Bladder Cancer Treatment

Function of the Urinary Bladder

The urinary system comprises the kidneys, ureters, bladder, prostate, and urethra. The bladder, located in the lower abdomen, serves as a temporary reservoir for urine produced by the kidneys and transported via the ureters. The most common type of bladder cancer originates from the cells lining the inner bladder surface, known as transitional cell carcinoma or urothelial cell carcinoma. Bladder cancer is the second most prevalent cancer of the urinary system after prostate cancer and is distinct due to its multi-focal nature and high recurrence rate—approximately 70% of tumors reappear after initial endoscopic removal.

Causes of Bladder Cancer

Bladder cancer results from a combination of external exposure to carcinogens and molecular changes leading to genetic damage. Smoking is the leading risk factor, accounting for 50–66% of cases in men and 35% in women. In India, the smoking rate among bladder cancer patients is significantly higher in men (74%) compared to women (22%). Occupational exposure to chemicals such as aromatic amines (common in petrochemical, textile, and printing industries) and professions like hairdressing, firefighting, truck driving, and plumbing also increase the risk. Additional risk factors include prolonged use of certain medications (e.g., Phenacetin, Cyclophosphamide) and exposure to arsenic or radiation. However, substances like alcohol, coffee, and artificial sweeteners have not been directly linked to bladder cancer.

Diagnosis of Bladder Cancer

The gold standard for diagnosing bladder cancer is cystoscopy, an endoscopic procedure that allows direct visualization of the bladder interior. Suspicious areas or tumors are removed via Transurethral Resection of Bladder Tumor (TURBT) for biopsy. Bladder tumors may present in different forms, including papillary, solid, or carcinoma in situ (CIS), a flat velvet-like lesion.

Recommended Diagnostic Tests

Ultrasonography is a commonly used imaging technique that can detect small papillary lesions in the bladder. It can also identify swelling in the kidneys caused by ureteric obstruction. A CT scan of the abdomen is helpful in assessing the extent of bladder tumor involvement and evaluating lymph node status, which is critical before the cancer spreads further.

Initial Treatment and Diagnosis Confirmation

If bladder cancer is suspected, an endoscopic instrument called a resectoscope is used to remove part or all of the tumor for biopsy. A technique called en-bloc resection, which involves removing the tumor in two to three pieces, has been found to improve the likelihood of complete tumor removal.

Treatment Options Based on Cancer Stage

Following a confirmed diagnosis, treatment is determined based on the tumor’s classification into either non-muscle invasive bladder cancer (NMIBC) or muscle-invasive bladder cancer (MIBC).

Treatment for Non-Muscle Invasive Bladder Cancer (NMIBC)

For NMIBC, treatment may include instillation of Mitomycin C or Bacillus Calmette-Guerin (BCG) therapy into the bladder. Mitomycin C is a chemotherapeutic agent, while BCG is a live bacterial treatment that stimulates the immune system to combat cancer cells in the bladder lining. Regular cystoscopic monitoring is required due to the high recurrence rate of these tumors.

Treatment Options for Muscle-Invasive Bladder Cancer (MIBC)

The gold standard treatment for MIBC is bladder removal (radical cystectomy). After bladder removal, urine must be diverted using a segment of the intestine, known as an ileal conduit, which leads to an external bag worn on the abdomen to collect urine. In younger patients with good kidney function, a neobladder (a new bladder constructed from intestinal tissue) can be created, allowing urine to pass through the urethra. However, neobladder formation is a complex procedure with a 20–30% complication rate, requiring thorough patient education and commitment.

In select cases, patients may opt for bladder-preserving treatments such as radiotherapy and chemotherapy. However, around 50% of such patients eventually require bladder removal.

Role of Robotic Surgery in Bladder Cancer Treatment

For MIBC, robotic-assisted surgery can be used to remove the bladder. This technology offers benefits such as reduced blood loss and pain, though it does not significantly impact hospital stay duration or complication rates.

Creating a New Bladder

When a bladder is removed, a new bladder can be constructed using a segment of the patient’s small intestine. The intestine is reshaped into a pouch and connected to the urethra, allowing normal urination.

Choosing the Right Urinary Diversion Option

Neobladder formation is a viable option for select patients after thorough discussion of the risks and benefits. Candidates should have good kidney function, no severe comorbidities (e.g., diabetes), and the ability to perform self-catheterization if needed. Self-catheterization is necessary to clear mucus, which is a normal secretion of the intestine and can obstruct urine flow.

Continent Cutaneous Pouch

A continent cutaneous pouch is another urinary diversion option that does not require an external bag. Instead, urine is stored in an internal pouch made from intestinal tissue and is emptied using a catheter through a controlled opening in the abdomen.

Life After Neobladder Surgery

Patients with a neobladder may need lifelong medications and occasional catheterization to clear mucus. Regular follow-up visits are essential to detect and manage any complications early. Most patients regain daytime urinary continence, though about 30% may experience minor leakage at night.

A New Bladder, A New Beginning

Bladder reconstruction provides renewed hope and confidence, enabling patients to urinate normally and maintain a good quality of life.