Bladder Cancer

Bladder Cancer
- Second most common genitourinary tract malignity

- Male-female ratio = 3:1

- Peak ~ 60-70 years of age

Aetiology

-	Chemicals (e.g.: benzidine, aniline dyes, cyclophosphamide)

-	Smoking

-	Chronic irritation of mucosa (chronic inflammation, lithiasis, schistosomiasis)

-	Often associated the Balkan nephropathy (which is labelled as precancerosis)

-	Analgesic (phenacetin) abuse (more frequent formerly)

Pathology

-	98% epithelial tumours of malignant or benign origin. Mesenchymal tumours are rare (sarcoma, lymphoma)

a)	Benign: urothelial papilloma, squamous papilloma

b)	Malignant: Urothelial carcinoma (90%), Epidermoid carcinoma (7%), Adenocarcinoma (2%)

Staging

Table 2002 TNM staging of bladder carcinoma [1]

Tx Primary tumor cannot be assessed

T0 No evidence of primary tumor

Ta Noninvasive papillary carcinoma

Tis Carcinoma in situ

T1 Tumor invades subepithelial connective tissue

T2 Tumor invades muscularis propria (detrusor): T2a inner half; T2b outer half

T3 Tumor invades beyond muscularis propria into perivesical fat:

T3a = microscopic; T3b = macroscopic (extravesical mass)

T4a Tumor invades any of prostate, uterus, vagina, bowel

T4b Tumor invades pelvic or abdominal wall

Nx Regional (iliac and para-aortic) lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 Metastasis in a single lymph node <2 cm in greatest dimension

N2 Metastasis in a single lymph node 2–5 cm or multiple nodes <5 cm

N3 Metastasis in a single lymph node or multiple nodes >5 cm in greatest dimension

Mx Distant metastasis cannot be assessed

M0 No distant metastasis

M1 Distant metastasis present

Symptoms

-	Haematuria in 85-90% of patients  (painless)

-	Vesical irritability: frequency, urgency, and dysuria

-	In advanced disease: bone pain (from metastases), flank pain (from retroperitoneal metastases), or ureteral obstruction

Diagnosis

-	Physical findings: rectal / Vaginal examintation --> palpable tumour

-	Laboratory: FW↑, BC↓, Urea↑, Creatinine↑

-	Cytology: tumour cells in urine --> staging

-	Flow cytometry

-	Tumour markers: BTA test (bladder tumor antigen)

-	X-Ray, IVU, Ultrasound, CT, MRI, Scintigraphy --> staging, metastes, etc

-	Cystoscopy + transurethral resection (biopsy) = TURB --> possibly with Fluorescence cystoscopy using blue light after application of 5-ALA

Treatment

1)	Superficial tumours

-	Transurethral resection --> electroresection or laser technology

-	Prophylaxis of tumour recurrence: local chemotherapy or immunotherapy (BCG-vaccine!)

-	Cystectomy + urine diversion: only if ≥ 50% of bladder mucosa is affected

2)	Infiltrative Tumours

-	Partial resection

-	Radical resection + urine diversion: in men --> prostate, seminal vesicles must also be removed // in women --> uterus, tubes, ovaries and part of the anterior vaginal wall must also be remove

Urinary diversion --> several surgical techniques possible. Several include the creation of a neobladder out of intestines. If possible, the urethra can be attached through anastomis to the neobladder.

References 1.	Oxford American Handbook of Urology - David M. Albala, Allen F. Morey, Leonard G. Gomella, John P. Stein 2.	Textbook of urology – Zbyněk Veselský et al. 3.	Smith’s General Urology – Emil A. Tanagho, Jack W. McAnich (17th edition)