Diseases & Conditions

Bladder Cancer

Author: Paul H. Lange, MD FACS
Last updated: March 31, 2006

• Overview |
• Symptoms |
• Causes |
• Risk Factors |
• Diagnosis
  
• Complications |
• Treatment |
• Self-care |
• Other Articles of Interest


• Providers |
• Request an Appointment

Overview

The bladder is a flexible hollow organ that stores urine which is made in the kidneys and transported to the bladder by the ureters. Periodically the bladder empties the urine through the urethra to the outside. The kidneys, ureter, bladder, and urethra comprise the urinary tract and this is lined by a layer (called the urothelium) which is composed of transitional cells. Cancers of these transitional cells are called transitional cell carcinomas and they can occur anywhere within the urinary tract. Here we will only talk about bladder cancer which composes the vast majority of urothelial cancers. In the normal urinary tract, deep to the transitional cell layer, is the lamina propria (a thin fibrous band) and deeper to that is the muscular layer called the muscularis propria. These layers are important when considering bladder cancer because how deep the bladder cancer extends into these layers has a lot to do with the seriousness of the bladder cancer. For example, the lamina propria separates superficial tumors that have not spread into the lamina propria from those that are invasive that have spread into the lamina propria or beyond into the muscle.

There are several types of bladder cancers: the major type is transitional cell carcinoma (80%); other types include squamous cell carcinoma (8%); and adenocarcinoma (2%). Bladder cancer can also be separated into so-called T stages based upon how deep it penetrates into the bladder wall. Thus, the designation superficial bladder tumors are ones that do not penetrate the lamina propria (T0) or those that only invade into the lamina propria (T1). Those bladder tumors that are deeply invasive are those that penetrate into the muscular propria (T2) and sometimes beyond into the fat layers around the bladder (T3) or even beyond to adjacent organs (T4). Finally, bladder tumors can be separated into the way they look. There are the papillary tumors, which look like small polyps or flower-like clusters of tumor cells, the sessile tumors, which look like more solid flatter tumors, and the non-invasive flat tumors, which are often called carcinoma in situ or CIS. CIS grows in layers of cells closest to the inside of the bladder and appears as flat lesions on the surface of the bladder. Bladder tumors metastasize (spread beyond the bladder). The tumor can grow into the surrounding organs (uterus and vagina in women and prostate in men) and that is called locally advanced disease. It can also spread to the lymph nodes and/or to the liver, bones, or lungs and that is called distant metastasis. Rarely bladder cancer spreads to other parts of the body.

Bladder cancer can be a serious malignancy. It is the 4th most common malignancy in men and the 8th most common in women. In the United States in 2006, 61,000 men will have been diagnosed with bladder cancer, but only 13,000 will die of it. This is because usually bladder cancer is superficial and although it may frequently recur, it rarely grows to become invasive cancer (i.e. grows into the muscle). When it does grow into the muscle or beyond (> T2), it is lethal in 50% or more.

Symptoms

For most people, the first symptom of bladder cancer is hematuria, or blood in the urine. Sometimes the blood can be seen when the patient urinates and occasionally blood clots will also be seen. At other times the urine looks clear but a “urinalysis” shows microscopic traces of blood. Other symptoms that might mean bladder cancer include:

• Frequent urination, or feeling the need to urinate without being able to do so
• Pain during urination
• Lower back pain
• Signs and symptoms of a blocked kidney such as flank pain, or imbalances in the chemicals in the blood having to do with the kidney

Causes

Bladder cancer has various risk factors. These include:

1. Using tobacco, especially smoking cigarettes. (This is by far the greatest risk factor in the USA).
2. Being exposed to certain substances, such as soot from coal, or chemicals used to make rubber, certain dyes, paint, hairdressing supplies or textiles.
3. Working as a dry cleaner or in places where paper, rope, twine, or clothing is made.
4. Having an infection caused by a certain parasite.
5. Taking A. fangchi, a Chinese herb.
6. Long-term use of urinary catheters.
7. Past treatment with certain anticancer drugs or radiation therapy to the pelvis.
8. Having a kidney transplant.
9. Having an inherited disorder called hereditary non-polypopsis colon cancer (HNPCC; Lynch syndrome).

Risk Factors

Same as above under causes.

Diagnosis

Diagnosis of bladder cancer can be made using the following tests:

• Cystoscopy: A urologist is able to examine the bladder using a small hollow lighted instrument inserted through the urethra into the bladder. Tissue samples (biopsies) may be taken through the scope for analysis
• Urine tests: Usually this is a so-called urine cytology; that is, an examination of urine under a microscope to check for abnormal cells. Sometimes sophisticated molecular tests are used in addition or instead of a cytology test
• CAT (CT) Scan: High resolution images of the kidneys, bladder and ureters to look for tumors are obtained via a special high speed rotating x-ray machine that creates sliced images of the body
• Intravenous Pyelogram (IVP): A series of x-rays of the kidneys, ureters, and bladder with contrast injected through a vein to find out if cancer is present in these organs and if they are causing blockages to the ureters.

