Bladder & Bladder Cancer

What is the bladder?

The bladder is the organ that sits within the bony pelvis connected to the kidneys above via the ureters and the urethra below. It is a hollow organ and acts as a reservoir for urine produced by the kidneys.

When the bladder contracts, the urine is expelled via a sphincter mechanism, down the urethra and out of the body. The outer wall of the bladder is formed by a meshwork of muscle fibres arranged in layers.

The inner wall of the bladder has a special lining called transitional epithelium, which is resistant to urine absorption.

What is bladder cancer?

Cancer develops when the cells of the body divide and reproduce in an uncontrolled manner to form a mass of tissue that can invade the surrounding organs and also spread to distant parts of the body (metastases).

The commonest type of bladder cancer is Transitional Cell Carcinoma (TCC), which arises from the inner lining of the bladder.

The majority of bladder cancers remain in this superficial lining and grow inwards towards the cavity of the bladder.

A more serious situation occurs when the cancer grows outwards into the muscle layers of the bladder.The cancer then has the potential to spread elsewhere in the body.

Am I at risk of getting bladder cancer?

Bladder cancer is the 5th commonest cancer in men and 10th commonest in women. In total more than 11 000 people are diagnosed with bladder cancer each year. Some known risk factors are as follows:

• Age: bladder cancer tends to affect an older age group and the average age at diagnosis is around 65.
• Sex: bladder cancer is more common in men compared to women. The ratio is around 3:1. This may be due to smoking and industrial exposure (see below).
• Cigarette smoking: smoking increases your risk of getting bladder cancer. Some of the additives in cigarettes can cause bladder cancer. The risk of developing bladder cancer if you smoke is 2-3 times higher than in people who don’t smoke.
• Occupational exposure: specific chemicals have been identified that are associated with an increased risk of developing bladder cancer. These include chemicals used in the dye and rubber industry, long-term exposure to some hair dyes and workers in the petroleum and PVC industries.
• Family history of bladder cancer: several genes have been identified as being important in the development of bladder cancer.
• Cyclophoshamide: this is used in some chemotherapy treatments and has been associated with bladder cancer.
• Chronic bladder inflammation: if the bladder is chronically irritated (for instance, recurrent urinary tract infections, bladder stones or long term catheterization) bladder cancer can occasionally develop. This is usually a Squamous Cell Carcinoma (SCC) which is more common in skin cancers, again due to chronic irritation.

What are the symptoms of bladder cancer?

The commonest symptom of bladder cancer is passing blood in the urine (haematuria).

This may range from a pinkish colour of the urine to an obvious deep red colour. You may experience dysuria (pain on urination). Some patients present with lower urinary tract symptoms such as frequency, urgency or nocturia.

How is the diagnosis usually made?

Patients usually consult their GP with one or more of the symptoms described.

Your doctor will take a clinical history, including any risk factors. You will be asked to provide a urine sample, which will be tested for blood cells and sent off for microscopic examination.

Your doctor will examine you and this may include a rectal or vaginal examination. If there is any blood in the urine or a suspicion of bladder cancer your GP will then refer you to a urologist.

At the consultation with your urologist, the clinical history and examination will be confirmed.

Are there any other investigations?

Once you have consulted with your urologist, a number of tests may be ordered. These include one or more of the following:

• Urine tests. A number of urine tests will be used to exclude infection or abnormal cells within your urine.
• Blood tests. A number of blood tests may be ordered that will check how well your kidneys are functioning and to see if you are anaemic.
• An ultrasound of your urinary tract. This is to look at your kidneys and your bladder to see if there are any obvious abnormalities to be found.
• KUB X-ray. KUB stands for kidney, ureter and bladder and it is a plain film to look at the urinary system and the abdomen as a whole. This plain X-ray usually reveals any obvious calcifications or stones within the urinary system that may be causing the blood in the urine.
• Flexible cystoscopy. This is a test using a small telescope to examine the urethra and bladder to check for any obvious causes of your bleeding.
• Intravenous urogram (IVU). This is a special X-ray test where some dye is injected into the arm and a series of x-rays are taken to outline the urinary tract. As the dye passes out in the urine, images of the kidneys, ureter and bladder can be seen and any abnormalities can be detected.
• CT scan. This is a special type of x-ray scan whereby the urinary tract is examined again for any abnormalities. Dye is usually injected into a blood vessel of the arm to outline the system.

