- What is Bladder?
- What is Bladder Cancer?
- Types of Bladder Cancer
- Symptoms of Bladder Cancer
- Diagnosis of Bladder Cancer
- Phases of Bladder Cancer
- Treatment of Bladder Cancer
- Treatment According to Phases of Bladder Cancer
- Bladder Cancer Surgery
- Neobladder Surgery
- Radiotherapy and Chemotherapy in Bladder Cancer
- Complications in Bladder Cancer Surgery
- Visuals on Bladder Cancer Surgery
What is Bladder?
The bladder (urinary bladder) is a balloon shaped organ located in the lower abdomen that stores the urine discharged from the kidneys. The bladder muscle shrinks & expands and therefore ensures the storage of urine inside. In the waist zone of humans, there are two pcs kidneys on the lateral sides of the spine. The miniscule tubes inside the kidney create urine by filtering the blood and the urine is transferred to the bladder through the ureter. And the urine stored in the bladder is discharged from the body via the urination channel, which is called the urethra.
What is Bladder Cancer?
70 percent of the bladder cancers, which start at the interior surface of the bladder and later advance to bladder layers, can be operated by closed method, as they don’t advance to deep layers. 30 percent of bladder cancers require the entire removal of the bladder and the construction of a new bladder. Surgeries thereof require more experience and skill.
What is Repetitive Bladder Cancer?
It is the repetition of cancer in the bladder itself or other parts of the body after the bladder cancer is treated.
Types of Bladder Cancer
Transitional cell cancer starts at the cells on the interior surface of the bladder. Transitional cell cancer is examined under two groups, which are low and high phase cancers, depending on the aggressiveness of the cancer. Those in low phase frequently repeat after treatment. But it doesn’t spread to the deep muscle layers of the bladder and other parts of the body. Those in high phase however, spread to the muscle layers of the bladder and from there, to the lymph nodes and other parts of the body in a short time. These cancers are lethal.
Squamous cell cancers develop due to long-period inflammations in the bladder.
Adenocarcinomas are formed from the secretory gland cells within the bladder layer. These are extremely rare.
Why Does Bladder Cancer Occur?
The most important cause for bladder cancer is smoking. Advanced age, presence of bladder cancer in the family (genetic factor) and employees in dye production are included in the risk group. Other important factor for bladder cancer is the radiotherapy applied to the organs within the pelvis. Drugs used for treating some cancers may also lead to bladder cancer.
Bladder Cancer and Smoking
Factors that increase the emergence risk of cancer are called “risk factors”. Tobacco use and especially smoking represent the most important risk factors. If long-time smokers encounter blood in their urine, this situation should always be clarified. Cancerous materials in cigarettes are discharged by urine. As bladder stores urine, cancer is frequently seen in the bladder.
Symptoms of Bladder Cancer
Bladder Cancer often reveals itself with blood seen in the urine. Frequent urination as well as pain during urination and back torso aches represent the symptoms of bladder cancer. Pain during urination is also a finding, but as pain may owe to various reasons, this is not a sufficient finding alone.
Diagnosis of Bladder Cancer
Urine analysis is helpful for diagnosing cancer. In addition, it may also be diagnosed by seeking cancer cells under microscope. It is especially beneficial for diagnosing high-phase cancers. This is called urine cytology. Another important means for diagnosis is entering the bladder from the urethra (urinary channel) and looking under light with a thin tube called cystoscope. This tool can also take tissue samples that will be sent to pathologic evaluation. Another diagnosis method is rendering the kidneys and the bladder visible using the contrasted (dyed) method.
Phases of Bladder Cancer
After the bladder cancer is diagnosed, the treatment is determined according to the spreading of cancer inside the bladder and to other parts of the body. Cancer spreads to other parts of the body after starting within the bladder. It is examined under 5 phases depending on the degree of spreading.
- Phase 0: Non-aggressive papillary cancer or aggressive inter-epithelium cancer (carcinoma insitu).
- Phase 1: The cancer has spread to the connective tissue that is located right beneath the most interior epithelium layer. 70 percent of the diagnosed cancers have not spread to the deep muscle layer of the bladder. Meaning that they represent tumors on the interior surface of the bladder. With closed method, it is removed by resecting it with high-frequency electric current. Nearly 25 percent of these surface cancers may spread to the muscle layer and gain aggressive character at any point of life. Meaning that these patients should be followed-up.
