The bladder
The bladder is a hollow, muscular, balloon-like organ that stores urine. It sits in the lower part of the abdomen.
The bladder is made up of three main tissue types:
- The innermost layer is the mucous membrane (urothelium).
- Surrounding the mucous membrane is strong tissue known as the lamina propria.
- The outermost layers are thick, protective muscle tissue, which is covered by a layer of fat.
The kidneys produce urine, which is carried to the bladder by tubes called ureters. When the bladder is emptied, urine passes through a tube called the urethra and out of the body.
In women, the urethra is a very short tube and opens in front of the vagina (birth canal).
In men, the tube is longer and passes through the prostate and down the penis.
What is bladder cancer?
Bladder cancer is when cells in the bladder grow uncontrollably and can possibly spread through the bladder and into other parts of the body.
Nearly all bladder cancers begin in the innermost layer of the bladder (mucous membrane). In some cases, the cancer may progress by growing into the deeper layers of the bladder wall.
Bladder cancers can be divided into two categories:
- Non-invasive tumours: the cancer is only found in the lining of the bladder. Sometimes these are called superficial tumours because the cancerous cells have not invaded deeper layers of the bladder. This does not necessarily mean the cancer is not serious.
- Invasive tumours: the cancer has spread beyond the lining of the bladder, either into the lamina propria, the muscle, or through the bladder wall. All invasive tumours are serious.
Types of bladder cancer
The three main types of cancers affecting the bladder are:
- urothelial carcinoma or transitional cell carcinoma (more than 90% of all cases)
- squamous cell carcinoma (1%)
- adenocarcinoma (1-2%).
Most – but not all – urothelial tumours are non-invasive (superficial) and do not spread to deeper layers of the bladder or other organs. There are several sub-types, depending on their shape and how invasive they are.
Squamous cell carcinomas and adenocarcinomas are almost always invasive.
How common is it?
Around 790 people are diagnosed with bladder cancer in NSW each year, according to the latest figures (2004).
More than 85% of bladder cancers at diagnosis are non-invasive.
Diagnosis
Tests to diagnose bladder cancer
Urine test
- Can show the presence of cancerous or precancerous cells.
- Can be examined for bacterial infection to eliminate cancer.
Blood test
- Shows whether different blood cell types are normal in number or appearance.
- Can indicate how well different organs are working.
Physical examination
- A rectal examination helps determine if there is anything unusual in the bladder area.
- In women, a vaginal examination can determine the size of a tumour and whether it has spread.
Cystoscopy
- This is the main diagnostic tool for bladder cancer, allowing the doctor to see inside your bladder by placing a cystoscope (tube with a lens and light) through the urethra.
- This procedure is usually done as day surgery under anaesthetic.
- If an obvious cancer is found, it can be removed at the same time.
Biopsy
- If suspicious growths are seen, a small piece of tissue is removed for examination under a microscope to see if there are any cancer cells.
Intravenous pyelogram (IVP)
- A type of x-ray procedure to view unusual changes in the urinary system.
- A dye is injected into a vein and travels through the bloodstream to the kidneys, ureters and bladder to show these organs clearly on the x-rays.
- You may feel hot and flushed, with discomfort in your abdomen, for a short time.
- Let your doctor know if you have an allergy to iodine as you may also be allergic to the dye.
Ultrasound scan
- A scan that uses soundwaves to create a picture of the abdomen and liver.
- It takes around 15 minutes and is painless.
- Gel is spread on the abdomen and a small device moved across it.
- It will show if cancer is present and how large it is. It may miss small tumours.
CT scan
- Uses x-ray beams to compile pictures of the body.
- You may have an injection of a special dye into your veins before the scan, which helps highlight unusual changes.
- You will be asked to lie still on a table while the CT scanner slowly moves around you.
- It can help diagnose cancer and show if it has spread.
Chest x-ray
- A chest x-ray may be taken to check the lungs for signs of cancer.
Radioisotope bone scan
- A small amount of radioactive liquid is injected into a vein in the arm.
- The radioactive substance collects in areas of abnormal bone growth.
- A scanner measures the radioactivity levels in the areas and records them on x-ray film.
- This is a long procedure as the scan needs to be taken a few hours after the dye has been injected.
A small amount of radioactive material is used, so it is safe to be with others after a few hours (except pregnant women and young children).
Staging and grading bladder cancer
Staging and grading bladder cancer helps your health care team work out what treatment is best and what your prognosis is.
Staging tells the doctor how far the cancer has spread.
The most common staging system used for bladder cancer is known as the TNM system:
- T (Tumour) indicates the depth of the tumour invasion.
- N (Nodes) indicates whether the lymph nodes are affected.
- M (Metastasis) indicates whether the cancer has spread to other parts of the body.
Grading describes how fast cancer cells are likely to grow.
There are two main grades for bladder cancer:
- Low-grade: cancer cells look fairly normal, behave similarly to normal cells and grow slowly.
- High-grade: cancer cells look very abnormal and grow quickly and chaotically.
Prognosis
Prognosis means the expected outcome of a disease.
Bladder cancer can be effectively treated if it is found early, before it spreads outside the bladder.
You can discuss your prognosis with your doctor, but it is not possible for anyone to give you an accurate prediction on the course of the illness. The rate and growth of the cancer, your treatments and how well you respond to them, and other factors such as age, fitness and medical history are all important factors in assessing your prognosis.
Which health professionals will I see?
Your GP will arrange the first tests to check out your symptoms.
