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Bladder Cancer

Bladder cancer is the seventh most common cancer in men, less common in women. Although the incidence of bladder cancer increases with age, it usually occurs after the age of 60-70. However, it should be known that this disease can be seen at any age. There is also a risk of recurrence of bladder cancer, which is more common in men than in women. For this reason, it is important to follow the patients closely.

What is bladder cancer?


The bladder, whose main function in the body is to store urine, is an organ that can stretch as it fills with empty urine. Bladder cancer usually starts in the urothelial cells of the mucosa lining the inner surface of the bladder. Bladder tumors can be malignant or benign. However, noncancerous benign bladder tumors can also be seen.


What are the symptoms of bladder cancer?


Bladder cancer symptoms are as follows:


  • Blood in the urine (hematuria): In bladder cancer, painless bleeding is usually seen in the urine. There may be visible bleeding in the urine, as well as bleeding that can be seen under a microscope. Bleeding may occur in the form of blood clots, not all of the urine. Blood in the urine can be caused by many reasons other than a tumor. It should be noted that different diseases such as kidney stones or infections can cause blood in the urine.

  • Painful urination

  • Urinating frequently

  • Feeling of urgency to urinate

  • Problems such as difficulty urinating and even inability to urinate due to a clot can be a symptom of bladder cancer.

In some cases, by the time the first signs of bladder cancer appear, the cancer may have already spread to another part of the body, metastasizing. The symptoms experienced in patients with metastasis may differ according to the region where the cancer has spread. In progressive bladder tumors:

  • Back pain

  • Pain in lower abdomen

  • Symptoms such as loss of appetite and weight loss may occur.


What are the causes of bladder cancer?


​Although the exact cause of bladder cancer is unknown, there are risk factors that can cause it.


  • Smoking: The most common risk factors for bladder cancer are smoking and tobacco use. Those who use cigarettes and tobacco products are 4-7 times more likely to develop bladder cancer than non-smokers. Passive smoking also increases the risk.

  • Age: Bladder cancer is more common after a certain age. The majority of people diagnosed with bladder cancer are over the age of 50.

  • Gender: Men are 3-4 times more likely to develop bladder cancer than women. However, the prevalence of cigarette consumption among women in recent years has led to an increase in the incidence of bladder cancer in women. Women are more likely than men to die from bladder cancer.

  • Chemicals: Chemicals used in the textile, rubber, leather, paint, chemical, battery industry or printing industry increase the risk of bladder cancer.

  • White people (caucasians) have the highest number of new cases of bladder cancer.

  • Chronic bladder infections.

  • Not drinking enough fluids and urinating too much.

  • Consuming a lot of high-fat or additive foods.

  • Having a family history of bladder cancer.

  • People who have received chemotherapy with cyclophosphamide and those who have received radiotherapy to adjacent areas of the bladder for other reasons have a higher risk of developing bladder cancer.


How is bladder cancer diagnosed?


Bladder cancer is determined by the symptoms experienced or as a result of suspicion during routine controls. First of all, an experienced urologist should be examined.


Urology doctor examination


The urologist will first evaluate risk factors for bladder cancer, such as genetics, smoking or exposure to radiation. In the physical examination of the urologist:

  • Systemic check and determine if there is a cancer sign.

  • It checks for swelling in the abdomen and liver.

  • Checks for enlarged lymph nodes in the groin, abdomen, and neck.


​In cases that are not normal and bladder cancer is suspected, additional tests may be requested to clarify the diagnosis.


Urine tests for bladder cancer


  • Urine test; It is a simple laboratory test. It is done to check for blood and other substances in a urine sample.

  • Urine cytology: The presence of cancer cells is checked by examining the urine sample under a microscope.

  • Urine culture: In the examinations made in the urine sample kept in the laboratory, what kind of microbes are examined. It is important to determine whether a bladder infection is present.

  • Urine tumor marker tests: A sensitive and specific marker has not been found yet. These tests look for substances released into the blood by bladder cancer cells.


Diagnosis of bladder cancer by imaging methods


  • Ultrasonography (USG): Ultrasound, which does not require the application of contrast material, easily detects bladder tumors larger than 5 mm, and can also help learn whether the kidneys or ureters are blocked. Ultrasound can also be used to determine the size of bladder cancer and whether it has spread to nearby organs or tissues.

  • Computed Tomography (CT urogram): It can provide information about the size, shape, and location of all tumors in the urinary tract, including the bladder. It can also help show enlarged lymph nodes, which may contain cancer, as well as other organs in the abdomen and pelvis. Sometimes a contrast agent is given orally or intravenously to the patient to obtain a more detailed image. Those who are allergic to iodine and other substances should tell their doctor beforehand.

  • Intravenous pyelogram (IVP): This method, which was used in the past to detect abnormalities in the bladder and urinary system, has left its place to newer and better informative methods.

