Bladder cancer

The urinary bladder is located in the pelvis, just behind the pubis, and is a reservoir for urine. Roughly speaking, the organ consists of an inner layer made up of urothelial cells and a multilayered muscular part, which is responsible for emptying. In between, there is connective tissue. Bladder cancer is a common disease and ranks fifth in frequency in men. It is less common in women, but is detected in the advanced stages of the disease.

Causes of occurrence

The cause of bladder cancer is not completely known. However, the risk factors are well known. These include smoking and agents that the patient comes into contact with in the chemical, petroleum, printing, dye and leather industries. Changes in certain genes are also known to be associated with a higher incidence of bladder cancer. Patients with bladder stones, patients with chronic urinary tract infections (inflammation with Schistosoma - a protozoan) and anatomical malformations (bladder diverticula) are more prone to developing cancer.

Bloody urine

The disease is rarely detected by chance, as part of the diagnosis of other diseases. Patients usually visit us because of bloody urine (Figure 1). Bleeding can completely disappear within a few days, which can be misleading and usually leads to a more severe form of the disease due to the loss of valuable time until therapy. Most often, there is no pain with bloody urination. Sometimes, more detailed examinations alert us to the disease, where erythrocytes or malignant cells are found under a microscope in the urine. Ultrasound, as the gold standard of diagnostics in urology, is not sufficient for smaller tumors. CYSTOSCOPY is required, where the entire urinary bladder is examined with a special instrument and the tumor is detected (Figure 2). If advanced disease is suspected or as part of preparation for further treatment, a CT or MRI scan is required.

Figure 1: Bloody urine (SOURCE: photo documentation MD Medicina)

Figure 2: Cystoscopic appearance of bladder cancer (SOURCE: photo documentation MD Medicina)

Therapy and definitive diagnosis

Transurethral resection

When a tumor is confirmed by cystoscopy, surgical treatment is required. The tumor is excised with an electrical loop through the urethra, and the tumor pieces are sent to a pathologist, who stains the tissue with special dyes and examines it under a microscope. This is how we arrive at a definitive diagnosis, and surgery itself can be the definitive form of treatment. If it turns out that the disease cannot be controlled in this way, the disease involves the muscle layer or recurs, more aggressive therapy is required. The pathologist distinguishes between high-grade and low-grade tumors and how deep the tumor grows into the bladder wall. Depending on the pathologist's report and the patient's general condition (comorbidities, psychophysical condition), we decide on further therapy. Most often, the above-mentioned surgical procedure represents the definitive therapy. The procedure is called transurethral resection of a bladder tumor. As a rule, superficial tumors that do not extend to the bladder musculature and do not recur after additional immuno/cytostatic therapy (BCG, Mitomycin) are treated in this way.

Cystectomy

If the tumor extends deeper, to the musculature, through it, or tumors recur despite additional therapy, the bladder must be removed, usually completely (cystectomy). Urine drainage must be ensured, which is achieved by creating a urine reservoir from the intestine and draining it naturally, or through a dry/wet urostomy. The operation can be performed open/classically, through a larger incision in the abdominal wall, or laparoscopically/robotically assisted. The results are comparable, but with the latter two methods, postoperative recovery is faster, blood loss is less, hospitalization time is shorter, and the cosmetic appearance is better. 

Irradiation

In case the patient is not fit for surgical therapy due to poor psychophysical condition or serious concomitant diseases, we decide to use radiation therapy in combination with chemotherapy. Radiation therapy is administered in fractions - every day for 5-8 weeks.

Chemotherapy

Approximately 15% of patients have affected lymph nodes or distant metastases at the time of diagnosis. Chemotherapy is effective in at least 2/3 of cases and is also used before surgery (neoadjuvant chemotherapy) or postoperatively (adjuvant chemotherapy). We decide on a combination of different cytostatics.

The disease tends to recur and progress.

Bladder cancer is an insidious disease that tends to recur and progress. Regular, in most cases lifelong, postoperative monitoring of the disease is necessary. Initially, cystoscopic examinations are performed every 3-4 months, later at longer intervals, depending on the risk of recurrence/progression. It is a misconception that surgery and medication are the only cure. In cases where the tumor recurs, the therapeutic procedure must be repeated from the beginning. After removal of the bladder, patients are monitored on an outpatient basis. Regular ultrasounds, and occasionally more advanced examinations, are necessary to determine whether the disease has recurred or metastasized. The disease is difficult to control in its advanced stages. In such cases, we usually opt for symptomatic therapy only, which alleviates the consequences of the disease.

Author: asst. Simon Hawlina, MD, FEBU, urologist specialist

How to protect yourself?

Avoiding smoking (Figure 3) is the best prevention. We recommend a healthy lifestyle, avoiding stress, and adequate hydration. If you already have the disease, we recommend regular check-ups with a urologist.

Figure 3: Avoid smoking

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Urology clinic

Dejan Galič, MD, FEBU, FECSM

urology specialist

He deals with general urology, especially urological oncology and prostate problems, as well as sexual medicine.

Assoc. Prof. Dr. Simon Hawlina, MD, FEBU

urology specialist

He performs a wide range of urological surgical procedures, focusing on minimally invasive techniques.

Prof. Dr. Andrej Kmetec, Dr. med.

urology specialist

He deals with the comprehensive treatment of urinary tract problems.

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