Bladder cancer

The bladder is a hollow organ located in the small pelvis, the function of which is to accumulate and remove urine.

Bladder cancer is formed when the cells of the bladder begin to grow abnormally. Instead of growing and dividing in an orderly manner, mutations occur in these cells, as a result of which they begin to grow uncontrollably, and the program of programmed cell death disappears.

Bladder cancer begins most often in the cells lining the inner surface of the bladder (epithelium) and occurs in the elderly, although its development can occur at any age.

Most often, bladder cancer is manifested by the following symptoms:

1. Hematuria - blood in the urine. Urine can be bright red, maroon, dark cherry color – this condition is called macrogematuria; however, the urine can have a normal color and transparency, but a laboratory examination of the urine reveals red blood cells – red blood cells of the blood) - microhematuria, which is also an indication for further examination.

2. Dysuria (violation of the process of urination): frequent, or painful, or difficult urination. It may be a combination of these symptoms. 

3. Pain in the back, lower abdomen, pelvic area.

Causes and risk factors.

Currently, it is not known for sure what causes bladder cancer. However, certain risk factors for this disease have been proven:

• Smoking cigarettes, cigars, or pipes can increase the risk of bladder cancer. During smoking, the human body processes the chemicals of smoke and releases some of them in the urine. These harmful chemicals can damage the lining of the bladder, thereby increasing the risk of cancer.

• Age. The risk of bladder cancer increases with age. Bladder cancer can occur at any age, but is rare in people younger than 40.

• Race and gender. White people have a higher risk of developing bladder cancer than people of other races. Men are more likely to develop bladder cancer than women.

* Exposure to certain chemicals. The kidneys filter harmful chemicals from the blood and remove them to the bladder. The presence of certain chemicals in the urine contributes to damage to the bladder mucosa. Arsenic and chemicals used in the production of dyes, rubber, leather, textiles, and paint products that enter the body can eventually lead to the appearance of bladder cancer.

• Heredity. If one or more of the close relatives suffered from bladder cancer, the risk of getting this disease increases.

* Chronic inflammation of the bladder (chronic cystitis). In tropical countries, squamous cell carcinoma is associated with chronic inflammation of the bladder caused by a parasitic infection known as schistosomiasis.

Types of bladder cancer.
The inner surface of the bladder (mucosa) consists of different types of cells. The type of cells in which the mutation occurred determines the type of bladder cancer. 

• Transient cell carcinoma occurs in the cells lining the inner surface of the bladder. These same cells line the upper urinary tract (pelvis, ureters) and urethra, where this type of cancer can also form. This is the most common type of bladder cancer.

• Squamous cell carcinoma. Squamous cells appear in the bladder in response to infection and irritation. Over time, they can become malignant. Squamous cell bladder cancer is a rare occurrence in Russia. It is more common in tropical African countries (such as Egypt), where there is a certain parasitic infection (schistosomiasis).

• Adenocarcinoma. A very rare type of bladder cancer. It comes from the cells of the mucous membrane, which normally produce mucus, so when microscopically examined, it has a glandular structure.

Stages of bladder cancer.

• Stage I. Surface (non-invasive) bladder cancer-spreads on the inner lining of the bladder, but does not grow through the muscle wall.
• Stage II. Invasive cancer - at this stage, the cancer sprouts the muscle wall of the bladder, but is confined to the bladder.
• Stage III. The tumor has grown through the wall of the organ, reaching the adipose tissue surrounding the bladder, but does not spread to neighboring organs. 
• Stage IV. At this stage, the tumor process involves neighboring organs: the intestine, pelvic walls, abdominal wall, in men - the seminal vesicles and prostate, in women-the vagina, ovaries and uterus.

Diagnosis of bladder cancer

Cytology. A sample of urine is analyzed under a microscope to check for the presence of cancer cells in its sediment. This test is called a urine test for atypical cells. 

Most often, a bladder tumor is detected during a routine ultrasound examination of the pelvic organs. It is important that the bladder is sufficiently filled before performing ultrasound, then all its walls will be visible and the study will be as informative as possible.

Cystoscopy. During a cystoscopy, the doctor inserts a narrow tube (cystoscope) into the urethra. The cystoscope has a lighting system, a lens and a fiber-optic camera, which allows the doctor to see and examine the mucous membrane of the urethra and bladder. During a cystoscopy, the doctor may take a tissue sample (biopsy) for histological examination from a suspicious area of the mucosa or from a detected tumor.

