The bladder is a hallow organ that stores urine. It is located inside the lower abdomen, is about the size of a grapefruit and is distensible (elastic) which allows its muscular wall to get larger and smaller. Bladder cancer is a disease in which cancer cells form in the tissues of the bladder. Over 67,000 new cases of bladder cancer are diagnosed in the United States each year.1 It is the fourth most common cancer among men and ninth most common among women in the U.S. Fortunately, most people with bladder cancer will not die of the disease but it does claim about 13,000 lives each year. 2 

Bladder cancer – causes

Bladder cancer -symptoms

Bladder cancer -process

Bladder cancer -screening and testing

Bladder cancer -staging

Bladder cancer – treatment options

Treatment Options

Treatment options depend on the stage of bladder cancer (Stage 0 to Stage 4). There are four standard treatment options for bladder cancer:

  • Surgery
  • Radiation
  • Chemotherapy
  • Biologic Therapy

Depending on the patient’s type and stage of bladder cancer, several treatments may be used in combination to increase the chances of a cure. Surgery is the primary bladder cancer treatment and is performed in over 90% of bladder cancers (either alone are in combination with another therapy). 3 When cancer has spread to the muscle wall of the bladder, a radical cystectomy is the preferred treatment choice. 4

Surgical Treatment: Cystectomy

A cystectomy is the removal of all or part of the bladder and possibly the removal of nearby lymph nodes and organs that may contain cancer. If the bladder is removed, the surgeon creates a new way or path for urine to be stored and to leave the body. 5

Cystectomy is traditionally performed using an open approach, meaning the surgeon must make a large abdominal incision to access the bladder. Another approach, conventional laparoscopy, is less invasive but limits the doctor’s dexterity, field of vision and control, compared to open surgery.

da Vinci ® Cystectomy

If your doctor recommends surgery for bladder cancer, you may be a candidate for a new, minimally invasive approach – da Vinci Cystectomy.

da Vinci uses state-of-the-art technology to help your doctor perform a more precise operation than conventional surgery allows. It offers several potential benefits over traditional open surgery, including:

  • Significantly less pain
  • Less blood loss
  • Fewer blood transfusions
  • Less risk of infection
  • Less scarring
  • Shorter hospital stay
  • Shorter recovery time
  • Better clinical outcomes, in many cases

The precision and dexterity of the da Vinci Surgical System’s advanced instrumentation allows for a minimally invasive approach to treating bladder cancer.

As with any surgery, these benefits cannot be guaranteed, as surgery is unique to each patient and specific condition. The da Vinci Surgical System is considered safe and effective, but may not be appropriate for everyone. Always ask your doctor about all treatment options, as well as the benefits and risks.

If you are a candidate for a cystectomy talk to a urologist who performs da Vinci Surgery for bladder cancer.

1. “General Information about Bladder Cancer”, National Cancer Institute, www.cancer.gov , URL:
http://www.cancer.gov/cancertopics/pdq/treatment/bladder/patient2. “Bladder Cancer”, American Urological Association, www.urologyhealth.org, URL: http://www.urologyhealth.org/content/moreinfo/bladdercancer.pdf

3. Wang GJ, Barocas DA, Raman JD, Scherr DS. Robotic vs open radical cystectomy: prospective comparison of perioperative outcomes and pathological measures of early oncological efficacy. Department of Urology, New York-Presbyterian Hospital, Weill Medical College of Cornell University . Jun 2007;17:1-5

4. “Cancer Facts and Figures 2007, American Cancer Society, www.cancer.org
5. “Bladder Cancer Treatment”, National Cancer Institute, www.cancer.gov , URL
http://www.cancer.gov/cancertopics/pdq/treatment/bladder/Patient/page4

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Bladder Cancer – Causes

Different cancers have different risk factors. Risk factors increase your chances of getting a disease but keep in mind many people with one or more risk factors may never develop bladder cancer. Others with this disease have no known risk factors at all.

It is important to know the risk factors so that appropriate action can be taken such as changing a health behavior or being monitored closely for a potential cancer.
Smoking

The greatest risk factor for bladder cancer is smoking. Smokers are more than twice as likely to get bladder cancer as nonsmokers. Smoking causes nearly half of the deaths from bladder cancer among men (48%) and nearly a third of bladder cancer deaths in women (28%). 1 Some of the carcinogens (cancer-causing chemicals) in tobacco smoke are absorbed from the lungs and get in the blood. From the blood, they are filtered by the kidneys and concentrated in the urine. These chemicals in the urine damage the urothelial cells that line the inside of the bladder. This damage increases the chance of cancer developing.

