Bladder Oncology

It is an uncontrolled growth of cells within urinary bladder (the part of our body which stores urine till it’s socially acceptable to empty). It is one of the most demanding cancer in that there is high chances of recurrence and demands commitment from both the physician and patient for optimal treatment. Neglected, it is uniformly fatal.

What are the symptoms of cancer of Urinary bladder?

The most dramatic symptom is painless bleeding while passing urine. The bleeding may be slight, just discoloring the urine or copious, associated with passage of clots of blood. Occasionally, the clots may obstruct passage of urine, leading to inability to pass urine, associated with severe discomfort or pain.
Any episode of blood in urine demands a thorough investigation under a trained urologist to rule out this progressive disease. In some patients, a persistent pain during passage of urine, not relieved with repeated course of antibiotics/treatment may be a sign of bladder cancer

What are the risk factors of bladder cancer?

• First degree relatives of patients suffering from bladder cancer
• People working in chemical industries like dye and rubber workers, polycyclic aromatic hydrocarbons, diesel mechanics and paint industries (30% increase in risk)
• Tobacco smoking – 2 to 6 times greater risk as compared to non-smoker. Intensity and duration of smoking linearly increases the risk. Cessation of smoking for more then 15 years lowers to risk to almost baseline.
• Infection with Schistosoma haematobium (bug found in middle East/Egypt)
• Prolonged catheterization/untreated urinary bladder stones for long period

A diet rich in fruits and vegetables is protective against bladder cancer formation

How is bladder cancer diagnosed?

Any person, especially, elderly persons with a history of smoking or working in chemical industries should NOT neglect even a single episode of blood in urine and consult urologist immediately.

Evaluation includes:

• Urine examination including cytopathology (to look for presence of cancerous cells in urine): for optimal reading, fresh whole sample should be submitted in the laboratory having expertise in cytopathology and NOT morning sample
• Ultrasound examination of urinary bladder
• CT scan/MRI scan if required
• Cystoscopic examination: the urinary bladder is inspected visually with the aid of a specialized telescope and camera on TV monitor to look for the growth. The procedure can be done in OPD basis under local anaesthesia or under anaesthesia cover. The urologist may combine cystoscopy with resection – biopsy of the growth to reduce the number of operation room visits.

What is the importance of biopsy?

Biopsy is taken to get a piece of suspicious tissue, which is subjected to examination under microscope by a trained pathologist. The examination characterizes the nature of growth and its likely grade and aggressiveness. Based on the report, further treatment is planned.

1. Superficial tumor

a. Low grade: low chances of recurrence and progression
b. High grade: high chances of recurrence and progression

2. Deep/Muscle invasive tumor:

A progressive tumor, may have spread widely

Are repeated visits to doctor and cystoscopic examination necessary?

A bladder cancer is notorious for recurrence and progression. Once confirmed by biopsy, the patient should commit to life long surveillance with cystoscopic examination to detect recurrence at initial stage and avoid progression of disease. Even with regular check up, the disease may progress and need further treatment. If the dictum is neglected, the disease can progress even after years of first diagnosis and can be fatal Initially, patient is asked for three monthly cystoscopic examinations. If no recurrence is found, the interval can be extended to six monthly and annually. The cycle returns to three monthly after every recurrence

What is the role of BCG instillation in urinary bladder?

BCG is a live vaccine, which is instilled into urinary bladder to generate immunogenic response locally and to kill tumor cells. It has been proven to decrease recurrence rate of the tumor.

What is the procedure of BCG instillation?

BCG instillation is started two to four weeks after initial surgery to allow internal wounds to heal and avoid spread of vaccine into blood. Patient is asked to restrict fluid intake for at least two hours before the scheduled procedure and empty bladder just before the procedure. After instillation, he/she should try to retain it for at least two hours for optimal effect. The procedure is repeated weekly for six cycles, then at three and six months – weekly for three cycles. After 6 months, it has to be repeated six monthly 3-week cycles till completion of 3 years or till patient tolerates (which ever is earlier)

Is there any contraindication for BCG therapy?

Yes, following patients are not the candidates

• Immunosuppressed and immunocompromised patients
• History of BCG sepsis
• Gross bleeding in urine
• Inability to retain urine

There are a few other conditions in which decision is made on case to case basis

Are there any side effects of BCG therapy?

As BCG therapy causes reaction within urinary bladder, it causes swelling and may result in pain while passing urine and frequency of urine. However, most of these symptoms are transient and can be readily managed by medications. There are a few signs of serious reaction, which need immediate attention of your urologist for proper care and treatment: -

• Severe frequency
• Painful voiding lasting more than 48 hours
• Blood in urine
• Temperature more than 38.5°C (101.3 F)

What are the options of invasive disease?

A disease, which has invaded the muscle wall of urinary bladder, is progressive and needs aggressive treatment to prevent it from spreading to other organs. To properly eradicate the disease from the body, available options are

1. Radical surgery

In radical surgery, the whole of urinary bladder is removed surgically and a new passage of urine is made with the help of intestines of the patient. Depending upon overall condition of the patient, stage of the disease and expertise of the surgeon, the options of urinary diversion are:

a. Conduit: The urine tubes (ureters) are connected to a small piece of intestine, which is brought out below and side of navel. A bag is attached, where urine collects and is emptied periodically.

b. New bladder: A new urinary reservoir is made out of intestines, which is placed where natural urinary bladder used to be. The patient is able to pass urine naturally, using help of muscles of abdominal wall. However, 1 in 5 patient is unable to empty new bladder naturally and needs to pass a catheter (specialized rubber tube) to empty the reservoir. Also, as the new reservoir is made out of intestines, natural mucous secretion occurs, which needs to be washed till it ceases after a few months.

2. Radiothrapy and Chemotherapy:

In patients not willing for major surgery, or concern of body image, can opt for the combination of radiotherapy and chemotherapy. In patients with advanced disease, where surgery is not a curative option, palliative radiotherapy can be considered.

Surgery versus radiotherapy and Chemotherapy

What are the chances of survival after having diagnosed bladder cancer?

A patient with stage 1 disease can expect a 10-year disease free survival of more than 90% as opposed to less then 65% in stage 2 and mere 15% overall survival of 2 years in stage 4.