Cancer in the bladder arises from the endothelial lining (urothelium). The majority are superficial (not invading the muscle) at presentation.
Risk Factors
Smoking and increased age are the main risk factors for bladder cancer.
Aromatic amines are worth noting as a carcinogen that causes bladder cancer. Aromatic amines were used in dye and rubber industries but have been heavily regulated or banned for many years. They are also found in cigarette smoke and seem to be the reason smoking causes bladder cancer.
Schistosomiasis causes squamous cell carcinoma of the bladder in countries with a high prevalence of the infection.
TOM TIP: The typical presentation to look out for in your exams is a retired dye factory worker with painless haematuria. Whenever an exam question mentions a patient’s occupation, it is almost certainly relevant and will tell you the diagnosis. Dye factory workers get transitional cell carcinoma of the bladder. Patients with asbestos exposure get mesothelioma. Outdoor workers with significant sun exposure get skin cancer.
Types
- Transitional cell carcinoma (90%)
- Squamous cell carcinoma (5% – higher in areas of schistosomiasis)
- Rarer causes are adenocarcinoma (2%), sarcoma and small-cell carcinoma
Presentation
Painless haematuria is the symptom to remember for your exams.
The NICE guidelines on recognising cancer (last updated January 2021) advises a two week wait referral for:
- Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI
- Aged over 60 with microscopic haematuria (not visible but positive on a urine dipstick) PLUS:
- Dysuria or;
- Raised white blood cells on a full blood count
The NICE guidelines also recommend considering a non-urgent referral in people over 60 with recurrent unexplained UTIs.
Diagnosis
Cystoscopy (a camera through the urethra into the bladder) can be used to visualise bladder cancers. The cystoscope can be rigid or flexible. Cystoscopy can be performed under local or general anaesthetic.
Staging
The TNM staging system is used for bladder cancer, rating the T (tumour), N (lymph node) and M (metastasis) stages.
There is a clear distinction between:
- Non-muscle-invasive bladder cancer (not invading the muscle layer of the bladder)
- Muscle-invasive bladder cancer (invading the muscle and beyond)
Non-muscle-invasive bladder cancer includes:
- Tis/carcinoma in situ: cancer cells only affect the urothelium and are flat
- Ta: cancer only affecting the urothelium and projecting into the bladder
- T1: cancer invading the connective tissue layer beyond the urothelium, but not the muscle layer
Invasive bladder cancer includes T2 – 4 and any lymph node or metastatic spread.
Treatment Options
Management of any cancer is guided by a multidisciplinary team (MDT) meeting to decide the best course of action for the individual patient.
Transurethral resection of bladder tumour (TURBT) may be used for non-muscle-invasive bladder cancer. The involves removing the bladder tumour during a cystoscopy procedure.
Intravesical chemotherapy (chemotherapy given into the bladder through a catheter) is often used after a TURBT procedure to reduce the risk of recurrence.
Intravesical Bacillus Calmette-Guérin (BCG) may be used as a form of immunotherapy. Giving the BCG vaccine (the same one as for tuberculosis) into the bladder is thought to stimulate the immune system, which in turn attacks the bladder tumours.
Radical cystectomy involves the removal of the entire bladder. Following removal of the bladder, there are several options for draining urine:
- Urostomy with an ileal conduit (most common)
- Continent urinary diversion
- Neobladder reconstruction
- Ureterosigmoidostomy
Chemotherapy and radiotherapy may also be used.
Urostomy
A urostomy is used to drain urine from the kidney, bypassing the ureters, bladder and urethra. This is the most common and popular solution after cystectomy.
Forming a urostomy involves creating an ileal conduit. A section of the ileum (15 – 20cm) is removed, and end-to-end anastomosis is created so that the bowel is continuous. The ends of the ureters are anastomosed to the separated section of the ileum. The other end of this section of the ileum forms a stoma on the skin, draining urine into a urostomy bag. Urine drains from the kidneys to the ureters, then the separated section of ileum (the conduit), then out of the urostomy.
Urostomy bags need to fit tightly around the urostomy to avoid urine coming in contact with the skin. Urine in contact with the skin will cause irritation and skin damage.
Continent Urinary Diversion
A continent urinary diversion involves creating a pouch inside the abdomen from a section of the ileum, with the ureters connected. This pouch fills with urine. A thin tube is connected between a stoma on the skin and the internal pouch. Urine does not drain from the stoma (unlike a urostomy), and the patient needs to intermittently insert a catheter into the stoma to drain urine from the pouch.
Neobladder Reconstruction
Bladder reconstruction involves creating a new bladder from a section of the ileum. This is connected to both the ureters and the urethra and functions similarly to a normal bladder. It may require intermittent catheterisation and bladder washouts to clear secretions from the small bowel tissue.
Ureterosigmoidostomy
A ureterosigmoidostomy involves attaching the ureters directly to the sigmoid colon. Urine drains into and collects in the sigmoid colon. Techniques are used to prevent urine refluxing into the ureters or back through the large bowel. The rectum may be expanded to create a recto sigmoid pouch (called a Mainz II procedure) to create a larger space for urine to collect. The patient can then drain the urine by relaxing the anal sphincter in the same way they open their bowels.
This used to be used more often but is very rarely done now. It is associated with infection in the kidneys, electrolyte imbalances and secondary cancer at the anastomosis (join) between the ureters and sigmoid colon.
Last updated May 2021
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