the instruments directly or may sit at a control panel in the operating room and use robotic arms to do the surgery (sometimes known as a robotic cystectomy). This type of surgery may result in less pain and quicker recovery because of the smaller cuts. But it hasn’t been around as long as the standard type of surgery, so it’s not yet clear if it works as well.
It's important that any type of cystectomy be done by a surgeon with experience in treating bladder cancer. If the surgery is not done well, the cancer is more likely to come back.
What is Robotic surgery (Da Vinci) and what are its benefits for Bladder cancer?
If your doctor recommends surgery for bladder cancer, you may be a candidate for minimally invasive da Vinci Cystectomy. da Vinci uses state-of-the-art technology to help your doctor perform a precise operation through a few tiny incisions with enhanced vision, precision, dexterity and control.
da Vinci Surgery offers several potential benefits to bladder cancer patients over traditional open surgery, including:
Benefits of Robotic-Assisted Cystectomy:
- Minimal damage to vital muscle and delicate nerve tissue as a result of the surgery.
- A shorter hospital stay and an even faster return to a normal level of activity.
- Fewer noticeable scars.
- Minimized risk of blood loss.
- Minimized chances of post-operative infections.
- Minimized chances of post-operative incontinence or impotence.
- Minimized chances of other complications commonly associated with cystectomy.
- Minimal post-operative pain and discomfort.
- The unprecedented technology of the da Vinci Surgical System which offer surgeons, oncologists and urologists a high-definition, three-dimensional view of the procedure, as well as the assistance of the robot in suturing.
Typical Open Surgical Cystectomy:
- Greater risks associated with any procedure that requires a large surgical incision.
- Potentially greater discomfort and longer post-operative hospital stay.
- Potentially more postoperative scarring, muscle and nerve damage.
- Potentially more postoperative soreness and a greater need for prescription pain medication.
- Longer post-operative recovery time.
This procedure is performed using the da Vinci Surgical System, a state-of-the-art surgical platform. By overcoming the limits of both traditional open and laparoscopic surgery, da Vinci is changing the experience of surgery for people around the world.
If you are facing bladder cancer surgery, talk to a doctor who performs da Vinci Surgery.
Reconstructive surgery after radical cystectomy
If your whole bladder is removed, you'll need another way to store urine and pass it out of your body. Several types of reconstructive surgery can be done.
One option may be to remove and clean a short piece of your intestine and then connect it to the ureters (the tubes that carry urine out of the kidneys). This creates a passageway, known as an ileal conduit, for urine to pass from the kidneys to the outside of the body. Urine flows from the kidneys through the ureters into the ileal conduit. One end of the conduit is connected to the skin on the front of the belly (abdomen) by an opening called a stoma. (This is also called a urostomy. )
After this procedure, a small bag sticks to the skin of your belly around the stoma to collect the urine. Urine slowly drains out non-stop, so the bag must be on all the time. It's emptied whenever it's full. This is called an incontinent diversion, because you cannot control the flow of urine out of your body.
Another way for urine to drain is a continent diversion. A pouch is made from a piece of intestine that's attached to the ureters. One end of the pouch is connected to an opening (stoma) in your skin on the front of your belly. A one-way valve is created at this opening. This allows urine to be stored in the pouch. You then empty it several times a day by putting a thin drainage tube (catheter) into the stoma through the valve. Some people prefer this method because there's no bag on the outside.
This method routes the urine back into the urethra, so you pass urine the same way. To do this, the surgeon creates a new bladder (neobladder) from a piece of intestine. As with the incontinent and continent diversions, the ureters are connected to the neobladder. The difference is that the neobladder is also sewn to the urethra. This lets you urinate normally on a schedule. (You won't have the urge to urinate, so a schedule is needed.) Over time, most people regain the ability to urinate normally during the day, but incontinence at night may be a problem.
If the cancer has spread or can’t be removed with surgery, a diversion may be made without taking out the bladder. In this case, the purpose of the surgery is to prevent or relieve blockage of urine flow, rather than try to cure the cancer.
Risks and side effects of cystectomy
The risks with any type of cystectomy are much like those with any major surgery. Problems during or shortly after surgery can include:
- Reactions to anesthesia
- Blood clots in the legs or lungs
- Damage to nearby organs
Most people will have at least some pain after the operation, which can be controlled with pain medicines.
Effects of cystectomy on urination
Bladder surgery can affect how you pass urine. If you have had a partial cystectomy, this might be limited to having to go more often (because your bladder can’t hold as much urine).
If you have a radical cystectomy, you'll need reconstructive surgery (described above) to create a new way for urine to leave your body. Depending on the type of reconstruction, you might need to learn how to empty your urostomy bag or put a catheter into your stoma. Aside from these changes, urinary diversion and urostomy can also lead to:
- Urine leaks
- Pouch stones
- Blockage of urine flow
- Absorption problems (depends on the amount of intestine that was used)
The physical changes that come from removing the bladder and having a urostomy can affect your quality of life, too. Discuss your feelings and concerns with your health care team.
Sexual effects of radical cystectomy in men
Radical cystectomy removes the prostate gland and seminal vesicles. Since these glands make most of the seminal fluid, removing them means that a man will no longer make semen. He can still have an orgasm, but it will be “dry.”
