What is bladder cancer?
Bladder cancer commonly causes blood in the urine – an alarming symptom which means that patients usually seek advice early. The urologist’s ability to pass a small flexible cystoscope into the bladder in a clinic or day surgery unit makes for rapid diagnosis as well as allowing simple follow-up of bladder tumours.
The treatment of these growths, and those affecting the kidney, is usually surgical removal by the urologist, sometimes followed by other forms of treatment such as radiotherapy or chemotherapy.
Symptoms of bladder cancer
It is very important that you visit your GP as soon as you notice anything unusual – the earlier that bladder cancer is diagnosed, the more quickly it can be treated and the better the outcome.
The most common symptoms are:
- Blood in the urine (even just once)
- Recurrent urinary infections
- Frequency or urgency or pain on passing urine when no infection found on urine tests by the doctor
Diagnosis
There are a number of tests that check for the possibility of bladder cancer and the grade and stage of the condition. These tests help the doctors, your specialist and nurses to consider the most appropriate treatment.
The usual first step is that your GP will discuss your general health, ask about symptoms and do a general examination. They may do a urine test at the surgery or send a sample to the lab. Then if necessary, a specialist, often the urologist, will conduct further tests.
One of the warning signs for bladder cancer is visible blood in the urine (visible haematuria). Unless there is another clear cause for the blood (e.g. confirmed urinary infection), people should be referred by their GP for further tests immediately under a policy of being seen by a urologist within two weeks of referral – the 2 week rule (as is now set out in the NICE guidelines for suspected cancer). This urgent referral particularly applies to people over the age of 45, but unexplained visible blood in the urine, at whatever age, requires further investigation.
When traces of blood aren’t actually visible but are only picked up on testing this is known as non-visible haematuria and similarly warrants prompt further testing in people over the age of 40 yrs. In patients under the age of 40, non-visible haematuria in the absence of any other symptoms is very rarely due to bladder cancer. The blood is usually a result of ‘leaky kidneys’ and is rarely of any consequence – however, there is a small link with kidney problems in later life, and persistent non-visible haematuria should be monitored by your GP surgery with an annual blood, urine and blood pressure test – to act as an early warning system if kidney problems should develop.
You should be aware that there are several types of disorders which might cause blood in the urine including: cancers (of the bladder, prostate, kidney); urinary tract stones (kidney and urinary bladder); infections; non-cancerous swelling of the prostate gland in men. Additionally, problems with kidney function can allow blood to pass into the urine. For most people, however, no serious problem is found.
The majority of people who have blood in their urine do not have bladder cancer. Of those referred to a hospital ‘haematuria clinic’, around 25% of people with visible blood in their urine will have bladder cancer identified. This means that 75% will not – but there may be other causes for the blood. For non-visible haematuria the figure is much lower, less than 5%.
It is therefore vital that you seek advice from your doctor to find the cause and have it treated appropriately.
Treatments
The type of treatment for Non-Muscle Invasive bladder cancer (sometimes called early or superficial bladder cancer) depends very much upon the cell type, grade and stage of the cancer. The main aim of treatment is to remove the growth as early as possible and prevent the cancer returning and progressing in the future.
There are three main types of treatment:
- Transurethral Resection of Bladder Tumour (TURBT)
- Intravesical therapies, including BCG (intravesical immunotherapy)
- Mitomycin (intravesical chemotherapy)
Treatment for low risk non-muscle invasive bladder cancer
If you have low risk bladder cancer, the main treatment is TURBT which is surgery to remove the cancer from the bladder lining. If the cancer is completely removed during TURBT, you may not need any on-going treatment, although you should receive a single one-off dose of Mitomycin chemotherapy immediately following your TURBT (within 24 hours). This reflects a specific recommendation from the NICE Bladder Cancer Guideline that recommends such treatment for all bladder cancer cases.
Treatment for intermediate risk non-muscle invasive bladder cancer
If you have intermediate (moderate) risk bladder cancer you should usually have a 6 week course of chemotherapy directly into your bladder after the TURBT operation.
Treatment for high risk non-muscle bladder cancer
If your first TURBT operation shows you have high risk bladder cancer, you will usually have a second TURBT, ideally within 6 weeks of the first, to check if any cancer remains and how far the cancer has grown. You may then have:
- A course of BCG vaccine treatment directly into the bladder
- An operation (primary cystectomy) to remove the bladder
Your urologist will talk to you about the risks and benefits of these treatments and the grade and stage of your cancer and the likelihood of it spreading. They will also tell you about effects and implications of both treatments and their impact on your life.
Surgery
You may have been told that is it necessary to have surgery to treat your bladder cancer effectively.
You can find information below for some of the most common surgical procedures to treat bladder cancer – whether this is an operation to remove your bladder (Cystectomy) or a type of urinary diversion.
Cystectomy
Cystectomy is surgery to remove the bladder. Removal of the bladder containing cancer is an effective method of management of muscle-invasive bladder cancer and can also be an option for high risk non-muscle invasive bladder cancer when either BCG therapy is considered unsuitable or where the BCG treatment fails or is not tolerated. The amount of tissue removed usually depends on the type of bladder cancer as well as the extent of disease.
Radical Cystectomy
Radical cystectomy is the removal of the entire bladder and surrounding tissues that may contain cancer cells.
In men, radical cystectomy usually involves removal of the urinary bladder, prostate and seminal vesicles as well as lymph glands that may harbour small deposits of cancer cells. Occasionally it may be necessary to remove the whole of the urethra (water pipe) as well.
In women, it usually involves removal of the urinary bladder, the whole of the urethra, part of the vaginal wall, the ovaries, the womb and the lymph nodes – for some women, the vagina and reproductive organs can be spared.
The extent of surgery is tailored to individual patients and procedures such as nerve sparing to improve sexual function can be considered.
Partial Cystectomy
Partial cystectomy is the removal of part of the bladder and is performed in patients with a specific type of cancer which makes up less than 5% of all cases.
Urostomy
The main function of the bladder is to store and expel urine. Urine is made by the kidneys to excrete waste products from your body. Urine drains through the ureters (tubes from the kidney) into the bladder. When the bladder is full the urine is passed through the urethra and out of the body.
A Urostomy (Ileal Conduit) is the most common type of non-continent urinary diversion. After you have had your bladder removed (radical cystectomy) a new way for the urine to be stored and expelled from your body will need to be created.
A Urostomy is one of the ways of creating this new route for the urine and for keeping your kidneys working efficiently.
Your surgeon will attach the ureters to a segment of bowel to divert urine to the outside of the body through a stoma and into a pouch. This is called an ileal conduit diversion.
The conduit is made from a small detached section of the part of your bowel called the small intestine which is known as the ileum. The rest of the bowel is then joined up so your bowels continue to function normally. The ureters are attached to the segment of ileum, one end is closed up and the other open end is then brought through an opening in the abdominal wall to form a stoma. Stoma is Greek for mouth.
Narrow plastic tubes called stents will be inserted into the ureters from the kidneys to help keep urine flowing freely until things have healed. The stents are either taken out about 10 days after the surgery or they will come out by themselves.
Neobladder
It may be possible, in the course of your radical cystectomy (bladder removal) for your surgeon to create an artificial bladder. A neobladder is a replacement bladder created from a section of your bowel and attached to your urethra, which means you can pass urine in the same way as with a normal bladder. It is known as an orthotopic neobladder (which means ‘same place’ and ‘new bladder’).