What is a bladder biopsy?

At the time of cystoscopy you may be informed that you have a growth within the bladder. This may be a bladder cancer, however until it is examined under the microscope your urologist will not know for sure.

If necessary, a small piece of tissue can be removed at the time of cystoscopy, which can then be examined more fully. If bladder cancer is detected under the microscope you will be advised to have a rigid cystoscopy, which is carried out under general anaesthetic.

At this time, a proper assessment of the bladder cancer can be made and removal of the growth is usually performed (resection).

What is a TURBT?

TURBT means Trans Urethral Resection of Bladder Tumour and is carried out under a general or spinal anaesthetic.

A rigid cystoscope is passed through the urethra into the bladder and the bladder cancer growth is removed using a small wire loop, which acts a heating element.

This enables the tumour to be removed and stops any bleeding that may occur.

What is staging?

If a bladder cancer has been diagnosed, your specialist will arrange a number of investigations to try and decide whether the bladder cancer is localised to the bladder or has spread beyond the bladder wall.

By knowing the stage of the disease, your urologist can decide on the best type of further management for the bladder cancer.

What are the staging investigations?

The staging investigations include:

• A CT scan of the abdomen and pelvis
• An MRI (Magnetic Resonance Imaging) scan
• Intravenous urogram (IVU)
• Bone scan
• Chest X-ray

What treatment will I need for my bladder cancer?

The treatment of your bladder cancer will be discussed with you once the staging investigations are complete.

The treatment plan is made on an individual basis once all the risks and benefits have been discussed with you. There are many treatment options available and these include surgery, radiation therapy and chemotherapy.

Treatment can also be categorised as follows:

• Treatment for early, superficial bladder cancer
• Treatment for muscle invasive bladder cancer

Treatment for early, superficial bladder cancer

75% of bladder cancers are superficial at diagnosis. They are treated by resection using the cystoscope, under general anaesthetic.

The reason for early treatment and subsequent close monitoring is to try and prevent progression of the cancer to invasive disease.

Once you have had your tumour resected, your specialist will probably advise that you have intravesical chemotherapy, which may prevent the tumours growing back. You will be advised to have regular cystoscopies, initially at three-month intervals, to make sure that there has been no return of the tumour to your bladder.

If the bladder remains clear, the intervals between checks will increase to annual flexible cystoscopy check-ups, carried out in the outpatients department.

Treatment for invasive bladder cancer

Up to 25% of bladder cancers are invasive at diagnosis. The treatment options include surgery, radiotherapy, chemotherapy or a combination of these.

Surgery will involve removing the entire bladder (radical cystectomy) and either forming a ileal conduit, which will allow the urine to drain into an attached stoma bag or fashioning a urinary reservoir or pouch from sections of bowel.

The treatment options for invasive bladder cancer are complex and have many overlapping risks and benefits to the individual patient. For this reason, extensive explanations have not been attempted, as this should be discussed with you on an individual basis at your consultation with the specialist.

What is carcinoma in situ (CIS)?

CIS, otherwise known as flat bladder cancer, is grouped within the superficial bladder cancers.

This tumour is thought to be the product of an unstable bladder wall lining and the tumour tends to grow into the wall of the bladder rather than into the bladder cavity.

Some 25% of patients will have CIS associated with the more common superficial type of bladder cancer.

Although this is classed as a superficial cancer, there is a high risk (upto 50%) of this type of tumour becoming invasive.