Bladder Cancer

The bladder is a hollow organ in the abdomen that holds urine. When the bladder is full, it contracts and expels urine through the urethra. A malignant tumor in bladder usually starts in the cells that line the bladder (transitional cells), although thin, flat cells in the bladder (causing squamous cell carcinoma) and cells that manufacture mucus and other fluids (causing adenocarcinomas) can also be the point of origin. Tumors that are wart-like with a stem are called papillary tumors. Those without a stem (nonpapillary) are more invasive and dangerous.

Causes and Risk Factors

Though the cause is uncertain, in many cases irritation and inflammation of cells in the lining of the bladder can cause tumors. Cigarette smokers are five times more likely to develop bladder tumors, as are people who have chronic bladder infection or parasite infection (schistosomiasis).

Other risk factors include workplace exposure to cancer-causing chemicals, including arylamines, the carcinogen most responsible for malignancies. Workers who use rubber, aluminum and leather, as well as truck drivers, and people who work with pesticides are also at increased risk, as are women who have had radiation treatments for cervical cancer. This includes recipients of the chemotherapy drug Cytoxan or any other cancer treatment with cyclophosphamide or arsenic. Caucasians and males are twice as likely to develop bladder tumors than the general population. A family history of the disease is also a substantive risk factor, as are certain chlorine byproducts.

Symptoms

Symptoms of bladder cancer include:

Abdominal pain
Anemia
Blood in the urine
Bone pain
Fatigue
Painful urination
Bone tenderness
Urinary frequency, urgency or incontinence
Weight loss

Diagnosing Bladder Cancer

In order to diagnose bladder cancer, your physician will conduct the following examinations and tests:

Physical examination of the abdomen and pelvis for tumors
Rectal or vaginal examination
Urinalysis for blood in urine and/or cancer cells

Additional tests may include:

Intravenous pyelogram: a test in which dye is injected into blood vessels. The dye then collects in urine, causing the bladder to become visible on an X-ray.
Cystoscopy: a cystoscope (a thin, lighted tube) is inserted into the bladder through the urethra. Bladder tissue can be observed and/or tissue samples removed (a biopsy) to check for cancer cells. The tissue is then examined by a pathologist. Anesthesia is usually necessary.

Stages of Bladder Cancer

Degrees of cancer are determined according to the aggressiveness of the growth of the cells, and how different they are from the surrounding tissue:

Stage 0 -- Non-invasive tumors limited to the bladder lining
Stage I -- Tumor has gone past the bladder lining, but not into the muscle layer
Stage III -- Tumor grows past the muscle layer into surrounding bladder tissue
Stage IV -- Cancer spreads to nearby lymph nodes or other sites (metastatic disease) including the prostate, uterus, vagina, ureters, rectum, pelvic lymph nodes, liver, lungs, and bones.

Treating Bladder Cancer

Treatment for bladder cancer depends on the stage of the tumor, the severity of the symptoms, and the number and degree of secondary conditions.

Stage 0 and 1:

Bladder cancer at stage 0 or 1 is usually treated by surgically removing the tumor, while leaving as much of the bladder in tact as possible. Surgery is usually followed by chemotherapy or immunotherapy and, since the risk of a recurrence is high, a permanent schedule of follow-ups is required.

Stage II and III:

Stage II and III bladder cancer is treated by surgically removing the bladder (radical cystectomy) or, in certain cases, partial removal. In almost all cases, removal is followed by radiation and/or chemotherapy. In some cases, chemotherapy or radiation therapy is administered before surgery to shrink the tumor.

Stage IV:

Stage IV bladder cancer is treated with chemotheraphy only. Surgical resection is almost never an option.

Chemotherapy

For Stage I tumors, chemotherapy can be administered into veins or directly into the bladder. For Stage II and III tumors, chemotherapy drugs are injected into a vein and can be given before surgery to shrink a tumor or after surgery to try to prevent recurrence of a tumor.

The choice of the particular chemotherapy drug depends on the kind of tumor being treated. Chemotherapy treatment can be given as a single drug or in combination with others drugs.

The side effects of chemotherapy drugs include bladder wall irritation and pain during urination.

Immunotherapy

Immunotherapy is an attempt to use a medication to trigger the immune system so that it seeks out and kills tumor cells. A frequent choice is Bacille Calmette-Guerin (BCG), which is genetically altered tuberculosis bacteria, which does not produce tuberculosis. Side effects from this type of therapy can include bladder irritability, urinary frequency, urinary urgency, and painful urination.

Transurethral Resection of the Bladder (TURB)

Used mainly in Stage 0 or 1 bladder cancer, this surgical procedure, done under
general or spinal anesthesia, removes the tumor with a surgical instrument inserted through the urethra.

Bladder Removal

Also called a radical cystectomy, this treatment is usually for Stage II or III bladder cancer that may require bladder removal. It is followed by radiation and chemotherapy.

In men, a radical cystectomy can include removal of the bladder, prostate and seminal vesicles. In women, this procedure may also include removal of the urethra, uterus, front vaginal wall, and lymph nodes. In addition to removal of the bladder, a urinary diversion surgery (surgical procedure to create an alternate method for urine storage) is usually performed.

Once the bladder is removed, there are several possible methods of replacing its function.

Ileal Conduit

A small urine reservoir called an ileal conduit is surgically created from a segment of bowel. Ureters to drain urine from the kidneys are attached to one end of the bowel segment, while the other end is brought out through an opening in the skin (a stoma). The urine is drained through the stoma. This procedure requires an external urine collection appliance. The risks include bowel obstruction, blood clots, urinary tract infection, pneumonia, skin breakdown around the stoma, long-term damage to the upper urinary tract.

Continent Urinary Reservoir

A second method is a reconstructive procedure in which a segment of colon is removed and used to create an internal pouch to store urine, which is called a continent urinary reservoir. Urine is drained through a catheter inserted by the patient into a stoma placed flush to the skin. The risks include bowel obstruction, blood clots, pneumonia, urinary tract infection, skin breakdown around the stoma, ureteral reflux, ureteral obstruction.

Orthotopic Neobladder

The third option is to fold over a segment of bowel to make a pouch or neobladder/"new bladder", which is attached to the urethral stump during surgery. This procedure allows patients to maintain a degree of normal urinary control, although rarely the same as before surgery. The risks include night leakage, the necessity of periodic catheterization, bowel obstruction, blood clots, pneumonia, urinary tract infection, skin breakdown around the stoma, ureteral reflux, and ureteral obstruction.