Bladder tumours can invade the thickness of the wall of the natural urine reservoir to varying degrees. Two categories of tumour are distinguished:
Bladder tumours represent 3 to 4% of all cancers and are the second most frequent urological tumour in men after prostate cancer. Males are affected three times more frequently than females and the mean age of diagnosis is about 60 years. No hereditary factor has been identified.
Two main factors able to promote the development of bladder tumours have been recognized:
The most frequent bladder tumours are transitional cell carcinomas, which are observed in 95% of cases. Squamous cell tumours, sarcomas or tumours secondary to schistosomiasis are much less common.
Bladder tumours are classified according to increasing degrees of invasion of the thickness of the bladder wall, bearing in mind that stage PTa, only involving he bladder mucosa, and stage PT1, only involving the lamina propria, are still accessible to endoscopic treatment, while from stage PT2 (tumour invading superficial muscle) to stage PT4, treatment is surgical.
The appearance of the tumour cells is also classified into grades: grade G0, normal cells, to grade G3, very poorly differentiated cells, i.e. they only barely resemble a bladder tumour. The aggressiveness of the tumour increases in proportion to the grade.
Carcinoma in situ must be considered separately, as it is a form of tumour which only affects the cells without inducing any real proliferation.
Metastases essentially affect lymph nodes, bone, lungs and liver.
Haematuria, i.e. bloody urine, is the key sign. This haematuria is usually terminal, i.e. it occurs at the end of micturition when the bladder contracts. It can also be total, occurring throughout micturition. Bladder tumours sometimes present in the form of voiding disorders, such as urgency, i.e. recent onset of an urgent desire to urinate, which is difficult to control, especially during the day. Recent onset of urgency in a male smoker is suggestive of a bladder tumour and complementary investigations must be performed. Much more rarely, bladder tumours are detected by systematic abdominal ultrasound examination.
There are three key examinations:
Other tumour sites are also investigated by intravenous urography, as this disease can affect all of the urinary tract mucosa from the renal calyx to the urethral meatus.
The key examination is endoscopic resection via natural passages.
An instrument called a resector is introduced into the urethra and is used to resect, i.e. remove by scraping, the polyp from the bladder wall. The polyp can then be examined under the microscope, an essential element for the decision concerning subsequent treatment. This endoscopic resection is performed in hospital under general or peridural anaesthesia, and requires insertion of a catheter and a hospital stay of several days.
This depends on the type of tumour detected on microscopic examination. No other examinations are required in the case of a superficial polyp. When the tumour is invasive, abdominopelvic CT scan looking for local extension or lymph node metastases, and hepatic ultrasonography looking for liver metastases, may be performed.
Bone scan is only performed in the presence of specific bone pain and should not be performed routinely. Finally, a chest x-ray is performed to verify the absence of lung lesions.
Once the diagnosis has been established, the therapeutic approach is determined, according to the two main types of tumour: bladder polyps and invasive tumours or cancer.
After performing complete endoscopic resection of a superficial polyp, when histological examination indicates that the lesion is isolated, exclusively mucosal, and not high grade, no further treatment is required.
External focal ultrasound is currently being studied in the context of an experimental protocol for the treatment of superficial tumours.
In contrast, in the case multiple tumours or stage PT1 tumours involving the lamina propria, or a high grade G3 tumour, intravesical instillation treatment with chemotherapy (Mitomycin C) or immunotherapy (BCG) is required. Both techniques provide useful results by reducing the frequency and number of recurrences and by limiting possible progression of certain fairly aggressive PT1-G3 tumours.
In every case, the urologist informs the patient as precisely as possible about the type of treatment required. These instillations are performed on an outpatient basis, generally once a week for six weeks, possibly followed by complementary treatment every month or every two months, for one or two years.
The real risk of superficial tumours (bladder polyps) is recurrence.
These recurrences can be multiple, and can occur at various intervals, from several months to several years, which is why surveillance is essential, every six months for about 18 months, then annually, by bladder ultrasound or cystoscopy and urine cytology.
Progression of a superficial bladder tumour to a cancer is much less common (between 5 and 10% of cases) and concerns fairly aggressive PT1-G3 tumours. In these cases, following chemotherapy or immunotherapy, the bladder must be verified by further resections and multiple biopsies.
When the tumour involves the muscle, treatment is much more aggressive as endoscopic surgery is no longer indicated. This surgery obviously confirms the diagnosis, and the tumour must then be removed as completely as possible. This surgery consists of radical cystoprostatectomy, removing the prostate, seminal vesicles and bladder, with ilio-obturator lymph node dissection, followed by bladder replacement either by using a segment of small intestine, approximately 30 to 50 cm long (intestinal neobladder), with implantation of the two ureters, or by placing the two ureters into the colon or rectum ensuring rectal micturition, or finally by diverting the urine onto the skin by bilateral cutaneous ureterostomy, in which each ureter is brought out onto the skin, or more simply by Bricker's procedure draining the two ureters into a small segment of small intestine, without the need for a catheter, but only one rather than two stomy bags.
When allowed by the extent of the disease, the prostate can be preserved, thereby allowing excellent continence, and preservation of a good quality sex life, while removing the bladder and replacing it with intestine.
Other treatments are proposed after endoscopic resection, consisting of chemotherapy associated with external beam radiotherapy, designed to sterilize the tumour. Radical surgical resection is required in the case of tumour progression.
When lymph nodes are involved or in the presence of metastases, chemotherapy has a certain efficacy and can be legitimately proposed to the patient. In contrast, systematic chemotherapy after resection of the bladder is much more controversial.
Depending on the type of urinary diversion, follow-up consists of blood tests with assay of serum electrolytes and creatinine and abdominopelvic and thoracic CT scan, or chest x-ray and hepatic ultrasonography, looking for any recurrences or metastases.
These examinations may be performed every six months for the first three years, then approximately annually thereafter.
In conclusion, bladder tumours are relatively frequent. They can be cancerous and therefore aggressive. Early management, right from the first sign of bleeding, allows a long survival and good quality of life, by means of less mutilating treatments.
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