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Bladder Cancer
Bladder tumors are uncontrolled growth of bladder cells.
Why these cells express themselves as tumors is unknown
and is at the very roots of all cancer research.
Are there different types of bladder tumors?
Other types of bladder tumors are: 1) inverted papilloma,
2) nonpapillary carcinomas, such as adenocarcinoma, 3) bladder
cancer associated with other disease, e.g., bladder stones,
diverticula, 4) metastatic cancer to the bladder, 5) cancer
in situ, 6) involvement of ureters, urethra, and renal pelvis,
and 7) sarcomas.
What are the signs or symptoms of bladder cancer?
The cardinal or principal sign is gross painless blood in
the urine. This occurs in about 2/3 of cases and is usually
total (occurring throughout urination). In 1/3 of cases
blood is seen only under the microscope (microscopic hematuria)
or with a chemical qualitative test. The most common symptom
is frequency and urgency with decreased bladder capacity
and pain. One must be cognizant of the fact that bladder
cancer may occur without any symptoms or visible blood in
the urine.
Do bladder tumors occur in children?
Bladder tumors are rare in children. Bladder tumors occur
primarily in adults in the 6th decade of life and beyond;
however, I and with other urologists have seen bladder tumors
in individuals in their early 40s. Historically bladder
tumors occur more frequent in men than women (2:1); however,
that may change due to the increased smoking habits of women
over the last 30 years. Black men and women have a lower
incidence rate of bladder cancer than their white counterparts
(approximately three fourths)... the reasons are unknown.
What are some environmental or occupational risk
relationships to bladder cancer?
Smokers develop bladder cancer at 2 to 3 times the rate
of non-smokers. Employees who work with dyes, metal, paints,
leather, textile, and organic chemicals have been suggested
to be at risk. These risks are likely to be causal. Many
of the occupational findings are preliminary and require
collaboration. A number of other drugs and chemicals have
been suggested as being linked to bladder cancer, but none
have proven to be responsible for bladder cancer when put
to scientific scrutiny. I mention them casually as theyhave
all appeared in the news media over the last two decades,
e.g., coffee, artificial sweeteners (saccharin and cyclamate),
phenacetin, hair dye, and diet (low Vitamin A). Also, the
use of a common cancer drug, Cytoxan, has been linked to
bladder cancer as has "chronic bladder infections".
How does one diagnose bladder cancer?
Cystoscopy, inspecting the bladder with a lighted telescope-like
instrument, and bladder biopsy remains the primary diagnostic
procedure.
What does staging of the bladder cancer mean and
consist of?
Staging of bladder cancer means determining the extent of
growth and spread, i.e., is the cancer confined to the inner
lining of the bladder or does it extend into the muscle,
or has it spread to other tissues or organs, e.g., lungs
and liver. Conventional staging consists of the following:
Bimanual examination, Transurethral resection or tumor biopsy,
Excretory Urogram (IVP), Computed Tomography (CT), Liver
and Bone Scans, Chest x-ray and possible CT of the chest,
and Liver and renal function blood test. Staging is very
helpful in planning treatment.
How do you treat bladder cancer?
Sperficial bladder tumors... transurethral resection and
intra-vesical pharmacotherapy, e.g., BCG.
For invasive (deep) bladder tumors... surgical removal of
the bladder and urinary diversion if total bladder removal
is required.
Should all patients with hematuria be referred for
urologic evaluation?
Usually. If there is no known reason for the hematuria and
if the hematuria is total painless and the patient is 50
years of age or older. You should have a high degree of
suspicion in smokers. The old urologic adage that "gross
total painless hematuria in an adult represents bladder
cancer until proven otherwise" is a good rule to follow.
Bladder Cancer Treatment
Superficial
Treatment of superficial bladder cancers has three objectives:
1) to eradicate existing disease
2) to provide prophylaxis against tumor recurrence
3) to avoid deep invasion into the muscle layers of the
bladder or metastases to regional lymph nodes. Transurethral
resection (TUR) is the primary treatment to eradicate stage
T1, Ta and Tis lesions. However, within 6-12 months 40%-80%
of these tumors recur after initial treatment. Due to this
high recurrence rate, adjuvant intravesicular pharmacotherapy
with cytotoxic and immunomodulatory drugs is currently being
used to decrease the recurrence rate of these superficial
tumors. Adjuvant intravesical pharmacotherapy has varying
potential beneficial effects for patients. At present the
agent demonstrating the most beneficial effect is BCG. Approximately
10%-25% of patients treated with TUR alone will develop
muscle-invasion or metastatic tumors, necessitating more
aggressive therapies, e.g., surgery and/or irradiation and/or
systemic therapies. Other common active pharmacologic agents
include doxorubicin, mitomycin C, thiotepa, etc.
Invasive
In the United States "radical cystectomy" (total
removal of the bladder) is standard treatment for muscle-invading
bladder cancer. This operation involves removing the pelvic
lymph nodes, the bladder, and the prostate and seminal vesicals,
and the construction of some form of urinary diversion to
manage urinary drainage. Five year survival rates are between
50%-80% depending on the grade, depth of bladder penetration,
and nodal status. Treatment failures occur most commonly
due to distant metastasis and not local recurrences. There
are a limited number of treatment options for invasive bladder
cancer:
A. Transurethral Resection (TURB). In general, TURB is considered
potentially applicable to the local control of small low
grade T2 lesions with limited muscle invasion.
B. Segmental Resection. Limited to patients with a localized
small tumor allowing at least a 2 cm margin.
C. Simple Cystectomy. Rarely done today; provides no information
on node status.
D. Neoadjustment Therapy. May prove to be beneficial in
improving survival.
Urinary Diversion
Urinary diversion is usually performed in conjunction with
a radical cystectomy for invasive bladder cancer. However,
other benign and malignant conditions of the pelvic organs
may necessitate urinary diversion, e.g., Bricker procedure.
However, quality of life issues associated with urinary
diversion are becoming increasingly important to both patient
and physician. The search for an ideal bladder substitute
continues; however, significant progress has been realized
over the last 40 years. The ideal bladder substitute should:
1) maintain continence; 2) maintain sterile urine; 3) warn
against overdistention; 4) empty completely; 5) protect
the kidneys; 6) prevent absorption of waste products; 7)
be socially acceptable; and 8) maintain a high quality of
life. With proper patient selection one is able to offer
patients a choice between a continent urinary reservoir
or an orthotopic neobladder (new bladder replacement). A
simplified explanation of the technical aspects of the procedures
is that a urinary reservoir is constructed from the patient's
intestines which are brought up to the skin, allowing the
patient to intermittently empty the pouch via self-catheterization
4-6 times per day, remain continent, and not wear an ostomy
bag (continent urinary reservoir). In the case of the orthotopic
neobladder, the reservoir attaches directly to the male
urethra allowing one to void through the urethra and not
wear an ostomy bag or require self-catheterization. There
are some technical differences in the construction of these
new forms of urinary diversion with reported and theoretical
advantages and disadvantages of one over the other, but
suffice it to say that continent urinary diversion offers
patients considerable improvement in self-image over the
wearing of an external appliance. Some common diversions
are the Kock pouch, ileal neobladder, Indiana and Barnett
pouch, etc. We offer our patients that meet the selection
criteria a continent urinary diversion.
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