Bladder Cancer

Bladder CancerThe bladder is a hollow organ in the lower part of the abdomen that is shaped like a small balloon and has a muscular wall that allows it to get larger or smaller. The bladder stores urine until it is passed out of the body. Urine is the liquid waste that is made by the kidneys when they clean the blood. The urine passes from the two kidneys into the bladder through two tubes called ureters. When the bladder is emptied during urination, the urine goes from the bladder to the outside of the body through another tube called the urethra.

Bladder cancer accounts for approximately 70,000 new cases of cancer per year, with approximately 15,000 deaths each year attributable to the disease. There are three main types of bladder cancer that begin in cells in the lining of the bladder. These cancers are named for the type of cells that become malignant (cancerous):
Cancer that is confined to the lining of the bladder is called superficial bladder cancer. Cancer that begins in the transitional cells may spread through the lining of the bladder and invade the muscle wall of the bladder or spread to nearby organs and lymph nodes; this is called invasive bladder cancer. Fortunately, two-thirds of newly-diagnosed bladder cancers occur only on the lining of the bladder (superficial bladder cancer) and can be treated effectively by the urologic surgeons at The University of Kansas Hospital.

Blood in the urine (called hematuria) is usually the first sign of bladder cancer. Other symptoms, which may not be recognized initially, include the need to urinate frequently both day and night, and the inability to hold the urine once the urge to urinate occurs. A simple test called cystoscopy can usually diagnose the cancer. Our physicians are experts in the diagnosis of bladder cancer as well as its treatment. In addition, we employ a number of methods to keep those with superficial bladder cancer from recurring.

For those patients with invasive cancer (into the muscle wall of the bladder), surgery to remove the entire bladder (cystectomy) is often needed. Our urologic oncologists will employ options to preserve the bladder when possible (bladder sparing), however, if removal is needed, our physicians are among the nation’s most experienced.

For patients whose bladder must be removed, surgeons must create a new way for the body to store and empty urine. The urologic oncologists at The University of Kansas Cancer Center are well versed in the different urinary diversion options. One such option performed by our urologists is the construction of a “new” bladder using intestine, called a neobladder. This allows patients to urinate in a normal fashion. We have had good success with these reconstructive techniques since their inception.

Unfortunately, some patients will have bladder cancer that has spread beyond the bladder (to the lungs, liver or bones) prior to surgery or after the removal of the bladder.

At KUMC, we have a specialized team of medical oncologists who specialize in the treatment of advanced urologic malignancies and has experience in the treatment of metastatic bladder cancer. Working closely with the urologic oncologists, our oncologists provide the latest and most advanced chemotherapy and immunotherapy for the treatment of bladder cancer.

Dr. Peter Vanveldhuizen is a medical oncologist who specializes in the treatment of urologic malignancies and has vast experience in the treatment of metastatic bladder cancer. Working closely with the urologic oncologists at our hospital, Dr. Vanveldhuizen provides the latest and most advanced chemotherapy for the treatment of bladder cancer.

Risk factors for bladder cancer include the following:
Smoking is the most common cause of bladder cancer. It is rare that patients who are not smokers develop bladder cancer. It takes 20 years of not smoking before the risk begins to decrease. However, patients who continue to smoke after being diagnosed with bladder cancer do much more poorly than those who quit. So quitting smoking is an essential part of being treated for bladder cancer. Your physician has many ways to assist you with this.

Other risk factors:
Being exposed to certain substances at work, such as rubber, certain dyes and textiles, paint, and hairdressing supplies. Chronic irritation of the bladder from infection or long-term catheterization can also lead to bladder cancer.

Stage and Grade
The stage of the cancer refers to whether it is superficial or invasive bladder cancer, and whether it has spread to other places in the body). Bladder cancer in the early stages can often be cured.

The type of bladder cancer cells and how they look under a microscope is called the grade of the cancer. Typically bladder cancers are referred to as High Grade or Low Grade. Most invasive bladder cancers are High Grade.