Because the bladder is the final exit from the body for many chemicals, they are the primary risk factors for bladder cancer. This is the case whether the chemicals are from tobacco smoke or from occupational exposure as explained below. 2

Occupational Exposures

Certain industrial chemicals are linked to bladder cancer. Chemicals called aromatic amines, such as benzidine and beta-naphthylamine, that are sometimes used in the dye industry, can cause bladder cancer.

Other industries that use certain organic chemicals may also put workers at risk for bladder cancer if good work place safety practices are not in place. The industries carrying highest risks include the makers of rubber, leather, textiles, and paint products as well as printing companies. Other workers with an increased risk of developing bladder cancer include painters, hairdressers, machinists, printers and also truck drivers because of exposure to diesel fumes.

Cigarette smoking and occupational exposures may act together in the development of bladder cancer. Also, smokers who work with the cancer-causing chemicals noted above have an especially high risk of developing bladder cancer.

Race

Caucasians are about twice as likely to develop bladder cancer as compared with African American and Latino populations. The reason for this difference is not well understood. People of Asian descent have the lowest incidence of bladder cancer. 3
Increasing Age

The risk of bladder cancer increases with age. Over 70% of people with bladder cancer are older than 65 years old. 4

Gender

Men get bladder cancer at a rate 4 times greater than women. 5

Chronic Bladder Inflammation

Urinary infections, kidney and bladder stones, and other causes of chronic bladder irritation have been linked to bladder cancer, especially squamous cell carcinoma of the bladder, but they do not necessarily cause bladder cancer. Schistosomiasis, also known as bilharziasis is an infection with a parasitic worm that can get into the bladder and increase the risk for bladder cancer. Although this parasite is found mostly in Northern Africa, it does cause rare cases of bladder cancer in the United States among people who had been infected by the worm before moving to this country.

Personal History of Bladder Cancer

Urothelial carcinoma is cancer of the urinary tract that begins with cells that form in the bladder as well as in the urothelium – the lining of the kidney, the ureters, and urethra. The ureters carry urine from the kidneys to the bladder. The urethra is a canal that carries urine from the bladder and in men also carries semen from the body. Even when one bladder tumor is completely removed, you will have a higher risk of forming another tumor in the same or another portion of the urothelium. For this reason, people who have had bladder cancer need close, routine medical follow-up. People who have family members who have or have had bladder cancer are at increased risk.

Bladder Birth Defects

Before birth, there is a connection between the belly button and the bladder. This connection, called the urachus , normally disappears before birth. If part of the urachus remains after birth, it could become cancerous. Cancers that start in the urachus are usually made up of malignant (cancerous) gland cells and are called adenocarcinomas . Cancer starting in this way is rare, causing less than a half of 1% of bladder cancers but it does represent about one third of the adenocarcinomas (cancerous gland tumors) of the bladder, which are also rare.

There is another rare birth defect called exstrophy , which greatly increases a person’s risk of developing bladder cancer. In exstrophy, the skin, muscle, and connective tissue in front of the bladder fail to close completely so there is a hole or defect in the wall of the abdomen. This leaves the inside of the bladder exposed to chronic infection and that may eventually lead to formation of an adenocarcinoma of the bladder.

Genetics

Bladder cancer is common within some families. This may account for 1% of all cases. 5 People with a mutation of the retinoblastoma gene, which causes them to develop cancer of their eye as infants, have a higher rate of bladder cancer. Many studies have found people differ in their ability to break down chemicals in their body and this is determined by certain genes they inherit. People who inherit genes that lead to slow breakdown of chemicals are more likely to develop bladder cancer.

Chemotherapy and Radiation Therapy

High doses of cyclophosphamide (Cytoxan), a drug used in the treatment of cancer, and ifosfamide (Ifex), a drug similar to cyclophosphamide, increase the risk of bladder cancer. A typical patient would be someone with a lymphoma – a tumor that begins in the lymph nodes – often cured by chemotherapy drugs that include cyclophosphamide. A drug called mesna is used with these two drugs to protect the bladder from irritation and decrease the risk of bladder cancer. People who receive radiation treatment to the pelvis are more likely to develop bladder cancer. 6

Drinking Water and Arsenic

Arsenic in drinking water has been associated with an increased risk of bladder cancer. Risk depends in large part on where you live, and whether your water system meets suggested standards for arsenic content.

Fluid consumption

Low fluid consumption increases risk. People who drink a lot of fluids each day have a lower rate of bladder cancer. This is thought to be because they empty their bladders often. By doing this, they keep chemicals from lingering in their bodies.

