Bladder Cancer Diagnosis and Treatment

Diagnosing Bladder Cancer

Based on a patient's unique condition, a urologist may order one or more tests to make a bladder cancer diagnosis. Appropriate methods may include:

Imaging tests: CT scans, MRI scans, ultrasound, and bone scans may be performed to provide more information beneficial in evaluating bladder cancer staging and whether or not the bladder cancer has spread (metastasized) beyond the bladder.

Urine cytology: Urine from the bladder is sent to the lab to determine if cancer cells (or pre-cancer cells) are present.

Urine culture: A sample of urine is sent to the lab to see if a patient has a bladder infection. Infections can sometimes cause symptoms similar to those of bladder cancer.

Cystoscopy: A urologist may perform a cystoscopy if signs of bladder cancer are present. In this procedure, a a tiny lighted tube called a cystoscope is inserted into the urethra in order to examine the bladder. A biopsy may be performed at the same time (under anesthesia), if necessary.

Blue light cystoscopy: This enhanced cystoscopy procedure helps the urologist find bladder cancer tumors of any size more easily. Cysview® (hexaminolevulinate HCL), an optical imaging agent, is instilled into the bladder. It interacts with cancerous cells causing them to appear bright fluorescent pink under a special blue light. This facilitates a more complete removal of all tumors, thereby decreasing the chances of reoccurrence. Winship at Emory is the only center in Georgia to offer the blue light cystoscopy procedure.

Surgery for Bladder Cancer

There are several types of bladder cancer surgery. The best option for each patient is determined by the bladder cancer stage.

Transurethral Resection: This is a minimally invasive bladder cancer surgery often chosen as an initial treatment for those in the early-stage of bladder cancer. A slender scope is placed in the bladder through the urethra to remove the cancerous cells with an electric current. The urologist may augment the procedure with blue light cystoscopy to improve his/her ability to see and remove all cancers in the bladder.

Partial cystectomy: A partial cystectomy may be an option for cancer involving only one area near the top of the bladder, away from other important structures. In this procedure, the bladder is spared by removing only the portion of the bladder with the tumor. The resulting hole in the bladder wall is then stitched closed.

Radical Cystectomy with Urinary Diversion: This surgery is used for advanced used in advanced bladder cancer cases where the entire bladder needs to be removed because the tumor has invaded the deep layers of the bladder. An extended pelvic lymph node dissection is performed in tandem to make sure any secondary malignant growth in this area is eradicated. Men also have the prostate, seminal vesicles and lymph nodes removed so that the bladder cancer does not return. Women may lose portions or all of the urethra, vagina, lymph nodes, uterus, fallopian tubes and ovaries.

After the radical cystectomy, a new way to drain urine from the body must be created. There are three common methods for doing this:

Ileal conduit: In this procedure, a short section of the small intestine is used to create a drainage system. The ureters (ducts which normally pass urine from the kidney to the bladder) are re-routed to one end of a small intestine segment which connects to an opening on the surface of the abdomen (called a stoma) on the other end. Here, the urine drains into a collecting pouch or ostomy bag. This is a relatively quick and easy procedure requiring less recovery time than other treatments.

Continent urinary reservoir: This procedure is similar to the Ileal conduit, however it requires an extra step to surgically create an internal pouch formed from the intestines. The ureters connect to the pouch which allows urine to pass from the kidneys and collect inside the body. Rather than flowing into an ostomy bag, the urine drains only when a catheter is inserted through the stoma into the pouch. 

Orthotopic neobladder: This is the most invasive of the three procedures and requires more recovery time. A new bladder pouch (created from intestine) is placed in the exact same location as a real bladder. The ureters are connected to one end of the pouch where the urine collects internally. The urethra is then connected to the other end of the pouch, allowing one to void through normal channels.

Robotic Radical Cystectomy with Intracorporeal Urinary Diversion: Historically, this surgery has been performed through an open incision in the patient’s abdomen. Now, Emory has fellowship-trained urologists who specialize in robotic surgery to remove the patient’s bladder through smaller incisions so the patient can recover quicker with less blood loss and pain. At most other centers that perform robotic radical cystectomy, the bladder is removed robotically but the patient is then opened through a standard incision to perform the urinary diversion, thereby losing any advantages of the robotic procedure. At Emory the entire procedure is performed robotically for all types of urinary diversion (intracorporeal urinary diversion) to help maximize potential benefits of robotic surgery for the patient.

Enhanced Recovery After Surgery (ERAS) Protocols: Emory has created a specific pathway for patients undergoing radical cystectomy with urinary diversion to help minimize complications and speed up recovery after the surgery so patients can return to their lives as quickly and safely as possible. This pathway addresses all patient needs before, during, and after the operation, including:

• Specific dietary and other recommendations to prepare the patient for surgery

• Special medications and teamwork between the surgeon and anesthesiologist during the operation

• Daily goals and expectations after the surgery - while patients are in the hospital as well as for the first couple of months at home after the patient leaves the hospital

Radiation Therapy for Bladder Cancer

Radiation is treatment with high-energy rays (such as x-rays) to kill or shrink cancer cells. After surgery, radiation can kill small deposits of cancer cells that may not be seen during surgery.

After transurethral surgery, a combination of radiation therapy and chemotherapy is sometimes able to completely destroy cancers that would otherwise require cystectomy. If the tumor is in a position that makes surgery difficult, radiation may be used to shrink the tumor, making surgery easier. Radiation might also be used to ease the symptoms of advanced cancer or limit bleeding from inoperable tumors.

Chemotherapy for Bladder Cancer

Chemotherapy for bladder cancer can be administered intravesically (directly into the bladder) or systemically (injected into a vein or given by mouth).

Chemotherapy placed directly into the bladder (intravesical) only reaches cancer cells near the bladder lining rather than those in other organs or deep in the bladder wall. This treatment is used only for early-stage (superficial) bladder cancer. One of the main advantages of this method of chemotherapy is that the drug doesn't usually spread throughout the body. This means that there are fewer unwanted side effects, but there can be local bladder irritation.

In systemic chemotherapy, the drugs travel through the bloodstream to all parts of the body. In this treatment, the drugs can attack cancer cells that have already spread beyond the bladder to lymph nodes and other organs. While chemotherapy drugs kill cancer cells, they also damage some normal cells and this can lead to side effects. These side effects depend on the type of drugs used, the amount given, and the length of treatment.

Immunotherapy for Bladder Cancer

This type of treatment is sometimes used for early or low stage bladder cancer that has high risk for returning (recurrence) or becoming more advanced disease (progression). A weakened bacterium called BCG is placed directly into the bladder. Immune system cells are attracted and activated by BCG, which in turn affects the bladder cancer cells. Treatments are given weekly for six weeks, and may be repeated or used as preventative therapy (maintenance) using three weekly treatments every six months for a few years. Sometimes, a reduced dose of BCG is used with another immune-active agent called interferon, which causes fewer side effects, but maintains effectiveness against tumors that may not have responded to BCG alone.

The Emory Department of Urology is affiliated with The Winship Cancer Institute of Emory University, Georgia's only National Cancer Institute-Designated Cancer Center and serves as the coordinating center for cancer research and care throughout the Emory University system. With NCI Designation Winship joins an elite group of 65 cancer centers in the United States to have earned this coveted status.

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