Complications

Bladder cancer can cause bleeding, urgency, and pain. Once it spreads it can cause death. The treatment of bladder cancer also has side effects. Cutting the tumor out of the bladder, that is, the so-called transurethral resection of bladder tumors (TURBT) can cause bleeding. Intravesical agents such as BCG can cause bleeding, pain, urgency, flu-like symptoms, and very rarely severe systemic infections. Cystectomy and the accompanying lymph node dissection (called a lymphadenectomy) is a complex operation and should only be performed by surgeons experienced in the procedure. Like all complex serious surgeries, complications caused by cystectomy include infection, bowel obstruction, nerve damage problems, cardiovascular problems, and even death. During cystectomy in men, often the nerves controlling erections must be cut, thus, resulting in impotence, although this side effect can be corrected later. With continent urinary reservoirs (CURs) or neobladders, complications can include leakage of urine, retention, or, (because larger amount s of bowel are often used), problems with bowel function such as diarrhea or constipation. With the diversion where small amounts of bowel that empty into a bag (so-called urine ileal conduits) are used, there can be leakage around the bag and also abdominal wall hernias. The construction of CURs and neobladders are complicated and tedious. If a neobladder or CUR is desired and/or possible, it is very important that the surgeon be very experienced in this procedure.

Treatment

Once bladder cancer is discovered, the urologist must “stage the disease”; that is, tell how deep the cancer has penetrated into the bladder (for T stage, see above) and also whether the cancer has spread outside the bladder or the lymph nodes, or beyond. The T stage is usually diagnosed by the pathologic examination of the bladder biopsies or resection. Sometimes more than one biopsy is necessary to accurately determine the T stage. Usially a CT scan is used to tell whether the cancer is outside the bladder to the lymph nodes or beyond.

Once staging is complete a treatment is determined. The chance of recovery depends on the following:

• The stage of the cancer, whether it is superficial or invasive bladder cancer, and whether it has spread to other places in the body. Bladder cancer in the early stages (T0-T3) can often be cured.
• The type of bladder cancer cells and how they look under a microscope (ie the “grade” of the tumor)
• The patient’s age and general health

The majority of bladder cancers are superficial bladder cancers. Superficial cancers are mainly treated by:

1. Cystoscopy and transurethral resection of the tumors. These procedures are done through the urethra using special small instruments. Small tumors are fulgurated without the need for resection. Larger tumors are completely excised through a special instrument know as the resectoscope.
2. Intravesical Immunotherapy: In addition to resection, patients may require instillation of special drugs into the bladder through a catheter to lower the risk of recurrence of the tumor. Commonly used drugs include mitomycin C, Bacille Calmete Guerin (BCG) and interferon. Often BCG is the first intravesical therapy offered and is given after resection of recurrent T0 tumors, after resection of T1 tumors especially if they are high grade, and all CIS cancers.

Advanced or muscle-invasive bladder cancers are treated differently from superficial cancers. These treatments may involve:

1. Cystectomy: The bladder is totally removed by the urologist together with the surrounding lymph nodes. In a man the prostate is also removed., In women most often the urterus and ovaries are also removed; sometimes part of the vagina must be removed also In selected cases with specific small tumors at the dome of the bladder, only part of the bladder is removed.
2. Urinary Diversion: After removal of the bladder, the urologist uses small bowel segments to create a new spherical low-pressure reservoir for the urine and connects this to the ureters to drain urine from the kidneys. This bowel segment can then be connected to either the abdominal wall or urethra in the pelvis. If a short piece of bowel is used, it is always connected to the abdominal wall and a urinary bag must be worn all the time; this is called a urinary bowel conduit. Alternatively, a larger piece of bowel can be used, sown into a sphere and then connected as a “continent urinary reservoir” (CUR) to the abdominal wall or to the urethra remaining after the cystectomy as a neobladder. In these cases no urinary bag is necessary. If it is a CUR, the patient has to catheterize the reservoir every 4-6 hours, then remove the catheter and cover the opening with a small bandage. With neobladders the patient voids spontaneously.
3. Chemotherapy: Chemotherapy refers to the use of drugs to kill cancer cells. Usually the drugs are given into a vein or by mouth. Once the drugs enter the bloodstream, they spread throughout the body. Chemotherapy is useful in treating cancer that have spread beyond the bladder to lymph nodes and other organs. Chemotherapy may be given before or after surgery.
4. Radiation Therapy: Radiation therapy is treatment with high-energy rays (such as x-rays) to kill or shrink cancer cells. The radiation comes from outside the body. After surgery, radiation can kill small deposits of cancer cells that may be too small to see.

Self-care

One must be alert to changes in urinary color. If one sees dark urine or actual blood in the urine, one must seek the advice of a physician immediately. This change in color may only occur periodically or only even once. One should not assume that the condition will go away if the normal color resolves. Other things to watch for include sudden changes in voiding patterns, especially urgency. Pain in the kidney area (flank) can also be caused by bladder cancer although that symptom is usually from other causes.

>>View all articles.

[to top]

Providers

Read about our surgeons:

• William J. Ellis, MD
• Paul H. Lange, MD

Request an Appointment

At UWMC

Call (206) 598-4294.

For more information, go to the UWMC Urology Clinic Web page.

At HMC

Call (206) 731-3241

For more information, go to the HMC Urology Clinic Web page.

[to top]