Primary urothelial carcinoma of the bladder occurs in patients who typically are smokers, or who have been exposed to occupational fumes in poorly ventilated work environments. These occupational risk factors include painters, exposure to dyes in the textile or rubber industries, engineers exposed to fumes in a poorly ventilated factory, hairdressing dyes – all of which are potentially carcinogenic and after inhalation, the agent enters the blood and is excreted into the urine and this agent takes effect on the urinary system lining, to cause a cancer.
Bladder cancer can effect the upper urinary tract, (ureter/renal pelvis). Therefore, whenever a patient is diagnosed with a tumour in the bladder, the urologist will assess the upper urinary system as well, to exclude a lesion present at the same time.
The patient typically presents with blood in the urine that is painless on passing urine. The urologist will undertake a full assessment including urine culture to exclude infection, voided urine cytology, imaging either by way of ultrasound or CT scanning and ultimately a cystoscopy must be performed to identify how many tumours exist in the bladder and they are surgically removed at cystoscopy.
The removal is either by way of a biopsy forcep with cautery to the base of the lesion, or a larger telescopic system is required to shave out the tumour using a loop resectoscope system with an irrigation set.
Subsequent management is dependent on the grade of each cancer under the microscope and its stage, in terms of how far through the bladder wall it has progressed.
Bladder cancer is generally divided into low grade cancers and high grade cancers. Low grade cancers tend to simply require a surveillance follow up cystoscopic protocol and there are several local and international guidelines we follow for this, however typically initially the check cystoscopy is performed every three months, and if there is no recurrence, this interval is lengthened to eventually yearly or second yearly.
The high grade bladder cancers require further endoscopic resection to make sure no cancer has been left behind at the initial resection. Subsequently intravesicle immunotherapy or chemotherapy instillations may be required with the possible involvement of the medical oncologist. Staging scans may be needed for high grade cancers that infiltrate through into the true muscular wall of the bladder, and in whom there is no distant spread to lymph nodes or other organs, the operation of choice is a cystoprostatectomy, with a urinary diversion, with pelvic lymph node clearance.
Pre-operative or post-operative chemotherapy may be required, again with the involvement of the medical oncologist.