The urinary bladder is the organ that collects and stores urine produced in the kidneys. It is an “elastic bag” composed of muscle tissue that expands as it stores urine, which it will then expel to the outside through the urethra.
What is bladder cancer?
Bladder cancer is an abnormal growth of tissue (a tumor) in the bladder. There are several stages of bladder cancer. Your treatment and the details of your specific case will depend on the specific characteristics of the tumor and the oncological experience of your medical team.
What are the causes of bladder cancer?
As with all diseases, there are multiple risk factors. Although it is not known by the general population, one of the greatest risk factors for developing bladder cancer is tobacco. According to the clinical guidelines of the European Association of Urology, tobacco smoking would be responsible for almost half of bladder cancer cases. Therefore, quitting smoking plays a fundamental role in preventing this disease and also in reducing the risk of its recurrence.
What are the symptoms of bladder cancer?
The presence of blood in the urine or “hematuria” is the most common symptom. Normally it is not accompanied by any other symptoms. Pain or voiding symptoms are not common at the initial presentation of this disease. Symptoms such as pelvic pain, flank pain, weight loss, or a feeling of mass in the lower abdomen may occur in cases where the tumor is more advanced.
Are all bladder tumors the same?
Not at all. A rapid diagnosis and treatment is essential to know the initial stage of the disease and adapt a correct maintenance and follow-up treatment program. The tumor that grows inside the bladder without affecting the muscle tissue (which is found in deeper layers) is called a “non-muscle invasive” tumor (or superficial tumor). These superficial tumors represent early stages of the disease. It is the most common type of bladder cancer and its prognosis is usually very favorable. In most cases, these tumors are not aggressive and rarely spread to other organs, so they are not usually lethal. However, non-muscle invasive tumors can recur frequently (called “recurrence”) or develop aggressive features (called “progression”).
When the tumor grows deep, affecting the bladder muscle and extends to neighboring muscles, it is called a “muscle-invasive” tumor. This type of cancer has a greater chance of affecting other parts of the body (metastatic disease) and is more difficult to treat. It normally requires more aggressive attitudes (radical surgery +/- chemotherapy +/- radiotherapy) .
How is bladder cancer diagnosed?
Different tests can be done to diagnose bladder cancer. Normally an ultrasound establishes the suspected diagnosis, which is confirmed with a cystoscopy (visualization with a camera introduced through the urethra).
How is bladder cancer treated?
TRANSURETHRAL RESECTION of the BLADDER (TURB) consists of the resection or surgical removal of bladder tumors endoscopically. This procedure is both diagnostic and therapeutic. It is diagnostic because the surgeon removes the tumor and all additional tissue necessary to perform the microscopic analysis. And it is also therapeutic because the complete removal of all the visible tumor constitutes the treatment of the tumor. A complete and correct TUR-v is essential for a good prognosis. In some cases, a second v-TUR may be necessary several weeks later (this is known as Re-TUR).
Once the bladder tumor has been categorized, it is often necessary to perform additional treatment with intravesical instillations of different chemotherapy products to reduce the risk of recurrence.
In certain cases, more aggressive surgery may be necessary, which involves complete removal of the bladder or “radical cystectomy.”
Complete removal of the bladder (radical cystectomy)
The fundamental pillar of the treatment of muscle-invasive bladder cancer is surgical removal of the bladder. Complete removal of the bladder is recommended in different situations:
- The presence of muscle-invasive bladder cancer.
- The presence of a bladder tumor that grows aggressively (high-grade tumors), has multiple foci of cancer in the bladder (multifocal), or is superficial but has recurred after receiving chemotherapy or immunotherapy (given as instillations into the bladder).
- Lack of response or recurrence (relapse) after performing a multimodal bladder preservation treatment option (chemotherapy together with radiotherapy, which is not the standard first-line treatment)
- If you present symptoms such as uncontrollable bleeding or pain in patients with incurable disease.
There are factors that are important to take into account such as your age (the state of your body at the specific age you are, assessed by your general condition and your life expectancy) and other diseases you suffer from (diabetes, heart disease, high blood pressure). Patients over 80 years of age have more problems recovering from this operation. We use different scoring indices to assess patients’ risks for undergoing this complicated operation. Radical cystectomy includes removal of the bladder, the end of both ureters, and lymph nodes in the pelvis. Depending on factors such as the location of the tumor and the type of urinary diversion to be performed, it is necessary to remove other parts of other organs depending on the patient’s gender (the prostate and seminal vesicles in men; the entire urethra, part of the vagina and uterus, in women).
Is it possible to preserve the bladder in case of muscle invasive tumor?
Bladder preservation treatments
Bladder preservation treatments (not completely removing the bladder) is currently used in a minority of cases, but deserves comment. Bladder preservation can be achieved at the cost of using different treatments, including the adverse effects of each one. To control the tumor locally, TUR-v is used together with radiotherapy. Chemotherapy is used to treat cancer cells that may have spread throughout the body (systemic disease). The goal is to preserve the bladder and its function as well as the patient’s quality of life without compromising the treatment of the cancer itself. Some studies have shown good results of the bladder preservation approach in selected patients (not generally valid for any case), of whom approximately a third of them will need to undergo bladder removal after failure of the bladder preservation treatment.
Algunos estudios han mostrado buenos resultados del abordaje de preservación vesical en pacientes seleccionados (no válido de manera general para cualquier caso), de los que aproximadamente un tercio de ellos precisarán someterse la extirpación de la vejiga después del fracaso del tratamiento de preservación vesical.
Access to clinical trials
All patients diagnosed with recurrent or metastatic bladder cancer, and particularly those in whom previous chemotherapy has failed, should be considered candidates for the clinical trials available in the centers. A limited but increasing number of studies are available in different phases for patients who have not received prior chemotherapy as well as those who have received chemotherapy.
Furthermore, the use of recent experimental drugs known as “immune checkpoint inhibitors” in advanced bladder cancer appear to be effective in a specific group of patients with this disease. Access to clinical trials should be the first option to discuss with your doctor (when trials are available). The therapeutic decision is made after reviewing all the information on the pros and cons of each option and depends on each individual patient and the characteristics of the disease.
