Bladder Cancer (cont.)
Kevin C. Zorn, MD, FRCSC, FACS
Gagan Gautam, MD, MCh
Charles Patrick Davis, MD, PhD
Charles Patrick Davis, MD, PhD
Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.
In this Article
What is surveillance for bladder cancer?
Patients diagnosed and treated with superficial bladder cancer need to be followed up regularly to detect recurrences and treat them effectively. The following is a typical follow-up protocol:
Cystoscopy and cytology detects recurrence in the bladder itself while CT/IVU is used to detect a tumor in the kidneys and ureters. Patients with bladder cancer are more likely to get upper-tract tumors which arise from the inner lining of these organs and share a common origin with bladder tumors. The risk of upper-tract recurrence depends on the stage and grade of the initial disease and the response of the tumor to BCG. Individuals with recurrent high-grade bladder tumors can have to a risk of developing a tumor in the upper tracts and need to be followed closely in this regard.
Commercially available tumor markers which are used to test urine samples for evidence of bladder tumor recurrence are also being used in follow-up protocols. However, their exact role is undefined as of now and they are not considered an adequate substitute for cystoscopy and cytology. Some of these markers are NMP 22, BTA Stat, BTA Trak, and UroVysion.
What is the treatment of muscle-invasive bladder cancer?
Muscle invasive bladder cancer generally requires a more aggressive treatment plan than superficial bladder cancer. The standard and most effective treatment is the surgical removal of the bladder and diversion of the urinary stream using intestinal segments. This procedure, known as radical cystectomy, is a major operation and a thorough discussion and counseling of the risks, complications, and benefits is warranted prior to this surgical procedure.
In short, the procedure entails removal of the bladder, prostate, seminal vesicles, and the fatty tissue around the bladder through an incision made in the abdomen. The surgery also includes removal of lymph nodes in the pelvis on both sides of the bladder to detect their involvement with the cancer. This helps in deciding further management after surgery including the need for chemotherapy. It has been shown that patients who undergo a thorough lymph node dissection have a better chance of cure as compared to patients who either do not receive one or undergo a less extensive dissection.
Radical cystectomy can be performed via open surgery, laparoscopy, or with robotic assistance. It has been shown that the outcomes in terms of cancer control and cure rates do not differ between these different approaches. However, the use of laparoscopic and robotic approaches significantly decreases blood loss during the surgery, decreases the need for blood transfusions, and may help in early recovery by decreasing postoperative pain at the surgical site. An additional advantage of the robot is that it permits an enhanced magnification of the surgical field with three-dimensional vision which helps to enhance surgical precision. It is very important to note that all these approaches can achieve comparable results in terms of cancer control in the hands of surgeons skilled and experienced in a particular modality. So, the comfort factor and experience of an individual surgeon in a particular approach should play a major role in the patient's decision regarding selection of the approach for surgery.
Once the bladder has been removed, the urine needs to be diverted. There are three popular ways of doing that. All of them require the use of segments of the intestine which are still connected to their blood supply but have been disconnected from the gastrointestinal tract.
Radical cystectomy (open, laparoscopic, or robot assisted) combined with one of the three urinary diversion methods is the gold standard for the treatment of muscle invasive and selected cases of high-grade superficial bladder cancer. Certain patients, however, may be unfit or unwilling to undergo this surgery. These patients can often undergo a combination of extensive TURBT, chemotherapy, and radiation in an attempt to cure or control the disease without the need to remove the urinary bladder surgically. Most experts believe that this regime may not be as effective as a radical cystectomy but can be used as an option in unfit/unwilling patients. Radiation to the bladder can, however, lead to its own set of problems and complications, including radiation damage to the bladder and rectum which give rise to bleeding and irritative symptoms ("radiation cystitis" and "radiation proctitis").
Reviewed by Charles Patrick Davis, MD, PhD on 11/26/2013
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