- Phase 2: Bladder cancer has exceeded the connective tissue and spread into the muscle tissue.
- Phase 3: Bladder cancer has exceeded the muscle, infiltrated the fatty tissue at the outer surface and in the periphery, has also spread to the prostate, the seminal vesicles and in women, to the womb & female genitals. It has not jumped to lymph nodes (phase 3a). At further stages, the cancer has jumped to nearby lymph nodes (phase 3b).
- Phase 4: Cancer has spread to the abdomen and the interior of the pelvis from the bladder. It has adhered to the lymph nodes on the iliac blood vessels. Further spreading to the lungs, liver and bones is also in question.
Phase Diagnosis in Bladder Cancer
Tomography: This technique takes pictures of the body’s interior by taking images from different angles. Administering dyed materials through the blood vessels or mouth enables a better imaging of organs and tissues. Images of not only the bladder, but of the interior abdomen, chest cavity and the organs inside the pelvis are also taken.
MR: Images of the interior body are taken by magnetic radio waves.
PET SCAN: Cancerous cells are fed by sugar. Radioactive sugar is administered through the blood vessel. The images show the sugar-fed cancer regions brighter than the normal cells. This method shows whether cancer is present in lymph nodes.
Lung X-Ray: It displays the organs within the chest cavity.
Even all such modern imaging methods cannot show how further the cancer has spread. They can only give an idea. It is an issue that should be underlined. Conclusive state of spreading can only understood when the entire organ and the lymph nodes, where the cancer has possible spread, are removed and later evaluated by a very competent pathology center.
Treatment of Bladder Cancer
Treatment of bladder cancer includes open and closed surgery, radiotherapy, chemotherapy and immunotherapy. Standard treatment means a traditionalized stable treatment. But there are other treatment procedures with lesser side effects that can replace standard treatment. This is called Clinical Trial. Clinical Trial means researching into new treatment methods that yield better results vis-à-vis old treatment protocols and replace the old method with a better one.
Treatment method for bladder cancer is determined by the patient’s age and general health condition, whether the cancer is present on the surface or deeply located, whether cancer has spread to other regions and whether it represents a caner that is comprised of anarchist cells that are called carcinoma insitu.
The dimension of cancer, number of bladder parts where cancer is present, and the interval of cancer repetition are other factors determining treatment.
Treatment According to Phases of Bladder Cancer
First Phase consists of resecting and removing cancer tissues by closed method. If the cancer is comprised of anarchist-structured cells, then chemotherapy or BCG is administered into the bladder within 15 days. For cancer types that are superficial but have extreme anarchist cellular characteristics, BCG is administered into the bladder for a period of 1-6 weeks following the surgery. Pursuant to the cystoscopic controls made after the 3rd, 6th and 12th month, BCG is administered weekly for three weeks. Some studies recommend the continuation of this treatment for 3 years in a similar format. It represents the traditionalized standard treatment. This prevents the repetition of superficial bladder cancers that have malign cellular characteristics. The bladder should be removed, meaning a Radical Cystectomy surgery should be performed for frequently repeating first phase cancers that don’t respond to BCG.
When Phase 2 and Phase 3 bladder cancers are first diagnosed, 30 percent of them have already spread to the muscle layer of the bladder. First treatment is to remove the bladder always with the neighboring organs and the lymph nodes where it cancer can potentially spread. This is called radical cystectomy surgery. Chemotherapy may be required as per the results of pathologic evaluation. Supplementary external radiotherapy may also be required. Experimental chemotherapy combinations are being developed in addition to standard chemotherapy.
In Phase 4 bladder cancer, radical chemotherapy surgery is performed following an initial chemotherapy or depending on the patient’s status, chemotherapy follows an initial chemotherapy surgery. A further radiotherapy is also required. Radical cystectomy surgeries performed in 4th phases aren’t primarily intended for treatment but rather for alleviating patient’s complaints and increasing his quality of life. Chemotherapy therapy is the first priority in types of Phase 4 bladder cancer that have spread to the lungs, bones and the liver. External radiation aims at removing the patient’s complaints about pain and increasing his quality of life. New cancer drugs are being developed on this subject.
