Bladder Cancer

What is Bladder Cancer?

The bladder is a urinary tract organ whose main function is to store the urine produced by the kidneys before it is expelled from the body.

The bladder wall consists of various layers, the uppermost of which is a specific urinary tract lining called the transitional epithelium or urothelium.

This layer sees a high level of cell renewal and these cells very often undergo a transformation, multiplying abnormally and leading to the formation of a tumour.

A bladder carcinoma is the second highest cause of death by urological neoplasia and the fourth highest cause of death by cancer in men.

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Bladder Cancer Risk Factors

The highest risk factors for bladder cancer are:

Smoking

Exposure to chemical products

Genetic changes

Chronic inflammation of the bladder

Some chemical products can cause bladder cancer, such as aromatic amines, aniline-based paints, nitrites and nitrates, and prolonged contact with coal and/or arsenic.

Finally, chronic catheterisation, infection by Schistosoma haematobium and pelvic radiotherapy are identified as factors causing chronic inflammation associated with the appearance of carcinomas.

However, the most common cause is smoking. Most patients with malignant bladder cancer are smokers.

Types of Bladder Cancer

Over 90% of bladder tumours are called urothelial carcinomas (UCC) or transitional cell carcinomas (TCC), because they originate in the cells of this type.

Urothelial carcinomas are classified into 2 groups with different behaviour:

Superficial cancers (that do not invade the bladder wall muscle, or “detrusor”);
Invasive cancers (muscle invasive) that are still limited to the bladder.

Invasive cancers can spread outside the bladder and invade the adjacent organs. They can spread to the lymph nodes or metastasise with lesions in other organs far from the bladder.

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Symptoms of Bladder Cancer

Haematuria (blood in the urine) is the most common way in which this type of cancer manifests itself. Other symptoms are:

Polaquiury (more frequent urination);
Sudden urge to urinate;
Urgent incontinence – associated with the sudden urge to urinate;
Burning sensation when urinating;
Erectile dysfunction;
Loss of weight.

Patients may only show these symptoms without detection of haematuria, mainly if it cannot be seen by the naked eye (it may only be detectable under analysis).

Diagnosis of Bladder Cancer

When there is a suspicion of bladder cancer, the symptoms or signs of the disease must be assessed.

Complementary testing is therefore essential for diagnosis, both to confirm the presence of cancer and to assess its stage.

Urethrocystoscopy is the most important exam as it is key to assessing if lesions exist (commonly known as “polyps”) and detecting bladder neoplasia.

Other tests are often used to diagnosis the cancer, such as urine cytology and ultrasound scans of the bladder. Besides these and routine blood and urine tests, other tests may be necessary to stage the cancer. The most common are abdominal, pelvic and also thoracic CT scans.

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Treatments for Bladder Cancer

The treatment varies according to the size, volume and aggressivity of the cancer.

In some bladder cancers, treatments like chemotherapy, radiotherapy and palliative therapies may be necessary. However, the most common and most effective treatment is surgery.

There are two types of surgery: endoscopic for superficial cancers; laparoscopic, or open, for more aggressive cancers (this is increasingly replacing classical open surgery).

Both surgical techniques are minimally invasive which reduces hospitalisation, post-operative complications and recovery time.

Endoscopic surgery is performed on superficial cancers. It is much less aggressive and better tolerated.

Laparoscopic surgery (open surgery) is reserved for invasive cancers, so it is much more aggressive and radical – far more "mutilating" – as it involves the removal of the bladder.

Endoscopic Surgery for Bladder Cancer

Endoscopic surgery is the preferred treatment for patients with superficial bladder cancer.

See Treatment

Laparoscopic Surgery for Bladder Cancer

Laparoscopic surgery is a technique used to treat bladder cancer in preparation for radical cystectomy.

See Treatment

Prognosis of Bladder Cancer

When assessing a cancer, different characteristics are analysed to define the prognosis. Examples of these are size, number of tumours, spread and the histological characteristics of the cancerous tissue.

Correctly identifying these characteristics allows for a better prognosis. Logically, this is more suitable for superficial cancers compared to those that have invaded the bladder wall and muscle (called “detrusor") or spread outside the organ.

This type of cancer has a high rate or recurrence, so the urologist establishes an active surveillance plan, particularly with regular bladder endoscopies (cystoscopies). A cystoscopy is therefore performed for the initial diagnosis and also after surgery to detect any recurrence early. After surgery, it should be performed at shorter intervals (initially and usually every 3 months). These intervals are gradually lengthened over time. After 5 years, these may become annual.

In most patients, the cancer remains superficial, even if it recurs (and it may recur multiple times during the patient’s life). In some cases, unfortunately, the cancer can become invasive and in these cases more aggressive surgery is necessary – not endoscopic to remove polyps but surgery to remove the bladder.

It is essential that patients stop smoking. If they don’t, there is greater risk that the disease will return.

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Dr. José Santos Dias

Clinical Director of the Instituto da Próstata

Bacherlor's Degree from the Faculty of Medicine at the University of Lisbon
Specialist in Urology
Fellow of the European Board of Urology
Autor dos livros "Tudo o que sempre quis saber Sobre Próstata", "Urologia fundamental na Prática Clínica", "Urologia em 10 minutos","Casos Clínicos de Urologia" e "Protocolos de Urgência em Urologia"

See Biography