The bladder is a hollow organ in the lower part of the abdomen . The shape is like a small balloon and has a muscular wall that allows it to get larger or smaller. The bladder stores urine until it is passed out of the body. Urine is the liquid waste that is made by the kidneys when they clean the blood . The urine passes from the two kidneys into the bladder through two tubes called ureters . When the bladder is emptied during urination, the urine goes from the bladder to the outside of the body through another tube called the urethra .
Bladder cancer accounts for approximately 70,000 new cases of cancer per year with approximately 15,000 deaths each year attributable to the disease. There are three types of bladder cancer that begin in cells in the lining of the bladder. These cancers are named for the type of cells that become malignant (cancerous):
Cancer that is confined to the lining of the bladder is called superficial bladder cancer. Cancer that begins in the transitional cells may spread through the lining of the bladder and invade the muscle wall of the bladder or spread to nearby organs and lymph nodes ; this is called invasive bladder cancer. Fortunately, two-thirds of the newly diagnosed bladder cancers occur only on the lining of the bladder (superficial bladder cancer) and can be treated effectively by the urologic surgeons at The University of Kansas Hospital.
Blood in the urine (called hematuria) is usually the first sign of bladder cancer. Other symptoms which may not be recognized initially include the need to urinate frequently both day and night, and the inability to hold the urine once the urge to urinate occurs. A simple test called cystoscopy, performed in the clinics at KU can usually diagnose the cancer. Our physicians are experts in the diagnosis of bladder cancer as well as its treatment. In addition, they employ a number of methods to keep those with superficial bladder cancer from recurring.
For those patients in whom the cancer is invasive (into the muscle wall of the bladder) surgery to remove the entire bladder (cystectomy) is often needed. The urologic oncologists at KU will employ options to preserve the bladder when possible (bladder sparing), however if removal is needed they have one of the nation’s largest experiences.
For patients whose bladder must be removed surgeons must create a new way for the body to store and empty urine. The urologic oncologists at KU are well versed in the different urinary diversion options. One such option performed by our urologists is the construction of a “new” bladder using intestine called a neobladder. This allows patients to urinate in a normal fashion. The Department of Urology at KU has had good success with these reconstructive techniques since their inception.
Unfortunately, some patients will have bladder cancer that has spread beyond the bladder (to the lungs, liver or bones) prior to surgery or after the removal of the bladder. Dr. Peter Vanveldhuizen, is a medical oncologist who specializes in the treatment of urologic malignancies and has a vast experience in the treatment of metastatic bladder cancer. Working closely with the urologic oncologists at KU, Dr. Vanveldhuizen provides the latest and most advanced chemotherapy for the treatment of bladder cancer.
Risk factors for bladder cancer include the following:
Smoking is the most common cause of bladder cancer. It is rare that patients who are not smokers develop bladder cancer. It takes 20 years of not smoking before the risk begins to decrease. However, patients who continue to smoke after being diagnosed with bladder cancer do much more poorly than those who quit. So quitting smoking is an essential part of being treated for bladder cancer. Your physician has many ways to assist you with this.
Other risk factors.
Being exposed to certain substances at work, such as rubber, certain dyes and textiles, paint, and hairdressing supplies. Chronic irritation of the bladder from infection or long term catheterization
Certain factors affect prognosis (chance of recovery) and treatment options.
The stage of the cancer (whether it is superficial or invasive bladder cancer, and whether it has spread to other places in the body). Bladder cancer in the early stages can often be cured.
The type of bladder cancer cells and how they look under a microscope, we call this the Grade of the cancer. Typically bladder cancers are referred to as High Grade or Low Grade. Most invasive bladder cancer's are High Grade.
The patient's age and general health.
Treatment options depend on the stage of bladder cancer.
Your stage of bladder cancer is determined by several tests.
- Cystoscopy and transurethral resection of the tumor. This is a biopsy of the tumor and will help to determine the stage (how deep the cancer is penetrating) and the grade (how aggressive is the tumor)
- A CT scan will determine if the cancer has spread outside of the bladder or to any other organs.