After surgery, many men have nerve damage that affects their ability to have erections. In some men this may improve over time. For the most part, the younger a man is, the more likely he is to regain the ability to have full erections. If this issue is important to you, discuss it with your doctor before surgery. Newer surgical techniques may help lower the chance of erection problems.
Sexual effects of radical cystectomy in women
This surgery often removes the front part of the vagina. This can make sex less comfortable for some women, though most of the time it's still possible. One option is to have the vagina rebuilt (called vaginal reconstruction). There's more than one way to do this, so talk with your surgeon about the pros and cons of each method. Whether or not you have reconstruction, there are many ways to make sex more comfortable.
Radical cystectomy can also affect a woman’s ability to have an orgasm if the nerve bundles that run along each side of the vagina are damaged. Talk with your doctor about whether these nerves can be left in place during surgery.
If the surgeon takes out the end of the urethra where it opens outside the body, the clitoris can lose some of its blood supply, which might affect sexual arousal. Talk with your surgeon about whether the end of the urethra can be spared.
Sexual effects of urostomy
It’s normal people to be concerned about having a sex life with a urostomy. Having your ostomy pouch fit correctly and emptying it before sex reduces the chances of a major leak. A pouch cover or small ostomy pouch can be worn with a sash to keep the pouch out of the way. Wearing a snug fitting shirt may be more comfortable. Choose sexual positions that keep your partner’s weight from rubbing against the pouch.
Intravesical Therapy for Bladder Cancer
With intravesical therapy, the doctor puts a liquid drug right into your bladder rather than giving it by mouth or injecting it into your blood. The drug is put in through a soft catheter that's put 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.
When is intravesical therapy used?
Intravesical therapy is commonly used after transurethral resection of bladder tumor (TURBT). It's often done within 24 hours of the TURBT procedure. Some experts say it should be done within 6 hours. The goal is to kill any cancer cells that may be left in the bladder.
Types of intravesical therapy
There are 2 types of intravesical therapy:
Immunotherapy for Bladder Cancer
Immunotherapy is the use of medicines to help a person’s own immune system recognize and destroy cancer cells. This type of treatment is sometimes used to treat bladder cancer.
BCG is a type of bacteria related to the one that causes tuberculosis. While it doesn’t usually cause a person to get sick, it can help trigger an immune response. BCG can be put right into the bladder as a liquid. This activates immune system cells in the bladder, which then attack bladder cancer cells.
For more details on this treatment, see Intravesical Therapy for Bladder Cancer.
Immune checkpoint inhibitors
An important part of the immune system is its ability to keep itself from attacking normal cells in the body. To do this, it uses “checkpoints” – proteins on immune cells that need to be turned on (or off) to start an immune response.
Cancer cells sometimes use these checkpoints to keep from being attacked by the immune system. But newer drugs that target these checkpoints, called checkpoint inhibitors, can help restore the immune response against cancer cells.
Chemotherapy for Bladder Cancer
Chemotherapy (chemo) is the use of drugs to treat cancer. Chemo for bladder cancer can be given in 2 different ways:
For this treatment, the chemo drug is put right into the bladder. This type of chemo is used for bladder cancer that's only in the lining of the bladder. It's described in Intravesical Therapy for Bladder Cancer.
When chemo drugs are given in pill form or injected into a vein (IV) or muscle (IM), the drugs go into the bloodstream and travel throughout the body. This is called systemic chemotherapy. Systemic chemo can affect cancer cells anywhere in the body.
When is chemotherapy used for Bladder Cancer?
Systemic chemo can be used :
- Before surgery to try to shrink a tumor so that it's easier to remove and to help lower the chance the cancer will come back. Giving chemo before surgery is called neoadjuvant therapy.
- After surgery(or sometimes after radiation therapy). This is called adjuvant therapy. The goal of adjuvant therapy is to kill any cancer cells that may remain after other treatments. This can lower the chance that the cancer will come back later.
- In people getting radiation therapy, to help the radiation work better.
- As the main treatment for bladder cancers that have spread to distant parts of the body.
Radiation Therapy for Bladder Cancer
Radiation therapy uses high-energy radiation to kill cancer cells.
When is radiation therapy used?
Radiation therapy can be used:
- As part of the treatment for some early-stage bladder cancers , after surgerythat doesn’t remove the whole bladder (such as TURBT)
- As the main treatment for people with earlier-stage cancers who can’t have surgery or chemotherapy
- To try to avoid cystectomy (surgery to take out the bladder)
- As part of treatment for advanced bladder cancer (cancer that has spread beyond the bladder)
- To help prevent or treat symptoms caused by advanced bladder cancer
What is the inheritance of bladder cancer ?
Bladder cancer is typically not inherited. It is usually associated with somatic mutations that occur in certain cells in the bladder during a person's lifetime.
In rare families, the risk of bladder cancer is inherited. In these cases, the cancer risk follows an autosomal dominant pattern, which means one copy of the altered gene in each cell is sufficient to increase a person's chance of developing the disease. It is important to note that people inherit an increased risk of cancer, not the disease itself. Not all people who inherit mutations in these genes will develop bladder cancer.