Bladder Ca

• Overview:

  • Common malignancy - most common urinary tract tumour
  • Higher incidence in males
  • Often present early with painless visible haematuria
• Urothelial (transitional cell) carcinoma:

  • Most common type
  • Bladder is lines with urothelium
  • As bladder becomes distended with urine, the urothelial layer becomes flattened and results in increased exposure to environmental chemicals in the urine that could lead to mutation
  • Most important risk factor is smoking
• Squamous cell carcinoma:

  • 5% of cases
  • Linked to conditions that cause prolonged inflammation within the bladder
  • More commonly seen in Africa and Asia due to infection with the parasite Schistosomiasis
  • Recurrent UTIs
  • Long term catheters
• The remaining histological subtypes comprise adenocarcinoma (2%) and other rare cases (e.g. sarcomas, small cell carcinomas
• The main risk factors for bladder cancer are increasing age and smoking.

  Other risk factors include:

  • Male sex: 3:1 increased risk compared to females
  • Occupational exposure to aromatic amides: found in industrial settings that process rubber, dyes, textiles, paints, and solvents
  • Pelvic radiation
  • Cyclophosphamide
  • Chronic inflammation from infection or indwelling catheters (squamous cell tumours)
  • Schistosomiasis (squamous cell tumours)
• Painless, visible haematuria is the presenting complaint in 80-90% of patients and may be the only symptom
• Other symptoms may include:

  • Non-visible haematuria: around half as likely to be linked to bladder cancer as visible haematuria
  • Difficulty passing urine
  • Change to urinary frequency and/or urgency
  • Recurrent urinary tract infections
  • Pelvic pain
  • Back pain
  • Weight loss
  • Fatigue
• Patients should be referred to a suspected cancer pathway (to be seen within two weeks) for bladder cancer if they are:

  Aged 45 and over with either:

  • Unexplained visible haematuria without urinary tract infection
  • Visible haematuria that persists or recurs after successful treatment of a urinary tract infection

  Aged 60 and over with:

  • Unexplained non-visible haematuria and either dysuria or a raised white cell count
• Relevant bedside investigations include:

  • Urinalysis and urine culture: to exclude infection
• Relevant laboratory investigations include:

  • Full blood count: to check haemoglobin for evidence of anaemia
  • Renal function
  • Urine cytology: detects abnormal cells within the urine, although it has a low sensitivity for bladder cancer, so is used in conjunction with cystoscopy
• All patients with a suspected bladder tumour should be offered urgent cystoscopy.

  The first line is usually a flexible cystoscopy, as it can be tolerated when the patient is awake with local anaesthetic gel
• NICE guidelines recommend considering a CT or MRI staging scan if the patient is suspected of having muscle-invasive bladder cancer after their cystoscopy.

  A CT urogram is also useful for detecting possible lesions in the ureters. 
• For a complete diagnosis of bladder cancer, a sample must be sent for histological analysis. To achieve this, the lesion is removed via a transurethral resection of bladder tumour (TURBT).

  The procedure is performed under general anaesthetic and involves a rigid cystoscope being passed through the urethra into the bladder.

  Removing the lesion should also include a sample of the underling muscle tissue to check for muscle invasion
• Management of bladder cancer depends on whether the tumour is muscle-invasive or non-muscle-invasive, and should always involve multidisciplinary team (MDT) discussion.
• Urothelial carcinoma:

  • Most arise primarily in the bladder
  • But also occur in the pelvicalyceal system, ureters, and rarely in the urethra
• Upper tract lesions can cause obstruction caused by tumour growth

  Very occasionally may cause ureteric colic and long stringy clots are seen in the urine

  Bladder tumours arising near a ureteric orifice can obstruct a ureter causing hydronephrosis

  Bladder tumours also predispose to infection - unexplained recurrent urinary tract infections need investigating
• Complications from invasive disease and metastatic spread include:

  • On-going urinary symptoms (e.g. haematuria, urinary incontinence, dysuria, urinary frequency)
  • Loin pain and ureteric obstruction
  • Hydronephrosis
  • Intractable haematuria: especially if the patient has received radiotherapy
  • Pelvic pain
• Prognosis:

  • superficial tumours = 5 year survival 80-90%
  • recurrent superficial tumour = 70%
  • Muscle invasive = 30-60%
  • Metastatic disease = 10-15%
• Management of non-muscle-invasive bladder cancer:

  • Cystoscopy - TURBT and give single dose of intravesical mitomycin C
  • Depending on histology results and whether moderate or high risk may be offered further mitomycin C, intravesical BCG, repeat TURBT, radical cystectomy, chemotherapy
• Management of muscle-invasive bladder cancer:

  • Cystoscopy - TURBT and give single dose of intravesical mitomycin C
  • Management is complex - radical cystectomy or radical radiotherapy, plus chemotherapy
• Management of advanced/metastatic bladder cancer:

  • Chemotherapy if fit enough
  • Palliative care input
  • Manage symptoms e.g. pain, bleeding
  • Nephrostomy and stents for obstruction
• Trans-urethral resection of bladder tumour (TURBT)

  • Can do this during cystoscopy
  • Resect lesion from bladder, ensuring to obtain some detrusor muscle too to work out if cancer is muscle-invasive
  • Main treatment for non-muscle-invasive bladder cancer
• Intravesical Bacillus Calmette-Guerin (BCG):

  • As well as a vaccine for TB, can also be used as immunotherapy in bladder cancer
  • Patient catheterised, BCG put through catheter and left in there a few hours until the patient next passes urine
  • Causes stimulation of immune cells in the bladder which grow and become active and destroy cancer cells
• Intravesical mitomycin C:

  • Antibiotic used as chemotherapy drug
  • Put into bladder via catheter