Bladder Cancer refers to the abnormal increase in the size and number of cells of the bladder. It can be restricted to the inner most layer of the bladder or can involve all the layers of bladder and spread to nearby organs like reproductive system, intestines, lungs, bones etc.
A urinary bladder is a hollow reservoir where urine is collected before it is expelled out through the urethra. The innermost layer of the bladder is called the endothelium or the urothelium. After that, is a layer of loose connective tissue called as lamina propria. The smooth muscle of the bladder lies outside the lamina propria. The bladder muscle is surrounded by a layer of fat.
Most of the times the cancer is limited to the urothelium and very rarely it invades the lamina propria and the muscular layer.
A person with bladder cancer may complain of blood in urine, pain during urination and increased frequency of urination. A CT scan of the bladder and urine analysis can help to diagnose and confirm the condition.
Treatment of the bladder cancer depends on the stage of cancer. If it is diagnosed recently and is superficial, then chemotherapy, radiotherapy, laser or tumor resection techniques are used. In case the bladder cancer is large, invasive or at multiple places in the bladder wall, then partial or complete cystectomy may be the only option available. This can be combined with postoperative radiotherapy and chemotherapy to restrict the spread of cancer to surrounding organs or limit its recurrence.
Treatment of Bladder Cancer at Super Speciality Hospital in India
Bladder Sparing Surgery: This involves using a combination of chemotherapy and radiotherapy to destroy the cancer cells locally and also if they have spread to other parts of the body. Transurethral resection of bladder tumour and partial removal of bladder are also types of bladder sparing surgeries which are used when the tumor is superficial or minimally invasive. These treatment techniques can be used in combination with each other.
a) Drug therapy and radiation therapy prior to surgery: can shrink the tumour and possibly completely eliminate the cancer. This technique is still in the experimental stage and can hope to offer patients an effective alternative to removing the bladder and an improved quality of life. Radiation therapy involves the use of focused high energy x-rays to destroy cancer cells. The x-rays are delivered from a machine that is outside of the patient. The damaging effect of radiation is cumulative, and a certain dose is required to stop the growth of cancer cells. In order to accomplish this, small radiation doses are administered for a few seconds each day (similar to having an x-ray), five days per week, for several weeks. Treatment is not painful.A chemotherapy drug, such as cisplatin, is usually given once every three weeks into a vein during radiation therapy. Cisplatin makes the tumor cells more sensitive to the radiation treatment, improving the chance of eliminating the cancer. The combination of chemotherapy and radiation therapy is associated with improved cancer control in the bladder and pelvic region compared to radiation therapy alone.
b) Intravesical chemotherapy and immunotherapy: Following removal of tumour by TURBT, intravesical chemotherapy or intravesical immunotherapy may be used to try to prevent tumour recurrences. Intravesical means "within the bladder". These therapeutic agents are put directly into the bladder through a catheter in the urethra (the catheter only stays in for a few minutes), are retained for one to two hours and are then urinated out.
Transurethral resection of bladder tumor: This surgery is performed under general or spinal anesthesia. It is a minimally invasive surgery. A thin slender fiber optic tube with a camera at one end called the cystoscope is inserted through the urethra into the bladder. The camera sends images of the size and location of cancer tissue within the bladder. Once the tumor location is confirmed, a thin wire loop is inserted through the cystoscope into the bladder. The loop scrapes of the tumor cells present in the urothelium. This tissue can then be sent for biopsy to grade the tumor.
d) Laser removal: If the tumor cells have invaded into the next layer, but are still localized to the bladder, the high frequency energy can be emitted to the area using a laser probe. The laser probe is inserted through the cystoscope and directed towards the cancerous are in the bladder. High energy radiation destroys the tumor cells completely in that area.
e) Partial cystectomy: This involves partial removal of the bladder wall and is performed when the tumor has invaded the bladder muscle. The affected portion of the wall is cut and removed and the remaining portion of the bladder is stitched up. This surgery reduces the bladder capacity as well as it contractile efficacy.
Neobladder or Urine diversion techniques: This is required after radical cystectomy or complete removal of bladder in cases where the tumor has penetrated the bladder wall and spread beyond it
a) Ilieal Conduit: A short piece of the intestine from the end of the small intestine or the colon is removed and connected to the ureters. This creates a passageway, known as an ileal conduit, for urine to pass from the kidneys to the outside of the body. Urine flows from the kidneys through the ureters into the ileal conduit. The conduit is connected to the skin on the front of the abdomen by an opening called a stoma (also known as a urostomy). After this procedure, a small bag is placed over the stoma to collect the urine, which comes out continuously in small amounts. The bag then needs to be emptied once it is full.
b) Continent Diversion: A valve is created in a pouch made from the piece of intestine. The valve allows urine to be stored in the pouch. The pouch is connected to the ureters. It is emptied several times each day by placing a drainage tube (catheter) into the stoma through the valve. Some patients prefer this method because there is no bag on the outside and they can control the emptying of the bag.
c) Neobladder or Reconstructive Surgery: A urinary reservoir resembling the bladder is made from a piece of small intestine or colon. The ureters are connected to the neobladder and the neobladder is sewn to the urethra. This allows the patient to urinate normally.
Radical Cystectomy
If the cancer is larger or is in more than one part of the bladder, a radical cystectomy or complete removal of the bladder is needed. This operation removes the entire bladder and nearby lymph nodes. In men, the prostate is also removed. In women, the ovaries, fallopian tubes (tubes that connect the ovaries and uterus), the uterus (womb) and a small portion of the vagina are often removed along with the bladder. These surgeries are typically done through a cut (incision) into the abdomen while the patient is placed under general anesthesia. The patient needs to stay in the hospital for about a week after the surgery. The patient can usually go back to his normal activities in 4 to 6 weeks.
Laparoscopic Radical Cystectomy
In some cases, the surgeon may operate through several smaller incisions using special long, thin instruments, one of which has a tiny video camera on the end to see inside the pelvis. This is known as laparoscopic, or “keyhole” surgery. The surgeon may either hold the instruments directly or may sit at a control panel in the operating room and maneuver robotic arms to do the surgery. If it can be done, laparoscopic surgery may result in less pain and quicker recovery after the operation (due to the smaller incisions). But it has not been around as long as the standard type of surgery and it’s not yet clear if it is equally as effective. This technique is still in its infancy and is not practiced very commonly.
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