Excretory urography. After intravenous administration of the contrast agent, an X-ray examination of the kidneys and urinary tract is performed, so that you can see their anatomical picture and determine the pathology. 

After the doctor has identified a patient with bladder cancer, additional research methods are prescribed in order to stage the disease, exclude / confirm metastases and choose the most effective treatment method. 

These are studies such as Magnetic resonance imaging (MRI), Computed Tomography (MSCT), Scintigraphy, and chest radiography.

Magnetic resonance imaging with intravenous contrast is an imaging method of investigation that has maximum sensitivity and specificity in the diagnosis of bladder cancer and the establishment of its stage of local spread. The clinical and diagnostic department of the MCSC is equipped with the most modern magnetic resonance imaging device, which helps urologists daily in the examination of patients with cancer, thereby making it possible to choose the most optimal treatment method for them.

Treatment of bladder cancer

The most effective and radical way to treat bladder cancer is surgical treatment.

The treatment method depends on the type and stage of bladder cancer, on the general condition of the patient. In the case of an advanced stage of the disease or a serious condition of the patient, when surgical treatment is not indicated, the patient may be offered alternative treatment methods, such as radiation and / or chemotherapy.

However, most cases of bladder cancer are diagnosed at an early stage. With early detection of bladder cancer, surgical treatment is the most effective and it can be performed in a minimally invasive (endoscopic) way. After the treatment, relapses are possible, and therefore patients are under the supervision of urologists and oncologists for many years. 

Transurethral resection of the bladder (TOUR of the bladder wall with a tumor). This method has become the "gold" standard of treatment for non-invasive bladder cancer. During transurethral resection, a special loop with electrical energy connected to it is inserted into the bladder through a cystoscope, with the help of which the tumor is resected with the wall that is subject to it and the cancer cells are "burned out" with an electric current. In some cases, a laser is used.

Use of chemical and biological preparations: instillation (introduction) into the bladder of chemotherapy drugs (doxorubicin, mitomycin) and vaccines (BCG) has a proven antitumor effect. The tour of the bladder should end with the instillation of a chemotherapy drug into the bladder, which prevents implantation metastasis (attachment of cancer cells) to the healthy walls of the organ and reduces the risk of relapse. 

Surgery for invasive bladder cancer.

The only radical treatment for invasive bladder cancer is the complete removal of the organ - radical cystectomy. This is an operation to remove the entire bladder and regional lymph nodes. In men, a radical cystectomy involves the removal of the prostate gland and seminal vesicles and is called a cystoprostatevesiculectomy. In women, radical cystectomy, in addition to removing the bladder, involves removing the uterus, ovaries, and part of the vagina - anterior exenteration of the pelvis.

After removing the bladder, it is necessary to create a replacement for it - a new reservoir for the accumulation of urine, in which the ureters are sewn. There are several options for replacement plastic surgery of the bladder. The surgeon can create a urinary reservoir (conduit) using part of the patient's intestine, which is then sewn to the patient's abdominal wall. In this case, the urine will flow into the pouch (urostoma), which the patient wears on his stomach. This method of removing urine is called the Bricker operation. 

Alternatively, the surgeon may use a portion of the intestine to create a small reservoir for urine in the pelvis at the site of the removed bladder, which is then sutured to the urethra. This allows you to urinate naturally, almost normally. This technique can be used if you are sure that the cancer has not gone far beyond the bladder wall.

Currently, endoscopic techniques for removing the bladder-laparoscopic or robotic cystectomy-are widely used. They are performed through small punctures on the abdominal wall and allow you to perform one of the most complex urological operations – cystectomy - minimally invasive. This reduces blood loss, reduces the number of complications, and reduces the patient's recovery time.

In most developed countries of America, Europe and Asia, where there are robotic surgical complexes, cystectomy is performed with their use. In a number of recent studies, robotic radical cystectomy has demonstrated significant advantages over open and laparoscopic surgery and claims to become the "gold" standard in the treatment of invasive bladder cancer.

We are proud to say that the surgeons of the urology department of the MCSC successfully perform such operations and have a rare experience in Russia of performing radical cystectomy using the Da Vinci Si robot.