Treatment options depend on the stage of bladder cancer. Your stage of bladder cancer is determined by several tests.
  1. Cystoscopy and transurethral resection of the tumor. This is a biopsy of the tumor and will help to determine the stage (how deep the cancer is penetrating) and the grade (how aggressive the tumor is). 
  2. Additionally, the bladder cancer surgeons at The University of Kansas Hospital may perform Blue-light cystoscopy, a novel method of detecting tumors not seen by the naked eye.
  3. A CT scan will determine if the cancer has spread outside the bladder or to any other organs.
  4. A bone scan may be used if the tumor is larger or appears very aggressive or if the CT scan detects cancer outside of the bladder. 

The following stages are used for bladder cancer:

Stage 0 (Papillary Carcinoma and Carcinoma in Situ) In stage 0abnormal cells are found in tissue lining the inside of the bladder. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is divided into stage 0a and stage 0is, depending on the type of the tumor:
Stage I: In stage Icancer has formed and spread to the layer of tissue under the inner lining of the bladder.

Stage II: In stage II, cancer has spread to either the inner half or outer half of the muscle wall of the bladder.

Stage III: In stage IIIcancer has spread from the bladder to the fatty layer of tissue surrounding it and may have spread to the reproductive organs (prostate, seminal vesicles, uterus or vagina).

Stage IV: In stage IVcancer has spread from the bladder to the wall of the abdomen or pelvis. Cancer may have spread to one or more lymph nodes or to other parts of the body.

Bladder

Treatment

Surgery
One of the following types of surgery may be done:
  • Transurethral resection, or TUR, with fulguration: Surgery in which a cystoscope (a thin lighted tube) is inserted into the bladder through the urethra under general anesthesia or spinal anesthesia. A tool with a small wire loop on the end is then used to remove the cancer or to obtain a specimen for diagnosis. Your surgeon will attempt to remove the entire tumor if possible but some very large tumors cannot be removed by TUR.

    Patients whose cancers are not invasive into the muscle wall of the bladder are candidates for intravesical treatments. These are medications given to the patient as instillations inside the bladder to help prevent or delay the recurrence of the cancer. Examples of these medications include Mitomycin-C, BCG, Valrubicin, and Gemcitabine. Our urologic oncologists are experts in administering intravesical treatments for bladder cancers. 

  • Radical cystectomy: Surgery to remove the bladder and any lymph nodes and nearby organs that contain cancer. This surgery may be done when the bladder cancer invades the muscle wall, or when superficial cancer involves a large part of the bladder. In men, the nearby organs that are removed are the prostate and the seminal vesicles. In women, the uterus, the ovaries and part of the vagina are removed. Sometimes, when the cancer has spread outside the bladder and cannot be completely removed, surgery to remove only the bladder may be done to reduce urinary symptoms caused by the cancer. When the bladder must be removed, the surgeon creates another way for urine to leave the body. Our urologic oncology surgeons are among the most experienced in performing cystectomies. 

  • Segmental or partial cystectomy: Surgery to remove part of the bladder. This is a rarely performed procedure used mostly for adenocarcinomas of the bladder or in patients with a single tumor that cannot be removed completely by TUR. 

  • Urinary diversion: Surgery to make a new way for the body to store and pass urine. There are several different types of urinary diversions, which include a neobladder (a new bladder made out of intestine), a continent catheterizable diversion (a pouch out of intestine with an opening on the skin through which you catheterize), and an ileal conduit, which is a piece of intestine that allows urine to drain into a bag that fits on the skin. You and your doctor will make the decision as to which is the best option for you.
An ileal conduit is a piece of small intestine (ileum) that is harvested from your own intestinal tract. It is usually about 12cm in length. The remaining bowel is reconnected at the time of surgery so that stool continues normally. Most patients have no side effects from the removal of 12cm of small intestine, although rarely some patients may have chronic diarrhea. This can be treated and should be brought to the attention of your doctor.

The small piece of intestine is connected to the ureters (the tubes from the kidneys through which urine drains). This connection is inside the abdomen. The other end of the intestine is brought up to the surface of the skin as a stoma.

A stoma is a small piece of intestine open in the middle allowing urine to flow out of the body into a bag, which fits around the stoma.