- A bone scan may be used if the tumor is larger or appears very aggressive or if the CT scan detects cancer outside of the bladder.
- PET scans are occasionally used but only rarely. This is because not all bladder cancers show up on PET scans. In addition, most insurance companies will not pay for PET scans which currently remain very expensive (about $3,000.00).
The following stages are used for bladder cancer:
Stage 0 (Papillary Carcinoma and Carcinoma in Situ) In stage 0, abnormal cells are found in tissue lining the inside of the bladder . These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is divided into stage 0a and stage 0is, depending on the type of the tumor:
Stage I: In stage I , cancer has formed and spread to the layer of tissue under the inner lining of the bladder .
Stage II: In stage II , cancer has spread to either the inner half or outer half of the muscle wall of the bladder .
Stage III: In stage III , cancer has spread from the bladder to the fatty layer of tissue surrounding it and may have spread to the reproductive organs ( prostate , seminal vesicles , uterus , or vagina).
Stage IV: In stage IV , cancer has spread from the bladder to the wall of the abdomen or pelvis . Cancer may have spread to one or more lymph nodes or to other parts of the body.
One of the following types of surgery may be done:
- Transurethral resection (TUR) with fulguration: Surgery in which a cystoscope (a thin lighted tube) is inserted into the bladder through the urethra under general anesthesia or spinal anesthesia in the operating room. A tool with a small wire loop on the end is then used to remove the cancer or to obtain a specimen for diagnosis. Your surgeon will attempt to remove the entire tumor if possible but some very large tumors cannot be removed by TUR.
Patients whose cancers are not invasive into the muscle wall of the bladder are candidates for intravesical treatments. These are medications given to the patient as instillations inside the bladder to help prevent or delay the recurrence of the cancer. Examples of these medications include Mitomycin-C, BCG, Valrubicin, and Gemcitabine. The urologic oncologists at KU are experts in administering intravesical treatments for bladder cancers.
- Radical cystectomy: Surgery to remove the bladder and any lymph nodes and nearby organs that contain cancer. This surgery may be done when the bladder cancer invades the muscle wall, or when superficial cancer involves a large part of the bladder. In men, the nearby organs that are removed are the prostate and the seminal vesicles . In women, the uterus , the ovaries , and part of the vagina are removed. Sometimes, when the cancer has spread outside the bladder and cannot be completely removed, surgery to remove only the bladder may be done to reduce urinary symptoms caused by the cancer. When the bladder must be removed, the surgeon creates another way for urine to leave the body. The urologic oncology surgeons in the Department of Urology at the University of Kansas Hospital have one of the nation's largest experiences in performing cystectomy.
- Segmental or Partial cystectomy: Surgery to remove part of the bladder. This is a rarely performed procedure used mostly for adenocarcinomas of the bladder or in patients with a single tumor that cannot be removed completely by TUR.
- Urinary diversion: Surgery to make a new way for the body to store and pass urine. There are several different types of urinary diversions which include a neobladder ( a new bladder made out of intestine), a continent catheterizable diversion ( a pouch out of intestine with an opening on the skin through which you catheterize) and an ileal conduit which is a piece of intestine which allows urine to drain into a bag which fits on the skin. Your doctor and you will make the decision as to which is the best option for you.
An ileal conduit is a piece of small intestine (ileum) that is harvested from your own intestinal tract. It is usually about 12cm in length. The remaining bowel is reconnected at the time of surgery so that stool continues normally. Most patients have no side effects from the removal of 12cm of small intestine, although rarely some patients may have chronic diarrhea. This can be treated and should be brought to the attention of your doctor.
The small piece of intestine is connected to the ureters (the tubes from the kidneys through which the urine drains). This connection is inside the abdomen. The other end of the intestine is brought up to the surface of the skin as a stoma.
A stoma is a small piece of intestine open in the middle allowing urine to flow out of the body into a bag which fits around the stoma.
Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy after surgery to kill any cancer cells that are left. Treatment given after surgery, to lower the risk that the cancer will come back, is called adjuvant therapy . This is determined after surgery by the results of the pathology. Typically adjuvant chemotherapy is used when the cancer has grown into the fatty tissue around the bladder (Stage III) or has spread to the lymph nodes (Stage IV).
Dr. Jeffrey Holzbeierlein , a national expert, and Dr. Moben Mirza are fellowship trained urologic oncologists with expertise in the diagnosis and treatment of bladder cancer. These University of Kansas Urologic cancer surgeons are now performing many bladder cancer surgeries robotically. With the recent advancements in robotic technology, our urologists are now performing this complex operation with the aid of the DaVinci robot. This allows greater visualization and less blood loss. In addition, we hope that this may lead to a quicker recovery and time to return to normal activities. The University of Kansas urologists perform more bladder removal surgeries than any other urologist or institution in the Kansas City area and continues to examine ways to decrease the side effects associated with this procedure.
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. Radiation treatments by themselves are not usually effective in getting rid of the cancer and thus are usually combined with chemotherapy (given through an IV). Most studies suggest that this approach is inferior to surgical removal of the bladder, but does have the advantage of “sparing” the bladder.
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. For invasive bladder cancer, the chemotherapy is given through the vein (intravenously) and is referred to as systemic chemotherapy. The most common type of chemotherapy for bladder cancer is gemcitabine (Gemzaar) and cisplatin. Chemotherapy is sometimes given prior to bladder removal (neoadjuvant chemotherapy) this is typically done when the doctor feels that the cancer is not confined to the bladder. Sometimes chemotherapy is given after bladder removal (adjuvant chemotherapy) when the pathology determines that cancer cells have grown into the fatty tissue around the bladder, into the prostate, or into the lymph nodes. Lastly, chemotherapy may be given if after surgery the cancer returns in another part of the body (salvage chemotherapy).
Follow-up tests may be needed.
Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Your doctor will usually want a CT scan within one month of a bladder removal surgery. If you are to receive chemotherapy first or are receiving chemotherapy and radiation some tests will be repeated in order to see how well the treatment is working (CT scan and cystoscopy). Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.
After bladder cancer surgery some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups. The frequency of these tests depends upon the stage and grade of your tumor.
In addition, your doctor will ask you to see an anesthesiologist prior to surgery. The anesthesiologist is the doctor in charge of putting you to sleep for the surgery and will need to evaluate you before surgery. Your doctor may also ask you to see a cardiologist (heart specialist) prior to surgery based on your other health problems or your age. A pulmonologist may also be needed before surgery if you have lung problems such as asthma, emphysema or COPD.
The primary purpose of a radical cystectomy is to cure the cancer by completely removing organs that have cancer cells or nearby organs where cancer cells are likely to grow. Your surgeon will then use part of your intestine to either make a new bladder (called a neobladder) or an ileal conduit. In doing these surgeries, you surgeon will preserve as much of your normal function as possible. Typically, in men the prostate is removed because of the chance (25%) of bladder cancer involving the prostate. Similarly in women the uterus, ovaries, and sometimes part of the vagina is removed in order to remove all of the cancer. The removal of these other organs can be associated with sexual side effects, such as the loss of erections in men or decreased sensitivity in women.
The type of urinary diversion will be up to you and your doctor to decide. The neobladder has the advantage of having no bags or appliances that fit to the body and represents the most “normal” reconstruction. However, it takes some retraining during which time you will experience leakage of urine. In addition, you will be required to catheterize the new bladder for the first month after all catheters are removed. The ilea conduit has the advantage of being the simplest to take care of but does require the changing of bags attached to the skin for the rest of your life. However, both options will allow you to participate in essentially any activity you wish to including swimming.
Most people have serious concerns about possible side effects and life changes after this surgery. Remember doctors and researchers are still learning about the treatment of bladder cancer. Talk with your surgeon any time you have concerns or questions.
For patients with bladder cancer who require a cystectomy (bladder removal) and need to review post op care from surgery - please see the patient support section of our website