  • Retrograde pyelogram: It is an application similar to the intravenous pyelogram procedure. The contrast material used is injected directly into the urinary system using cystoscopy, not intravenously. The retrograde pyelogram procedure is used to find out what is causing the obstruction in the normal flow of urine. It can also help diagnose cancer in the lining of the ureter or kidney.

  • MRI (Magnetic Resonance): It can be used to measure the depth and size of a bladder tumor and to view the lymph nodes where the cancer has spread. In order to get a detailed image about the tumor and its effects, the patient needs to be given contrast material.

  • PET CT Scan: A small amount of radioactive material is injected into the patient's body. Since this radioactive substance is absorbed by cancerous cells that tend to use energy, where the cancer has spread in the body is displayed. PET CT is not considered standard imaging for bladder cancer. It may have potential in the evaluation of metastatic bladder cancer.

  • Chest X-ray: It can be used to determine if bladder cancer has spread to the lungs. A chest X-ray is not needed if a chest CT scan has been done.Urine test; It is a simple laboratory test. It is done to check for blood and other substances in a urine sample.


Cystoscopy


Cystoscopy is one of the gold standard procedures in the diagnosis of bladder cancer. The inside of the urethra and bladder is examined with a thin flexible endoscope with a light and camera at the tip. In the cystoscopy procedure, the size, location and growth patterns of the abnormalities in the bladder can be determined. Biopsies and urine samples may also be performed during cystoscopy.​


Biopsy - Transurethral resection of bladder tumor (TUR-CT)


The urology doctor takes a piece of tissue that he sees as abnormal during cystoscopy and sends it to the laboratory for examination. During this procedure, which is also called transurethral resection of bladder tumor (TUR-CT), a sample of the bladder tumor and bladder muscle close to the tumor can be removed. During the biopsy procedure, he or she can evaluate the bladder to see if any mass is felt. TUR-CT can also be used in the treatment of non-muscle invasive bladder tumors.


Treatment of bladder cancer


Bladder cancer treatment options depend on several factors, including the patient's general health, the type of cancer, the extent of the cancer, and the stage of the cancer.


Surgical treatment of bladder cancerThe type of surgical treatment in bladder cancer may vary depending on the type of bladder tumor and the stage of the cancer.​


TUR surgery (Transurethral resection): Transurethral resection of bladder tumor, i.e. TUR surgery, is generally used to remove non-muscle invasive tumors that are located in the mucosa of the bladder but do not extend to the muscle layer of the bladder wall. TUR can also be used for bladder cancer diagnosis and staging.​


TUR surgery can be performed under general anesthesia or under regional anesthesia. TUR surgery is performed by entering the natural hole at the tip of the urinary tract without making any incisions in the body. 


During TUR surgery, the bladder is reached with an endoscope, which has a small U-shaped wire at the end of the urologist. The cancerous tissue is cut and removed from the body with an electric current. In very small tumors, after the piece is taken, the cancerous cells area is burned and the treatment is eliminated. 


After TUR surgery, the urologist may recommend chemotherapy, which is administered once a week or once a week for 6-8 weeks, to destroy the remaining cancer cells and prevent recurrence. 


Partial or segmental cystectomy: It is the surgical removal of the tumor and part of the bladder. The role of partial cystectomy in the treatment of bladder cancer is extremely limited, but it is applied in the treatment of some cancers with special histology. 


Radical Cystectomy: It is a surgical method in which the tumor and the entire bladder and nearby tissues and organs are removed. In radical cystectomy surgery, in addition to the bladder, the prostate and seminal vesicles of men, and the entire urinary tract in necessary patients are removed. In women, in the classical definition, the uterus, fallopian tubes, ovaries and all or part of the uterus are removed, but removal of the bladder within safe limits, leaving the gynecological organs in place, has also been practiced in recent years.​


The removal of lymph in the pelvis, called pelvic lymph node dissection in both men and women, is also part of the surgery. Pelvic lymph node dissection is the most accurate way to detect cancer that has spread to the lymph.


​In radical cystectomy surgery, which can be performed laparoscopically or robotically, the surgical procedure can be completed with smaller incisions instead of the larger incisions in open surgeries. 


New bladder from the intestine (Neobladder reconstruction): Since the bladder of the patients who underwent radical cystectomy surgery, a new way should be made for the urine to exit the body. There are different urinary diversion surgeries along with the methods in which a new bladder is created from a part of the intestine. Which urine diversion method is suitable for the patient is decided by the urology doctor by evaluating the biological age of the patient, the current diseases, the stage of the disease, and the possibility of treatments such as chemotherapy and radiotherapy that may be needed later. The final decision is made by discussing this decision with the patient in detail.


