Revised January 1999

General Information / Anatomy / Function / Statistics

• Muscular sac that acts as a reservoir for urine
• Urine is carried down from the kidneys to the bladder by the ureters
• The bladder empties the urine through the urethra
• Transitional cells line the inner surface of the bladder - this lining begins in the kidneys and extends through the urinary tract
• Bladder cancer is the most frequent cancer in the urinary tract
• More than 4,500 new cases are diagnosed yearly in Canada
• Bladder cancer is quite common for those in their 50s, 60s, and older and affects men three times is frequently as women
• Patients with low grade superficial cancer have a five-year survival rate of over 70% following TUR (transurethral resection)
• Patients with more invasive disease have a lower life expectancy

Symptoms / Signs

• First and most common sign is usually persistent or intermittent visible blood in the urine (even once may be significant) but this may be absent or microscopic only
• Can occur abruptly and without pain
• Color of urine can range from smoky to rusty to bright or deep red: hematuria
• Bladder irritability, frequency, urgency and pain are found in about one third of patients.  These are also symptoms of bladder infection
• Symptoms of advanced disease include weight loss, loss of appetite, weakness and general discomfort

Etiology / Carcinogens / Risks

• Cigarette and tobacco smoking are also linked to bladder cancer. Risk is more than three times that of non-smokers
• Workers employed with dyestuffs, rubber compounds, leather, print, petroleum and other organic chemicals are at risk
• Carcinogenic chemicals are absorbed by the blood and filtered into the urine
• Chronic bladder infections. Changes occur in the bladder as a result of repeated or persistent infection
• Schistosomiasis, a disease occurring mostly in the Middle East, particularly Egypt, has been associated with bladder cancer. The parasitic worm called SCHISTOSOMA HAEMATOBIUM which lodges in the bladder has been found in 97% of Egyptian patients with bladder cancer (not relevant in B.C. except for immigrants from Middle East)
• The excessive use of drugs containing phenacetin

Prevention

• Urinalysis is used to look for microscopic blood in the urine
• Stop smoking

Screening

• The microscopic examination of a fresh sample of urine is a useful test for the detection or recurrence of cancer of the bladder in patients who have been treated for the disease, since these tumours tend to recur
• It is not used as a routine screening test because of the relatively low frequency of the disease

Staging

• Superficial papillary tumours involve only the inner lining of the bladder (stages Ta and T1). They are usually low grade
• Diffuse superficial high grade disease is called carcinoma-in-situ, and is much more likely to behave aggressively, and may require cystectomy (removal of bladder by surgery)
• More advanced tumours may extend into superficial or deep bladder muscle (stages T2 and T3a), through muscle (stage T3b), or into other structures (stage T4). These are usually high grade and require radical treatment

Types

• Transitional cell cancer is the most common type (over 90%)
• Occasional bladder cancers are squamous, or adenocarcinomas or mixed

Papillary Tumour:

• Superficial growth attached to the inner bladder lining
• They tend to recur on different area of the bladder wall
• Invasive tumour grows inward through the tissue, penetrating epithelium into muscular wall and may develop from papillary cancers or be solid from first diagnosis
• Once they invade muscular tissue, they may spread to lungs, liver, bone, or lymph nodes
  Approximately 90% of patients will be alive 5 years after diagnosis

Squamous Cell Carcinoma:

• Less common form
• Tumour grows directly on the bladder wall mucosa and invades muscle tissue
• The more abnormal the cells the more invasive the cancer

Treatment

Surgery

• Removal of the tumour can often lead to cure
• The extent and exact nature of surgery depends on individual cases
• Superficial papillary tumours are generally treated by transurethral resection and fulguration
• This procedure involves the use of an instrument (cystoscope) which is passed through the urethra which permits electrical cutting and burning of the cancer. Can be repeated as often as necessary. Periodic follow up is essential to detect new cancers
• More aggressive superficial tumours are treated by transurethral surgery and intravesical (within the bladder) chemotherapy
• TUR (transurethral surgery) may be used to relieve the symptoms of high stage and high grade tumours
• Invasive or high grade tumours are usually treated by removal of the bladder (cystectomy) and urinary diversion
• Urinary diversion involves attaching the ureters to a segment of small intestine which has been isolated to form a pouch for urine collection. One end of the pouch is brought through the abdominal wall to form a small opening or stoma. An external bag holds the urine until it is emptied manually
• Newer methods of urinary diversion have been developed which allow intermittent release of urine from the stoma by catheter, or reconstruction of an internal bladder made from bowel
• A complication of bladder surgery in men may be impaired sexual function
  In women additional surgery may include removal of the uterus, fallopian tubes and ovaries

Chemotherapy

• Chemotherapy shows some results but generally not dramatic or long-lasting
• Chemotherapeutic agents such as THIOTEPA, BCG, or MITOMYCIN are sometimes introduced into the bladder at regular weekly intervals, usually for a total of about six weeks. The chemicals are administered through a catheter inserted into the bladder and may cause bladder irritation
• Intravenous chemotherapy may be administered in combination with surgery and radiation in the management of deep or metastatic cancer
• Cisplatin is a chemotherapy drug given overnight in hospital. Usually every three weeks. It can only be given safely if kidney and heart function are adequate. Side-effects include nausea, reduced kidney function and high pitch hearing loss. Other drugs such as vinblastine and methotrexate may be used as well
• Preoperative chemotherapy is still considered investigational

Radiation