Bladder Cancer

• Introduction

Bladder cancer is one of the most common malignant carcinomas in humans. The disease affects more frequently men than women and the mean age at diagnosis is 68 years. Symptomatology is present in early stages of the disease and the tumor is usually located exclusively in the bladder. Extension of the disease outside the bladder is diagnosed only in a small percentage of the patients at their presentation.

• Diagnosis

The main symptom of bladder cancer is hematuria. Less common symptoms are pain during urination (dysuria) or frequent urination. As a result, each case of hematuria should be examined by the urologist with the suspicion of bladder cancer. Ultrasound examination of the bladder and the urine cytology are useful tests for the diagnosis of bladder cancer. Nevertheless, cystoscopy is the most important examination. The latter test is performed by inserting a special instrument through the urethra into the bladder and the urologist evaluates the morphology of the bladder mucosa.

The examination is not painful when carried out under local or general anesthesia. Therefore, the diagnosis of bladder cancer most often arises after cystoscopy and visual recognition of the characteristic image of exophytic tumor. Urine cytology significantly contributes to the diagnosis since cancer cells are detected in the urine. The final diagnosis is set by the histological examination of biopsy samples taken from the tumor. A biopsy will also determine the aggressiveness of the tumor and the extent of bladder wall involvement. It is worth noting that for small lesions with low aggressiveness, the resection of the tumor for the performance of biopsy is adequate treatment.

• Prognosis

The prognosis of bladder cancer depends on the depth and extent of the tumor in the bladder wall and the degree of differentiation of tumor cells. If the muscular layer of the bladder wall (clinical stage Ta, T1, CIS) is not involved, the 5-year survival ranges from 82-100% with proper treatment. Involvement of the muscular layer without any extension outside the bladder (clinical stage T2) is associated with 63 – 83% 5-year survival rate. Extravesical extension of the tumor is characterized by poor prognosis.

• Treatment

⇒ Transurethral Resection

Superficial bladder tumors are treated with transurethral resection. But it is worth noting the high rate of recurrence with over 80% of cases expected to have at least one recurrence after initial treatment. The periodically repeating cystoscopy with ablation is often sufficient in low-grade tumors. Alternative means such as repeated injections of chemotherapeutic agents into the bladder are necessary to address intermediate grade tumors. The injections significantly reduce the recurrence rates and the incidence of tumor progression to more aggressive neoplasm. In case of tumors extending to muscular layer or across the bladder wall, transurethral resection is not indicated. These patients are candidates for radical cystectomy if there is no evidence of distant metastasis. Systemic chemotherapy and local radiation therapy are also management options but are usually limited to the patients that are not fit or are not willing to undergo radical cystectomy.

⇒ Laparoscopic Radical Cystectomy

Radical cystectomy is considered to be one of the most demanding urologic procedures. It can be performed by open or laparoscopical approach. Despite the higher technical challenge of laparoscopic cystectomy in comparison to open surgery, the laparoscopic approach is associated with less perioperative morbidity and faster recovery. The surgery involves the complete removal of the bladder along with fatty tissue around the bladder and lymph nodes. In addition, the prostate and seminal vesicles are removed in male patients while the uterus, fallopian tubes, ovaries as well as the anterior vaginal wall are removed in the female patients. An appropriate procedure to restore the urinary tract is concomitantly performed in order to restore the urinary tract. There several different techniques to restore the urinary tract such as the drainage of urine into a small segment of bowel which releases its content to a urostomy bag attached on the abdominal wall (ileostomy), the construction of a pouch by bowel which is used as artificial bladder (continent pouch).

• Prognosis After Cystectomy

Overall, radical cystectomy offers disease free survival during the first 5 years in 60-70% of patients. Disease free survival up to 77% at 10 years is possible if the tumor was limited to the bladder during surgery. Extravesical extension significantly limits disease-free survival to 44% of the patients while the presence of lymph node involvement further reduces the above rate to 34%.

• Postoperative course After Laparoscopic Cystectomy

Laparoscopic radical cystectomy is associated with significantly faster recovery of the patient in comparison with open cystectomy. The patient is mobilized on the day of surgery and fed with the return of normal bowel on the fourth postoperative day. Discharge day is scheduled one week after surgery while ureteral catheters (inserted intraoperatively) are removed 2 weeks after surgery.

• Complications

Complications are limited when the surgery is performed in a specialized center with extensive experience. The most common complications are postoperative ileus, fever, and leakage of urine. These complications are in the majority of cases treated conservatively. Other complications are disturbed wound healing, thrombosis or embolism, injury of adjacent organs and lymphocele. Mid-term complications include ureteral strictures at sites where the ureter is sutured to bowel, compromised renal function, formation of kidney stones and infection.