Knowing theand of your helps your doctor decide which methods are most suitable for treating your cancer. It is important to remember that patients must expect to be closely followed by their urologists, with regularly scheduled cystoscopies and cytology as bladder tumors often . Early detection is crucial to a good long-term prognosis.
Ta papillary tumors are usually low(most closely resemble normal cells) and, even though a large majority will multiple times after the initial diagnosis and removal, 85-90% will never invade the bladder wall and become life-threatening. Further treatment beyond removal may not be necessary, but regular follow-up is required.
Although CIS is also non-invasive, as thehas not grown into the (the layer of blood vessels and cells that is situated between the bladder lining and the muscle wall), it is more aggressive than Ta non-invasive tumors and will probably be treated with more aggressive therapies, including (BCG). Once the has invaded the , it is considered an invasive with the potential of spreading through the muscle wall and ultimately affecting organs that border the bladder ( , , etc.) or other organs such as the lung, bone, and liver. therapy and may be considered. If invasion of the muscle is seen on the , the is at least T2, in which case more aggressive treatments ( , radiation, and/or ) are typically considerations.
There are many lymph nodes that also surround the bladder. Lymph nodes are small glands that store the white blood cells that help to fight disease throughout the body. Cancer cells from invasive bladder tumors may appear in the lymph nodes. Although they can often only be seen with a microscope, they may be seen on scans as enlarged lymph nodes – cancer cells in the lymph nodes indicate that thehas spread and will influence the management of the patient. may be suggested.
Generally, after the diagnosis of a bladder, the will suggest that the patient have an outpatient procedure in the hospital to examine the bladder more completely under (general or spinal) and to remove, if possible, those tumors which are suitable for resection. The doctor may refer to this procedure as a TURBT ( of a bladder ).
The TURBT is “medical centers.-less” usually performed as an outpatient procedure. It is the first-line surgical treatment for bladder tumors. Like the , the resectoscope, the instrument used to remove the in the TURBT, is introduced through the into the bladder. Attached to this scope is a small, electrified loop of wire which is moved back and forth through the to cut and remove the . Newer technology known as “blue light” uses an optical agent is often used during this procedure at major
Electricity is also used to seal off bleeding vessels. This is sometimes called electrocauterization or. One of the advantages of this procedure is that it can be performed repeatedly with minimal risk to the patient and with excellent results. There is less than a 10% risk of infection or injury to the bladder, and both are easily correctable.
The most common risks of the TURBT are bleeding, pain, and burning when urinating and all three are temporary. If the bladderis large, the may choose to leave a in the patient’s bladder for a day or two to minimize problems occurring from bleeding, clot formation in the bladder or expansion of the bladder due to possible storage of excess or blood. Even if the is small, a may be inserted to rinse the bladder out if the bleeding persists.
All the specimens from the TURBT will be sent to thefor review. The will confirm the type of and the depth of invasion into the bladder wall, if any. These findings, along with results from such as CT scans, will determine if further treatment is necessary.
Check out our Patient Tipsheet on the TURBT (PDF), filled with advice from patients who have experienced it.
Certain types of bladder tumors are hard to remove using surgical procedures like a TURBT, particularly flat tumors (). In addition, some tumors may be likely to after initial resection. In these cases, special medications that destroy cancer cells may be placed directly into the bladder. This treatment is called therapy.
There are two principal drugs that are used asor .
- Bacille Calmette-Guerin or BCG is which causes an immune or allergic reaction that has been shown to kill cancer cells on the lining of the bladder. BCG is often preferred for patients who have high- tumors or who have CIS or T1 disease.The may also suggest maintenance therapy using BCG. The rationale for maintenance therapy is that the initial therapy plus intermittent therapy for 2 to 3 years may provide a decreased likelihood that the tumors will . The disadvantage to maintenance therapy is prolonged bladder irritation, fever, and bleeding which may force the doctor to decrease the BCG dosage or to discontinue the therapy. Both Mitomycin C and BCG are administered through a which is placed in the bladder through the . The drug is then introduced into the bladder.
- Mitomycin C is an , anti-cancer drug that has been shown to be effective after the TURBT in reducing the number of recurrences of bladder tumors by as much as 50%. An advantage of Mitomycin C is that it is not easily absorbed through the lining of the bladder and into the blood and, thus, less risky than given intravenously. from the drug can be pain when urinating and/or “chemical cystitis”, an irritation of the lining of the bladder which can feel like a urinary tract infection. Both these are temporary and will disappear when the therapy is stopped. This drug may be delivered into the bladder immediately after TURBT. For more information, see the video above about TURBT and .
For some patients,may be used. The drug is indicated for patients whose CIS did not respond to BCG treatment or and who cannot have right away to take out the bladder.
Check out our Patient Tipsheet on BCG (PDF), filled with advice from patients who have experienced it.
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If a bladderinvades the muscle wall or if CIS or a T1 still persists after BCG therapy, the may suggest removal of the bladder or a . Before any radical is performed, a series of CT scans or an MRI will be ordered to exclude the possibility of metastatic or “distant” disease in other parts of the body. If the patient has metastatic disease, to remove the bladder is not recommended and patients will be referred to a to discuss . The two types of performed for muscle- are partial or complete .
Partialis fairly uncommon and is only performed:
- if the muscle-invasive bladder is the first and only bladder the patient has had and
- if the is in a location where it is easily accessible for and, if removed, will leave the bladder with enough capacity for the patient to have normal bladder function.
