A Matter of The Bladder

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Bladder cancer, also known as urothelial (cells that line the urinary tract) cancer, is fairly common and about half of the cases are not that dangerous. Formerly known as transitional cell carcinoma, urothelial cancers can occur in the bladder, ureters (tubes that connect the kidneys to the bladder), and kidneys, but by far most occur in the bladder. A common symptom of urothelial cancer is painless hematuria, or blood in the urine. Blood in the urine may be visible or the urine may look normal but test positive for blood using a dipstick or lab test. Painful urination (dysuria) and back pain may be other symptoms. Thankfully, the two other, more invasive types of bladder cancer, squamous cell and adenocarcinoma, are both exceedingly rare in the U.S. One problem with urothelial cancer is that recurrence is common, so close monitoring of anyone who has had it is important.

Urothelial cancer, like most other cancers, is caused by DNA mutations. Smoking is a significant risk factor. Other risk factors include advanced age, male sex (it occurs much more commonly in men), and long-term exposure to certain chemicals such as those used in the manufacturing of dyes, rubber, leather, textiles, and paint. Previous cancer treatment that used cyclophosphamide (chemotherapy) or radiation in the pelvic area is also a risk factor, as are recurrent urinary infections and a family history of bladder cancer. Prevention recommendations include avoiding smoking, using care with industrial chemicals, and eating a diet high in fruits and vegetables (because they contain antioxidants which prevent or repair DNA mutations).

Diagnosing urothelial cancer uses cystoscopy (looking inside the bladder with a scope) and biopsy, urine cytology (looking for cancerous cells in the urine), and a CT cystogram (putting dye into the bladder while under a CAT scanner). Once diagnosed, it is important to look for spread (metastasis) using PET, MRI, CAT, or bone scans. The cancer is staged from 0 to IV, where 0 is no spread (in situ) and IV is distant metastasis. Also, the tumor cells are graded under the microscope from low grade dysplasia (the cells appear nearly normal) to high grade dysplasia (the cells are a jumbled mass with no semblance of normal tissue).

Treatment depends on staging and grade. Low grade, stage 0 or 1 tumors, can be treated locally with radiation and or medications put into the bladder, whereas high grade tumors are treated with surgical removal of the tumor using transurethral resection of the bladder (TURBT) or full removal of the bladder (radical cystectomy). Radical cystectomy in men includes removal of the prostate, and in women the ovaries, fallopian tubes, uterus, and part of the vagina, almost guaranteeing significant sexual dysfunction. Also, in radical cystectomy the urine must still exit the body somehow, which is achieved by using intestinal tissue to create a new bladder outside (ileal conduit) or inside (neobladder) of the body. If the tumor has invaded the wall of the bladder or metastasized outside of the bladder, combinations of surgery, intravesicular (into the bladder) and/or intravenous chemotherapy, radiation, and immunotherapy can be used. The goal, obviously, is to extend the life of the patient as long as possible.

For more information go to the US National Library of Medicine at:

www.medlineplus.gov/bladdercancer.html 

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 By Peter Galvin, MD

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