Bladder Cancer Surgery
Closed Surgery in Bladder Cancer
Transurethral Resection (TUR-Mt): We enter the bladder via urinary channel by a tool called cystoscope that has a small wire hoop on its edge, and we clean cancer by resecting the cancer tissue with an electrocautery. It operates with high electric energy. It is the beginning and the main treatment.
Open Surgery (Radical Cystectomy) in Bladder Cancer
Radical Cystectomy: The bladder, prostate and seminal vesicles are removed all together during this surgery. In women however, the womb, ovaries and a portion of the vagina is removed together with the bladder. In advanced stages of bladder cancer, removing only the bladder and the neighboring organs represents a deficient surgery. One should always remove the lymph nodes on the main blood vessels till the top. That is because no imaging method can determine whether cancer has spread to lymph nodes and removing lymph nodes is therefore vital. This important for entirely removing cancer and to identify the extent of cancer metastasis. It has vital significance for the patient.
How is Radical Cystectomy Surgery Performed?
During Standard Radical Cystectomy surgery, we enter interior abdomen by an incision on the middle line of the abdomen, after which the bladder is removed inclusive of the womb in women and the seminal vesicles in men. The lymph nodes chain is removed from the right and left with all chains until 3-4 cm upwards of the zone that is crossed by the aorta.
As the bladder is removed during radical configuration surgery, body’s urine discharging system should be restructured. For this reason, urostomy should be performed for the urinary channels coming from both kidneys (creation of an outlet on the skin). 2 methods can be applied.
In the first one, a small intestine part about 15-20cm is placed and anastomosed to the abdominal skin. A urinary bag is attached to the patient’s skin during surgery. The patient urinates into this bag throughout his life.
In the second method, a small or large intestine bowel of 20-30cm is taken. This is initially folded into 2 and later into 4 by incision. A new balloon-shaped bladder is constructed from the intestine. This method allows the patient to urinate through normal means.
How Do We Perform Radical Cystectomy Surgery?
In fact, the standard Radical Cystectomy Surgery is a more difficult one. That is because the more one enters the abdomen, which hosts vital organs, the more difficult post-operative rehabilitation becomes for the patient and the higher rate of complications occur. And as anastomosing the urinary channels to the intestine during Standard Radical Cystectomy Surgery occurs within the abdomen, post-operative urine leakage occurs within the abdomen and this highly impacts the post-operative complication rate for patients. Originally, the bladder is outside the peritoneum as opposed the procedure in standard surgery.
During the Radical Cystectomy operation we perform, we remove the prostate and the lymph nodes without entering the peritoneum. We follow the same procedure for our female patients without entering the peritoneum. A 7-8 cm incision is made from the middle line of the abdomen. We reach the bladder from outside the peritoneum. Beginning with the prostate region, the prostate, seminal vesicles and the bladder are freed and removed in an upwards direction. Also in our female patients, this phase of the surgery is concluded entirely from outside the peritoneum. Also, the lymph nodes situated on the large blood vessels that are located on both sides are cleaned entirely from outside the peritoneum. We don’t make unnecessary intervention on the vital organs within the peritoneum. The patient therefore has a fast post-operative rehabilitation and suffers a minimum rate of complications.
During standard radical cystectomy in females, the bladder is removed together with the womb, ovaries, fallopian tubes, a section of the front vagina wall and lymph nodes. If the bladder cancer is situated at the bladder base and extremely anarchist, one should remove all these organs.
But studies have shown that only 3-10 percent of bladder cancers metastasize into the womb, ovaries and fallopian tubes. Today the world of medicine has concurred that cancers not located on the bladder base, cancers that aren’t extremely anarchist, and cancers located in other zones of the bladder don’t require the removal of the womb and the ovaries. This preserves the living standards of female patients as their sexual organs aren’t removed. Also in patients where the womb isn’t removed, a new bladder is constructed from the intestines and the patient can therefore urinate through normal means.
The patient’s urinary system should be reconstructed as in radical cystectomy surgery, the bladder and the periphery tissues are removed. That’s because the patient is required to urinate somehow. There are 2 methods in this operation. Both surgical methods take into consideration the patient’s status and the prevalence of the disorder.
