Bladder cancer occurs predominantly in elderly men, though can occur in other age groups and women. A third of cases are related to smoking. Certain occupations have been associated with the development of bladder cancer, often many years after exposure to the causative chemicals. These include the rubber, dye and chemical industries.
- Blood may be seen in the urine (haematuria), or found on testing with dipsticks. This is the most important symptom, and requires urgent investigation
- Bladder symptoms including frequent urination, urgency in needing to urinate and pain on urination
- Recurrent unexplained urinary infections
- Abdominal or loin pain
Assessment & Diagnosis
Investigation of these symptoms involves simple outpatient tests including urine and blood testing, ultrasound and X-rays of the kidneys and bladder and telescopic inspection of the bladder.
This is the inspection of the urethra and bladder using a small flexible telescope. This is carried out using local anaesthetic, commonly as an outpatient. It carries a low risk of infection and is very well tolerated, taking only a few minutes. No sedative is required so patients are able to drive home afterwards. It provides an excellent view of the lining of the bladder and is very sensitive in detecting even very small bladder cancers.
Most tumours are removed telescopically via the urethra under a general anaesthetic. This may require an overnight stay in hospital. After surgery, a tube is left in the bladder (catheter). Chemotherapy can be flushed into the bladder before its removal to treat any remaining cancer cells. The tissue removed is sent for examination by a pathologist to assess if the tumour is confined to the lining of the bladder and how aggressively the tumour is likely to behave in the future. This will determine the need for further treatment.
The majority of tumours only need telescopic removal, though this frequently needs to be repeated. Photodynamic diagnosis or ‘blue-light cystoscopy’ increases the effectiveness tumour removal by increasing the sensitivity of tumour detection and aiding more extensive removal.
If tumours recur rapidly, or are found to be ‘high risk’ (showing signs of invading the lining of the bladder, or aggressive looking microscopically), chemotherapy may be offered as a course of weekly instillations into the bladder via a catheter. BCG may be used in a similar way to boost the immune system to eradicate the cancer. This is a very effective way of controlling high-risk disease which may spare patients more extensive surgery.
Treatment for advanced bladder cancer
Bladder tumours growing into the muscle wall of the bladder, or which look aggressive (‘high grade’) carry a high risk of spreading beyond the bladder and causing harm. These are poorly controlled telescopically. Treatment for these tumours entails treating the whole bladder with radiotherapy, or specialist surgery to remove the bladder.
This is a highly specialist operation, carried out by limited numbers of surgeons working in specialist centres. This involves removing the bladder, with the prostate or uterus/ovaries in women, and the surrounding lymph glands. The drainage of the kidneys is most commonly restored by using a section of bowel. Surgeons can also, in carefully selected patients, create an artificial or neo- bladder, removing the need for a stoma (opening on the abdomen requiring a bag).
Cystectomy is commonly performed with open surgery. Specialist centres, including the Royal Wolverhampton NHS Trust, offer robotic cystectomy, which significantly reduces post-operative pain, and length of stay. Peter Cooke and his team perform robotic cystectomy routinely, with internal robotic reconstruction. Selected patients can undergo formation of a neo (new) bladder made from bowel, with nerve-sparing to help preserve continence and sexual function. Patients are able to eat and drink rapidly after the surgery and follow an enhanced recovery program, being discharged from hospital on average in under seven days.
Patient who are not suitable for cystectomy can be treated with radiotherapy. This may be preceded by chemotherapy given by an Oncology specialist.