Bladder Cancer

Bladder cancer affects over 52,000 men and women in the United States on an annual basis, and more than 12,000 people die each year from this disease. It is the fourth most common cancer in men in this country and the eighth most common in women.

Bladder cancer starts in the bladder's inside lining. Approximately 80 percent of these cancers are confined to the lining or tissue underneath the lining. About 20 percent invade the muscle of the bladder and can spread to the pelvic lymph nodes. In men, bladder cancer can spread into the prostate and seminal vesicles, and in women, these cancers can invade the cervix, the uterus, and the vagina. When bladder cancer spreads beyond the confines of the pelvis, it can invade lymph nodes around the heart and spread to other organs, most commonly the lung, liver, or bones.

Bladder cancer usually is associated with blood in the urine (hematuria). Patients may report rust-colored urine or the passing of tissue, clots or blood. Approximately 10 percent of patients with hematuria will be found to have a bladder tumor.

Frequently, however, urine that appears perfectly normal to the naked eye will be shown by the microscope to contain abnormal numbers of red blood cells (microhematuria). This condition can be diagnosed by simply analyzing the patient's urine in the doctor's office.

Other symptoms include burning or frequency of urination in the absence of a urinary tract infection and pelvic pain along with the symptoms mentioned above.

Bladder cancer is diagnosed by cystoscopy, a procedure in which the urologist passes a lighted telescope through the urethra into the bladder and looks directly at the inside lining of these structures. Through a cystoscope, a biopsy can be performed, and, frequently, if a tumor is found, it can be removed entirely.

A rectal examination in a male and a vaginal bimanual examination in a female may reveal a mass on the outside surface of the bladder.

Once the pathologist establishes the diagnosis of bladder cancer, additional tests are required, possibly including x-rays of the kidneys and bladder, ultrasound, and an X-ray exam of your urinary tract. Alternatively, a CT scan may be performed. An additional urine test called cytology will be performed. This method of detecting cancer cells under the microscope is very similar to a PAP smear for women.

If the cancer is invasive, spread to the lymph nodes and other organs must be evaluated.

Removal of the tumor through a cystoscope frequently is adequate treatment. Over time these tumors have a tendency to recur and, therefore, regular cystoscopy is performed in the office to examine the bladder. Urinalysis and cytology will also be performed, usually every 3 months for 1 to 2 years, and then annually. For patients who experience multiple tumors or recurrent tumors, additional treatments, like chemotherapy, are warranted in an attempt to reduce the probability of recurrence and/or progression to a more aggressive cancer.

When the cancer invades the muscle or deeper portions of the bladder, the risk of cancer spreading to the lymph nodes is approximately 20 percent. Complete removal of the bladder (cystectomy) is the treatment of choice. This provides excellent control of the primary tumor and removes all of the primary lymph node drainage and any potential cancerous lymph nodes. 

When the bladder is removed, the urinary tract must be reconstructed to allow passage of urine. This is called a urinary diversion. In a male the nerves responsible for the urge for erections run alongside the prostate, and a nerve-sparing operation can be done in order to preserve erectile function. When it is necessary to remove these nerves, a nerve graft can be performed to bridge the gap between the cut ends of the nerves. 

There are three general choices for bladder reconstruction.

• Ileal conduit urinary diversion.
• Indiana pouch reservoir.
• Neobladder-to-urethra diversion.

These procedures utilize parts of the small or large intestine to pass urine through the body.

For patients not suitable for surgery, radiation therapy is an acceptable alternative to cystectomy. For patients who are interested in bladder salvage and are medically fit, experimental programs combining chemotherapy, radiation therapy, and extensive tumor resection via cystoscopy can be performed. These treatments are associated with a slightly lower probability of long-term cure than cystectomy and lymph node removal.

When the bladder is removed, the pathologist examines in detail the bladder and any adjacent structures, as well as the lymph nodes. When the cancer has spread to other surrounding areas, additional chemotherapy is recommended.

At the time of the initial diagnosis in approximately five percent of patients, the disease will already have spread to lymph nodes outside the pelvis or to other organs, such as lungs, liver, and bones. These patients can be treated with multi-agent chemotherapy.

The treatment for both non-muscle invasive and invasive bladder cancer is becoming more sophisticated daily as we gain knowledge of the behavior of these cancers, identifying new targets for therapy and improving surgical techniques and both chemotherapy and immunotherapy. At Baylor Medicine we have an extensive clinical trials program, led by Dr. Seth P. Lerner.