First Method (orthopedic neobladder); During the second phase of radical cystectomy surgery, meaning the construction of a new bladder, we enter the peritoneum from a small opening, a part of the intestine is taken and the peritoneum is closed thereafter. Depending on the type of artificial bladder to be constructed, a 15 or 40 cm small or large intestine is separated while protecting its blood vessel. This part is incised, initially folded into 2 and later into 4, and given a cylindrical pipe shape for constructing the new bladder. Shaping the new bladder is performed entirely from outside the peritoneum. The urinary channels are anastomosed to the new bladder. The patient can therefore urinate through normal means. This allows the placement of urinary channels and the bladder entirely outside the peritoneum. Originally, the bladder is already located outside the peritoneum. However, the standard technique wrongfully places the newly constructed bladder or the new urinary channel inside the peritoneum. This causes potential urine leaks to occur inside the peritoneum, which may result in serious problems. But our new technique places the bladder outside the peritoneum. The bladder is originally situated outside the peritoneum at birth. Thus, possible urinary leakages in the post-operative phase don’t occur inside the peritoneum, which hosts vital organs, and therefore doesn’t become life-threatening. Post-operative rehabilitation phase is fast. Complication rate is low.
You can find the surgery videos and visuals on this subject at the bottom of this page.
The second method (uretero illeo cutaneostomi) is a simpler method. The patient cannot urinate through normal means. Two channels coming from the kidneys are anastomosed to each other. Initially a 15-20 cm stemmed intestine part is taken. The anastomosed urinary channel is added to one edge of this intestine part. Other edge of this intestine part is anastomosed to the abdomen skin. As the patient’s bladder is completely removed, the patient’s discharges his urine over the skin through a 15 cm interim intestine part. A urinary bag is attached to the patient’s skin, which procedure is called urostomy. The patient continues his life with a urine bag. The name of this operation is uretero illeo cutaneostomi.
Radiotherapy and Chemotherapy in Bladder Cancer
Surgery has a major importance for treating bladder cancer. Chemotherapy and radiotherapy also have vital importance. Combined with surgery, these treatment methods have a major impact on the living quality and lifetime of the patient.
Radiotherapy Treatment in Bladder Cancer
The radiation therapy of cancer aims at killing cancer cells or preventing their growth using high-energy X-Rays or other types of rays. There are 2 types of radiation.
External Radiation: High-energy radiation is externally sent to the body in order to kill cancer cells. External radiotherapy is mostly used for bladder cancer.
Internal Radiation: Small, rice-sized wires, seeds or catheters that emit radiation are placed in locations proximate the cancer.
Chemotherapy Treatment in Bladder Cancer
These drugs kill cancer cells or prevent the reproduction thereof. They enter blood circulation from mouth or through injection. They reach cancer cells. This is call systemic chemotherapy. Sometimes, chemotherapy is directly administered to the cancerous organ or the body cavity and directly effects cancer cells. This called regional chemotherapy. Regional chemotherapy in bladder cancer involves administering drug into the bladder by a tube through the urinary channel. This is especially used for the majority of superficial bladder tumors.
Also in bladder cancers, weakened tuberculosis microbe is administered inside the bladder, which triggers the body’s immune system. It therefore prevents the repetition of bladder cancer.
Complications in Bladder Cancer Surgery
One side-effect is strictures owing to the anastomosing of urinary channels to the intestinal part.
This refers to metabolic disorders that occur when the intestine, meaning the internal surface of the newly constructed bladder, absorbs urine. The inability of the new bladder that is constructed from intestine to fully substitute the original bladder is the cause behind this side-effect. The internal surface of the intestine-made-bladder absorbs some electrolytes within the urine. This owes to tissue difference. Treatment is partially easy. The patient is recommended to urinate 2 times a night. Some protective drugs are prescribed.
In the presence of an intestine-made-bladder, patients cannot urinate with a sensation of normal urination and discharge. Different perceptions occur. They can suffer occasional urinary incontinence. The method that anastomoses the interim intestine part to the skin of abdomen is easier for the physician. Complications are similar. This method involves no metabolic disorder. That’s because urine is discharged without being stored. Both methods have advantages and disadvantages. Decision on this subject is taken after discussion with the patient and his relatives.
Another complication is the occurrence of cystic formations called lymphocele, which owe to the removal of lymph node chains. Especially in our technique, such cystic formations stay behind the peritoneum and spontaneously disappear overtime. Unfortunately, serious problems may occur during unnecessary early interventions that try to discharge these cysts.