Chemotherapy treatment in bladder cancer


It is used to destroy bladder cancer cells that have spread throughout the body. Living without a bladder can sometimes negatively affect the patient's social life. For patients eligible to retain all or part of the bladder, chemotherapy and radiation therapy may be used as an alternative to bladder removal.​


Chemotherapy can be applied in two different ways in bladder cancer.​


  • Systemic Chemotherapy: Systemic chemotherapy is also known as whole body or intravenous chemotherapy. In the method applied by the Medical Oncologist, it is aimed that intravenous chemotherapy drugs circulate throughout the body and destroy cancerous cells. It is used in metastasized bladder cancers or in selected cases after radical cystectomy operations. Systemic chemotherapy can also be applied to shrink the tumor before surgery.

  • Intravesical Chemotherapy: Intravesical or local chemotherapy is usually administered by a urologist. Since cancer cells do not reach deep muscle tissues in superficial bladder cancers, intravesical chemotherapy can be used as a complement to TUR therapy in these patients. In intravesical chemotherapy, drugs are delivered to the bladder through a catheter placed in the urethra.


Radiation Therapy in Bladder Cancer


It can be used in addition to or after TUR with chemotherapy to treat bladder cancer in patients who are unsuitable for surgery or do not want surgical treatment. It can be preferred to reduce complaints caused by a tumor such as pain, bleeding or obstruction, or in the treatment of metastasized cancers.


Immunotherapy in Bladder Cancer


Immunotherapy, also called biological therapy , is the use of drugs to help the immune system recognize and destroy cancer cells. In the treatment of bladder cancer, immunotherapy is usually administered directly into the bladder. BCG vaccine is used as the standard immunotherapy drug for bladder cancer. BCG vaccine, which is administered by catheter into the bladder as a liquid, activates the immune system cells in the bladder and provides treatment. In recent years, studies on T cells, which are known to support the immune system and have a protective effect against infection and cancer, have yielded positive results.


FREQUENTLY ASKED QUESTIONS ABOUT BLADDER CANCER

How common is bladder cancer?


Bladder cancer is the seventh most common cancer in men, less common in women. However, bladder cancer is a more deadly cancer in women. The American Cancer Society estimates that 80,000 people (62,000 men, 18,000 women) will be diagnosed with bladder cancer in 2019 in the United States.


Which doctor should be consulted for bladder cancer or benign bladder tumors?


Although it is usually seen after the age of 50, the diagnosis and treatment of bladder cancer or benign tumors of the bladder, which can occur at any age, are carried out by urology doctors. Since there are surgical methods in the treatment of bladder cancer and benign bladder tumors, it is important to choose a urology doctor specialized in this field.


What are the types of bladder cancer?


Different types of cells in the bladder can be cancerous. It can be divided into types of bladder cancer according to the bladder cell in which the cancer starts. The type and stage of bladder cancer are also determined by the tests used in the diagnosis of bladder cancer. 

  • Urothelial carcinoma: Urothelial carcinoma, also known as transitional cell carcinoma, is the most common type of bladder tumor. It occurs in urothelial cells lining the inside of the bladder. Urothelial cells are also found in other parts of the urinary tract. For this reason, all urinary tracts of patients with bladder cancer should be checked.

  • Squamous cell carcinoma: A long-term infection in the bladder begins with the formation of thin, flat-shaped cells in the bladder after bladder irritation or long-term use of catheters. When viewed under a microscope, the cells look very similar to the flat cells found on the skin surface.

  • Adenocarcinoma: About 1% of bladder cancers are adenocarcinomas. It occurs in the mucus-secreting glands of the bladder. It occurs after prolonged irritation or infection in the bladder.

  • Small cell carcinoma: Less than 1% of bladder cancers are small cell carcinomas. It begins in nerve-like cells called neuroendocrine cells. These cancers often grow rapidly and must be treated with chemotherapy, which is usually used for small cell carcinoma of the lung.

  • Sarcoma: Sarcomas start in the muscle cells of the bladder but are very rare.​


Classification of bladder cancer tumors can also be made based on microscopic images of cancerous cells.


  • ​Low-grade bladder tumor: Also called well-differentiated bladder tumor. The appearance and organization of cancerous cells are close to normal healthy cells. A low-grade bladder tumor grows more slowly.

  • High-grade bladder tumor: Also called poorly differentiated bladder tumor. The appearance of cancerous cells and tumors does not resemble normal healthy cells. High-grade bladder tumors show a more aggressive behavior.​


Bladder cancers can also be diversified by their proximity to the bladder wall.​


There are many layers of different cells in the wall of the bladder. Most bladder cancers start from the innermost layer of the bladder that comes into contact with urine and spread to the muscles of the bladder over time. After reaching the bladder muscle layer, it is seen that it spreads out of the bladder and into nearby neighboring structures. Cancer of the bladder can metastasize to nearby lymph or to other parts of the body. Bladder cancer usually spreads to distant lymph nodes, bones, lungs or liver.​


  • Non-invasive bladder cancer: It is a cancer of the bladder that does not spread to the muscle and remains in its inner layer. It is also known as superficial bladder cancer or early-stage bladder cancer.

