Bladder (Urothelial) Cancer

Signs and Symptoms:

Bladder cancer most commonly presents due to blood in the urine (hematuria). Hematuria may be either gross (visible to the patient) or microscopic (detected by microscopic examination of the urine). A small number of patients with bladder cancer present with symptoms of urgency, frequent urination, or pain with voiding (known collectively as irritative voiding symptoms). Rarely, bladder cancer is detected on CT scan which was performed during evaluation of an unrelated problem.

Blood in the urine always demands evaluation by a urologist. Hematuria due to bladder cancer is typically intermittent- it frequently stops temporarily without treatment. Often, blood in the urine is attributed to urinary tract infection, especially when the patient has irritative voiding symptoms. If a patient has irritative voiding symptoms and blood in the urine, urinary infection must be confirmed by performing a urine culture. Otherwise, patients with painless hematuria need to undergo upper urinary tract imaging and cystoscopy. Anticoagulants such as aspirin, coumadin, and Plavix usually do not cause blood in the urine; consequently, patients who are diagnosed with hematuria must undergo examination as noted above.

Incidence:

There are 55 thousand new cases and 12 thousand deaths attributed to bladder cancer in the United States each year.

The average age at the time of diagnosis of bladder cancer is 66 and the ratio of males to females with bladder cancer is 2:1. Women, though less frequently affected, typically present more advanced bladder cancer. This is probably due to menopausal women being less alarmed by the signs and symptoms related to voiding abnormalities (hematuria, incontinence, and urinary tract infections) whereas these symptoms are much less common in similar aged men prompting medical evaluation sooner in the course of the disease.

Bladder cancer arises from the lining membrane of the bladder (the urothelium). The urothelium forms the lining of the entire urinary tract from the kidneys, through the ureters (the 10 in. tubes through which urine passes from kidney to bladder), the bladder, the urethra (the tube through which the bladder empties). Risk factors associated with bladder cancer (smoking, radiation, chronic infection, exposure to aniline dyes) increase the risk of urothelial cancers throughout the urinary system- but bladder cancer is the predominant site of urothelial carcinoma.

Diagnosis:

The Diagnosis of bladder cancer is made by cystoscopy (telescope designed to go through the urethra into the bladder) and confirmed by biopsy and/ or urine cytology.

Prior to cystoscopy, a CT urogram is performed to image the entire urinary system. This scan can identify lesions in the urinary tract above the bladder that might require more complicated diagnostic procedures and provides an assessment of the stage of bladder cancer (invasion through the bladder wall or spread of cancer to the lymph nodes). If bladder cancer is confirmed, then a bone scan is performed to assess the possibility of cancer spread to the bone in high risk patients (see below).

Cancer Stage and Grade:

All cancers are staged based upon the extent of disease. This staging process assesses the primary bladder tumor and any cancer that has spread (metastasis) beyond the bladder. The bladder cancer is given a T stage related to the depth of invasion of the tumor which originates in the lining mucosa. Ta is a tumor limited to the lining membrane (mucosa), TIS signifies a high grade cancer limited to the mucosa, T1 tumor indicates invasion into the bladder layer immediately beneath the mucosa (lamina propria), T2 indicates tumor growth into the bladder muscle, T3 cancer grows through the bladder wall into the fat around the bladder, and T4 tumor grows through the bladder wall and into adjacent organs (in men: rectum, sigmoid colon, prostate, pubic bone; in women: vagina, cervix and uterus, sigmoid colon, and pubic bone).

The presence of lymph node metastasis may be detected by CT scan but usually requires removing the lymph nodes so that they can be analyzed by the pathologist. This is only required in high grade high stage tumors. Lymph node status is designated as follows: NX (lymph node status not known), NO (lymph nodes removed and no cancer is present), N1, N2, N3 (increasing the number of involved lymph nodes and/or increasing size of the lymph nodes involved).

Bladder cancer most commonly spreads to the lungs, liver and bones. The M-category (metastasis) status is the final component of staging: MX signifies distant metastasis not assessed, MO indicates no distant metastasis found, and M1 distant metastasis are present.

Grade: Tumor grade is based upon the appearance of the tumor cells under microscopic examination by the pathologist and correlates with the cancers behavior in terms of growth rate and predilection for metastasis. In bladder cancer, tumors are graded either high (more aggressive) or low (less aggressive). The treatment selection is based on stage and grade.

Treatment:

The most common category of bladder cancer is low stage (no evidence of metastasis), low grade disease. The primary symptom is blood in the urine prompting cystoscopy and diagnosis. Management consists of tumor resection using trans-urethral techniques (telescope surgery), ideally with complete rermoval. Following recovery, patients with high grade or recurrent disease receive intravesical chemotherapy- chemotherapy instilled in the bladder through a catheter. This is performed in the office as an outpatient treatment procedure. The benefit of intravesical chemotherapy is the lack of systemic side effects (no change in immune system, no loss of hair, no decrease in blood counts). In general, such patients do not die of their bladder cancer.

However, bladder cancer can occur in other sites or reoccur in the bladder (75%), and all patients undergo routine surveillance with cystoscopy and, if indicated, CT urogram. Patients with low stage and high grade bladder cancer may suffer recurrence (up to 75%) and recurrent bladder cancers may be at a higher grade or stage. Patients with high grade tumors limited to the mucosa (lining membrane) or tumors that have infiltrated to the layer immediately beneath the mucosa (lamina propria) may require a second resection to assure that the cancer has been completely resected and confirm that staging is accurate.

The best but most toxic intravesical chemo therapy Bacillus, Calmette-Guerin (BCG) is a weakened form of tuberculosis which is instilled into the bladder several weeks after the resection and weekly for six weeks. This treatment has the highest success in preventing or delaying bladder cancer recurrence but occasionally has side effects which includes infection and inflammation.

High grade tumors may grow through the lamina propria into the bladder muscle and sometimes into the fat beyond the muscle. These tumors have a high probability of spreading. To cure the patient in this situation, the bladder and the lymph nodes must be removed if there is no evidence of spread beyond the bladder.

The treatment options for high grade, high stage tumors include surgical removal of the bladder, the anterior vaginal wall in women and the prostate in men, and the lymph nodes that drain the bladder which are the lymph nodes around the iliac artery and vein. When the bladder is removed, the patient may have a ileal neo-bladder constructed (a bowel reservoir into which the urine flows from the kidney and then voided through the natural opening or urethra) or the urine is diverted through a segment of bowel (typically ileum) which drains into a bag on the anterior abdominal wall (an ileal conduit).

Chemotherapy can improve the results in high risk bladder cancer and can be given either before the bladder is removed (neo-adjuvant chemotherapy) or after the patient has recovered from bladder removal (adjuvant chemotherapy).

Metastatic Bladder Cancer:

There are patients in whom cancer spreads into the common sites for metastatsis (lung, liver, and bone. These patients are best treated with chemotherapy.

The University of Cincinnati Urology Division is one of the leading urology programs, not just in Cincinnati, but in the U.S. UC Urology provides quality health care using the most advanced technology and state-of-the-art diagnostic treatments. Many of our urologists are recognized in multiple national and local "Best Doctors" and "Top Doctors" listings. We provide minimally invasive surgical treatments which include laparoscopic, robot-assisted laparoscopic and endourologic procedures as well as comprehensive care for all urologic conditions.