A completerequires complete bladder removal, and in men, almost always involves removal of the as well. For women, in addition to removing the bladder, the may also remove the , , and cervix, and occasionally a portion of the wall. In addition, the will remove lymph nodes surrounding the bladder, and perhaps even more, to determine whether the cancer has progressed to the lymph nodes, which then could result in . The removal is an important method of accurately the progression of the disease. can be performed through an open or laproscopically, typically with robotic assistance. Removal of the bladder also requires the to create a passage for the to go from the kidney to outside the body. Even though the bladder is removed, the , ureters and are still in place. Because no artificial bladder has yet been invented that is tolerated by the urinary tract system, the has learned to create the passageway or conduit between the and ureters and the using a piece of the patient’s own intestine.
Check out our Patient Tipsheet on (PDF), filled with advice from patients who have experienced it.
- An Read some practical questions & answers from Nancy, a and check out our survivor with an Patient Tipsheet on the (PDF), filled with advice from patients who have it. is the easiest and most common reconstruction performed by the . A small portion of the ileum or is disconnected. One side of the piece of ileum is attached to a skin opening on the right side of the and a small or mouth is created. A plastic appliance or bag is placed over the to collect the . The ureters are sewn or re-implanted near the other end of the ileum. Because the nerves and the blood supply are preserved, the conduit is able to propel the into the appliance.
- A continent cutaneous pouch (CCP) is an internal storage “container” for Read some practical questions & answers from Karen, a and check out our survivor living with a CCP,Patient Tipsheet on the Indiana Pouch (PDF), filled with advice from patients who have it. . Using a combination of small and large intestine, the reconstructs the tubular shape of the intestine and creates a sphere or pouch. This pouch is connected to the skin on the by a small creating a type of continent urinary reservoir; no external bag is necessary. The patient drains the pouch periodically by inserting a (a thin tube) through the small and then removing the and, in some cases, covering the with a bandage.
- A Read some practical questions and answers from Michael, a and check out our survivor living with a , Patient Tipsheet on the (PDF), filled with advice from patients who have it. is also a type of internal reservoir for storing . Using a portion of , the reconstructs the tubular shape of the intestine and creates a sphere. The then connects the pouch to the , creating a , in which case the patient can void (pass out of the body) normally. By tensing the abdominal muscles and relaxing certain pelvic muscles, the patient is able to push the through the .
Ais considered major and at least 20% of patients have complications as a result, regardless of approach. The choice of which type of reconstruction to utilize is a highly-individualized decision between the patient and the doctor, and depends on a variety of factors, including the patient’s overall health, age, and extent of disease. There are advantages and disadvantages to each type of reconstruction.
Watch BCAN’s “The New Normal: Living with a Urinary Diversion” video series profiling eight survivors discussing their urinary diversion choice and sharing their experience to let others know about living well with a urinary diversion.
refers to drugs used to treat cancer systemically. These drugs are administered by injection directly into the patient’s veins, and circulate through the bloodstream to attack cancer cells anywhere in the body. is typically used to treat that has metastasized, which means the cancer cells have spread beyond the bladder to other organs.
Neoadjuvantis the term used for prior to . An important has shown that the use of before improves survival for patients with . This type of initial , termed neoadjuvant , works to shrink the within the bladder and may also kill small metastatic deposits of disease that have spread beyond the bladder. It is important to note that it does not appear that single-agent is helpful in improving the survival of patients with locally advanced . The two regimens recommended for neoadjuvant treatment are either Dose Dense MVAC or GC (discussed below).
is the term used for following . Typically, removal of the bladder also involves removal of a number of lymph nodes surrounding the bladder, which are then sent to the pathology lab for analysis. If the pathology results indicate that the cancer has spread to the lymph nodes, the doctor may recommend to help prevent any cancer recurrence. Dose Dense MVAC or GC are typically recommended in this setting.
Ifis found to have spread to other sites, systemic is recommended. It is very difficult to permanently cure metastatic . In most cases, the goal of treatment is to slow the spread of cancer, achieving shrinkage of , relieving symptoms, and extending life as long as possible.
Cisplatin basedhas been the standard treatment for for many years, based on the results of clinical trials from the 1990s. The two regimens most commonly used are dose-dencse (DD) MVAC and GC. MVAC uses four drugs: methotrexate (MTX, Amethopterin, Rheumatrex, Trexall), vinblastine (Velban), doxorubicin (Adriamycin, Rubex), and cisplatin (Platinol). The advent of effective anti-nausea medication and injections that can keep immune systems from being depleted by have improved our ability to give MVAC safely on an accelerated dose dense schedule. The NCCN now recommends MVAC be given according to the “dose dense or DD” schedule due to improved toxicity and suggested improvement in efficacy compared with the standard schedule. A conducted in the late 1990s showed that the combination of gemcitabine (Gemzar), plus cisplatin (GC), gives similar anticancer effects to standard MVAC combination. Both GC and DD MVAC have been useful in in delaying recurrence, extending life and sometimes achieving cure, and both regimens are routinely used in the neoadjuvant and metastatic settings. Clinical trials are underway to assess whether the addition of another agent to these regimens improves outcomes.
In recent years,and radiation have been combined to provide a “bladder preservation” therapy for higher risk (i.e. muscle-invasive) cases. In the past alone was used because it effectively shrunk tumors. Bladder cancers are chemosensitive and therefore adding combined (multiple chemotherapeutic agents given together) to radiation has improved results. To ensure the success of bladder preservation therapy, there are at least three requirements which should be met: 1) a “complete” resection of the (s) by TURBT; 2) no obstruction of 1 or both as a result of the bladder ; and 3) no T4 bladder tumors.
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