If these tests do not rule out cancer, your doctor will refer you to a specialist, who will arrange further tests and advise you about treatment options.
Health professionals who may care for you include:
- urologist – a surgeon who specialises in diseases of the urinary tract
- medical oncologist – responsible for chemotherapy
- radiation oncologist – responsible for radiotherapy
- nurses – support and assist you through all stages of your cancer
- stomal therapy nurse – assists in support and care relating to a stoma
- dietitian – recommends the best eating plan to follow during and after treatment
- social worker, physiotherapist and occupational therapist – link you to support services and help you get back to normal activities.
Treatment
Surgery for non-invasive bladder cancer
Surgery is used alone or with other treatments.
A transurethral resection (TUR) is the main type of surgery. This is done under a general anaesthetic. A cystoscope (a tube with a light and lens) is passed through the urethra into the bladder. The cystoscope has a wire loop or laser which allows the doctor to remove the tumour. The cystocope can also burn any remaining tumour at its base (fulguration).
Immunotherapy for non-invasive bladder cancer
Immunotherapy encourages the body’s own natural defences to fight the disease. It is the main way of treating:
- carcinoma in-situ (CIS), which is an aggressive type of superficial cancer
- invasive cancer that has grown into the lamina propria but not the muscular layer of the bladder.
Bacillus Calmette-Guerin (BCG) is the most effective immunotherapy. It is given directly into the bladder through a flexible tube called a catheter. It is usually administered once a week for six weeks. Sometimes long-term BCG therapy is used. This is called maintenance treatment.
Intravesical chemotherapy for non-invasive bladder cancer
Chemotherapy is the treatment of cancer with anti-cancer drugs.
In intravesical chemotherapy the drugs are put directly into the bladder using a flexible tube called a catheter. This is called an installation. You may have one installation at the time of surgery, or weekly installations over about six weeks.
An advantage of intravesical chemotherapy is that the drugs stay in the bladder and don’t usually spread throughout the body. This limits the unwanted side effects that can occur when chemotherapy is given orally or intravenously (via the veins).
Surgery for invasive bladder cancer
A cystectomy is done when the cancer is too large to be removed by a cystoscope (used in non-invasive bladder cancer), or if the cancer has invaded the muscular layer of the bladder wall.
Partial cystectomy: removes part of the bladder.
Radical cystectomy: removes the whole bladder and nearby lymph nodes. In men, the prostate and sometimes the urethra are removed. In women, the uterus (womb), ovaries, some of the vagina and the Fallopian tubes are often removed.
In a partial cystectomy, your bladder will be smaller and hold less urine, so you may need to pass urine more often.
In a radical cystectomy, a new bladder will be created to store and remove urine.
Reconstructive surgery
If you have had a radical cystectomy, reconstructive surgery will allow you to store urine with a urinary diversion or a neobladder.
Urostomy or urinary diversion
A urostomy or a urinary diversion is the most common way to store urine after a radical cystectomy.
- Urostomy: urine drains into a bag attached to the outside of the abdomen in an ileal conduit procedure. The doctor uses a piece of your small intestine (ileum) to create a passageway (conduit) that connects between the ureters and an opening on the outside of the body (stoma). A watertight bag is placed over the stoma to collect the urine.
- Continent urinary diversion: urine drains into a pouch within the abdomen. The doctor uses a piece of intestine to form a pouch with a valve in it so the urine can be stored within the abdomen and then drained via a stoma throughout the day.
Before the operation, the doctor or stomal therapy nurse will plan the position of your stoma, taking into account any wrinkles, scars or prominent underlying bones. These must be avoided, as placing the stoma near them may cause leakage later on.
Neobladder
Another way of making a storage place for urine is to use a segment of the bowel to make a new bladder called a neobladder. This usually means you can urinate as usual, without the need for a stoma.
Your doctor will use about 60cm of the small intestine to make a new bladder, which is connected to the top of your urethra. The ureters are stitched into the new bladder so that urine drains directly into it from the kidneys. For some people, a catheter is needed to drain the neobladder, as the pouch doesn’t empty completely.
A neobladder is not suitable for everyone.
Radiotherapy
Radiotherapy uses radiation to kill cancer cells or injure them so they cannot multiply.
Radiotherapy may be used to treat invasive bladder cancer so the bladder does not have to be removed. Usually chemotherapy is given with radiotherapy so the cells will be made more sensitive to the radiation.
The course of treatment is usually five sessions from Monday to Friday, for several weeks. The length of treatment will depend on the type and size of the cancer.
Systemic chemotherapy
Chemotherapy is the use of anti-cancer drugs, which aim to kill cancer cells while doing the least possible damage to normal cells. It may be helpful for some people with invasive bladder cancer.
For invasive bladder cancer, the drugs are given intravenously (by injection into a vein). A course of several drugs is given over a few days. This is repeated every few weeks for several months. This type of chemotherapy is sometimes called systemic chemotherapy to distinguish it from intravesical chemotherapy, which is used to treat non-invasive (superficial) bladder cancer.
You may have systemic chemotherapy:
- before surgery to shrink the cancer and make it easier to operate
- after surgery if there is a high risk of the cancer coming back
- with radiotherapy
- if the cancer has spread to other parts of the body.
Palliative treatment
Palliative treatment helps improve quality of life by alleviating the symptoms of cancer without trying to cure the disease. It is particularly important for people with advanced cancer.
Sometimes treatment is concerned with pain relief and stopping the spread of cancer. In other cases, it manages emotional symptoms of cancer.
Treatment may include radiotherapy, chemotherapy and other medication.