  • Invasive bladder cancer: It means that the cancer cells have spread deeper than the inner layer of the bladder, into the muscle layer. If left untreated, there is a risk of the cancer spreading to other parts of the body. These cancers are more likely to spread and must be treated. 


Bladder cancer is also diversified by the way it grows.​


  • Papillary Urothelial Carcinoma: Papillary tumors begin in the urothelial cells of the bladder mucosa and are growths that extend into the inner cavity of the bladder. Sometimes, these cancers stay in the bladder without spreading even though they grow. But the more aggressive types of this cancer can spread to the deep layers of the bladder and then to other organs.

  • Flat carcinoma (Carcinoma in situ): It does not grow into the deep part of the bladder or its inner cavity. It is an invasive tumor form that spreads in the bladder wall in a flat tumor layer structure.


What are the stages of bladder cancer?


Three criteria are considered to determine the stage of bladder cancer. 


  • The depth of the cancerous tumor in the bladder wall and the grade of the tumor

  • Whether the bladder tumor has spread to regional lymph nodes

  • It is examined whether the bladder cancer has metastasized to other organs such as the lung or liver.


Information from pathology and examinations is used to find out which parts of the bladder are cancerous, whether the cancer has spread from where it first started, and where the cancer has spread. Bladder cancer staging is done according to the international TNM system.​


Risk and Side Effects of Surgical Treatment in Bladder Cancer​


TUR surgery


  • Side effects of bladder cancer TUR surgery are usually mild and do not last long. After TUR surgery, pain and slight bleeding may occur while urinating. The effects seen return to normal within 1-2 weeks.

  • Although the bladder tumor is completely removed after TUR surgery, the tumor may recur.

  • More than one TUR surgery may cause problems such as stenosis in the urinary tract.


Radical Cystectomy and bowel neobladder or ileal loop diversion surgery


  • Radical cystectomy operations are more severe than TUR operations. Side effects of anesthesia can be seen.

  • Bleeding

  • Infection

  • Blood clots in the legs or lungs

  • Damage to neighboring organs

  • Urinary incontinence or obstruction of urine flow

  • In men, the disappearance of sperm output, erection problem can be seen. Erection problems and sexual reluctance can be prevented with new nerve-sparing surgical techniques. Women may experience menopause and sexual reluctance, but organ preservation techniques are preferred in age-appropriate patients.


What should be the follow-up process after bladder cancer treatment?


The follow-up process is very important in bladder cancer patients, as there is a risk of recurrence (recurrence) of bladder cancer after treatment. Follow-up is an important part of cancer treatment. Follow-up after bladder cancer treatment may vary depending on the stage and grade of the cancer and the type of treatment applied. Bladder cancer has a high probability of recurrence in the first 2 years after treatment, after which the follow-up is extended up to 10 years, although the probability of recurrence decreases.


​​Although the follow-up process varies according to the patient, it is important to check every 3 months in the first year. In the follow-ups, while the liver and lymph nodes are checked, the bladder is observed with cystoscopy to determine if there is any recurrence in the bladder. In cases where the treating doctor deems it necessary, imaging methods such as CT, MR, ultrasound, PET CT are also used.


What is the survival rate in bladder cancer?


Survival or recovery from bladder cancer varies from person to person. Success depends on the type and stage of bladder cancer, the number and size of the tumor, the characteristics of the cancer, its recurrence, the treatments chosen, and the patient's response to the treatment. That's why bladder cancer survival rates are actually personal. In the study of the American Cancer Society, considering all stages of bladder cancer, the 5-year survival rate for people with bladder cancer is 77%, the 10-year survival rate is 70%, and the 15-year survival rate is 65%.


Bladder cancer most commonly metastasizes to which organ?​


Bladder cancer most commonly metastasizes to the lungs, liver, or bones.


What should someone with bladder cancer eat?


It is not known exactly what reduces the recurrence rate after bladder cancer treatment. The benefit of nutrition in the development of bladder cancer or after treatment is not clear in scientific studies. With this; quitting smoking, eating a natural and balanced diet, and engaging in regular physical activities can be beneficial.


Is there any herbal or natural treatment method for bladder cancer?


There is no scientific evidence that diet, herbal products, vitamins and minerals prevent the development of bladder cancer or reduce the possibility of recurrence. Many studies have been done on this subject, in general, natural and healthy diet and active activity are recommended.


Does bladder cancer occur in young people?


Bladder tumor is a common disease over the age of 50. However, in practice, it is observed that it is seen even in the 20s. In addition, the incidence of bladder tumors in men is approximately 4 times higher than in women. However, it tends to have a worse prognosis when seen in women.

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