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The type of urinary diversion will be up to you and your doctor to decide. The neobladder has the advantage of having no bags or appliances that fit to the body and represents the most “normal” reconstruction. However, it takes some retraining, during which time you will experience leakage of urine. In addition, you will be required to catheterize the new bladder for the first month after all catheters are removed. The ileal conduit has the advantage of being the simplest to take care of but does require the changing of bags attached to the skin for the rest of your life. However, both options will allow you to participate in essentially any activity you wish to, including swimming. Most people have serious concerns about possible side effects and life changes after this surgery. Remember, doctors and researchers are still learning about the treatment of bladder cancer. Talk with your surgeon any time you have concerns or questions. For patients with bladder cancer who require a cystectomy (bladder removal) and need to review post op care from surgery–please see the patient support section of our website.

Dr. Jeffrey Holzbeierlein, a national expert, Dr. Moben Mirza, Dr. Eugene Lee, and Dr. Hadley Wyre are all fellowship-trained urologic oncologists with expertise in the diagnosis and treatment of bladder cancer. These surgeons also perform many bladder cancer surgeries robotically. With the recent advancements in robotic technology, our urologists are now performing this complex operation with the aid of the daVinci® robot. This allows greater visualization and less blood loss. In addition, we hope that this may lead to a quicker recovery and return to normal activities. Our urologists perform more bladder removal surgeries than any other urologist or institution in the Kansas City area and continue to examine ways to decrease the side effects associated with this procedure.

Radiation Therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. Radiation treatments by themselves are not usually effective in getting rid of the cancer and thus are usually combined with chemotherapy (given through an IV). Most studies suggest that this approach is inferior to surgical removal of the bladder, but does have the advantage of "sparing" the bladder. This treatment is appropriate in select patients and will be discussed by your provider.

Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. For invasive bladder cancer, the chemotherapy is given through the vein (intravenously) and is referred to as systemic chemotherapy. The most common type of chemotherapy for bladder cancer is Methotrexate, Vinblastine, Adriamycin, and Cisplatin or Gemcitabine and Cisplatin. Chemotherapy is sometimes given prior to bladder removal (neoadjuvant chemotherapy), this is typically done when the doctor feels that the cancer is not confined to the bladder. Sometimes chemotherapy is given after bladder removal (adjuvant chemotherapy) when the pathology determines that cancer cells have grown into the fatty tissue around the bladder, into the prostate, or into the lymph nodes. Lastly, chemotherapy may be given if after surgery the cancer returns in another part of the body (salvage chemotherapy).

Follow-up tests may be needed.
Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Your doctor will usually want a CT scan within one month of a bladder removal surgery. If you are to receive chemotherapy first or are receiving chemotherapy and radiation, some tests will be repeated in order to see how well the treatment is working (CT scan and cystoscopy). Decisions about whether to continue, change or stop treatment may be based on the results of these tests. This is sometimes called re-staging.

After bladder cancer surgery, some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups. The frequency of these tests depends upon the stage and grade of your tumor.

In addition, your doctor will ask you to see an anesthesiologist prior to surgery. The anesthesiologist is the doctor in charge of putting you to sleep for the surgery and will need to evaluate you before surgery. Your doctor may also ask you to see a cardiologist (heart specialist) prior to surgery based on your other health problems or your age. A pulmonologist may also be needed before surgery if you have lung problems such as asthma, emphysema or COPD.

Bladder Cancer Research Program
At the University of Kansas Medical Center, Drs. Holzbeierlein and Lee lead a team of researchers hoping to find treatment strategies to reduce the burden of bladder cancer. In the laboratory, Dr. Lee is studying the effects of refined carbohydrates on cancer growth and progression. Additionally, there are ongoing trials including the DEAL (Diet, Exercise, and Lifestyle modification) Trial which will look at the effects of a low carbohydrate diet along with increased exercise in patients with high-risk non-muscle invasive bladder cancer. Additionally, our urologic oncology team is working with a mobile app to improve outcomes in patients undergoing radical cystectomy to improve post-operative outcomes, enhance patient centered communication, and decrease readmission rates following surgery. We also collaborate with multiple investigators throughout the institution on bladder cancer specific research projects. Our work is consistently presented at local, regional, and national meetings.

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