1. “Detailed Guide: Bladder Cancer”, American Cancer Society, www.cancer.org
2. Ibid.
3. Ibid.
4. Ibid.
5. Ibid.
6. Ibid.

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Bladder Cancer – Symptoms

Common symptoms of bladder cancer include: 1,2

  • Blood in the urine (making the urine slightly rusty to deep red)
  • Pain during urination
  • Frequent urination or feeling the need to urinate without results
  • Low back pain

These symptoms are not sure signs of bladder cancer. Infections, benign tumors, bladder stones, or other health problems also can cause these symptoms.

Anyone with signs or symptoms of bladder cancer should see a doctor to be diagnosed and treated for any condition or disease they may have as early as possible. People with symptoms like these may see their family doctor or a urologist –a doctor who specializes in diseases of the urinary system.

1. “What You Need To Know About Bladder Cancer”, National Cancer Institute, www.cancer.gov , URL: http://www.cancer.gov/cancertopics/wyntk/bladder/page5
2. “Bladder Cancer”, National Institutes of Health , URL: http://www.nlm.nih.gov/medlineplus/bladdercancer.html

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Bladder Cancer Process

Origins

The development and progress of bladder cancer is not fully understood. Doctors do know more than 90 percent of all bladder cancers originate in the urothelium – a thin surface layer that lines the inside of the bladder. 1 The majority of bladder tumors do not invade the bladder muscle and are confined to the urothelium or the lamina propria – a layer of loose connective tissue next to the urothelium.

Varied Growth

Most cancerous bladder tumors are not aggressive, but when they are the tumors can invade the wall of the bladder and spread to other parts of the body. This can possibly result in death but even aggressive forms of bladder cancer may not spread or become life-threatening if they are found and treated in the early stages. There are several stages of bladder cancer and several types of diagnostic tests used to determine if and how far the disease has spread.

How Cancer Spreads

Cancer can spread in the body in three ways:

1. Cancer can invades the surrounding normal tissue.

2. Cancer can invade the lymph system and travels through the lymph vessels to other places in the body.

3. Cancer can invade the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the original or primary tumor and travel through the lymph or blood to other places in the body, a secondary tumor may form. This process is called metastasis. The secondary or metastatic tumor is the same type of cancer as the primary tumor. For example, if bladder cancer spreads to the bones, the cancer cells in the bones are actually bladder cancer cells. The disease is metastatic bladder cancer, not bone cancer .

The prognosis or chance of recovery depends on the stage of the cancer, the type and appearance of bladder cancer cells, and the patient’s age and general health. Keep in mind, early detection is critical since most early stage bladder cancers are curable. 2

1. “Bladder Cancer”, American Urological Association Foundation, www.urologyhealth.org
2. “Bladder Cancer Treatment”, National Cancer Institute, www.cancer.gov , URL: http://www.cancer.gov/cancertopics/pdq/treatment/bladder/Patient/page2

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Screening and Testing for Bladder Cancer

Overview

This year in the United States , over 68,000 people will be told they have bladder cancer and an estimated 14,000 will die of the disease. Screening means testing for cancer before you have any symptoms. A screening test can often help find cancer at an early stage. Bladder cancer in the early stages can often be cured since it’s less like to have spread to other parts of the body. 2

There are several screening tests and procedures that examine the urine, vagina, or rectum to help find and diagnose bladder cancer.

CT scan

A CT or CAT Scan is a procedure that takes a series of detailed pictures of areas inside the body at many different angles. The pictures are created by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. A CT or CAT Scan stands for Computerized Tomography, or Computerized Axial Tomography.

Urinalysis

Urinalysis is a test that checks the color of urine and its contents, such as sugar, protein , red blood cells , and white blood cells .

Internal exam

This consists of an exam of the vagina and/or rectum . The doctor inserts gloved fingers into the vagina and/or rectum to feel for lumps.

Intravenous pyelogram (IVP)

Intravenous pyelogram (IVP) is a series of x-rays of the kidneys, ureters (tubes that carry urine from the kidneys to the bladder), and bladder to find out if cancer is present in these organs. A contrast dye is injected into a vein and as the dye moves through the kidneys, ureters, and bladder, x-rays are taken to see if there are any blockages.

Cystoscopy

A cystoscopy is a procedure that looks inside the bladder and urethra to check for abnormal areas. A cystoscope is inserted through the urethra into the bladder. A cystoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples, that are checked under a microscope for cancer.

Biopsy

A biopsy is the removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. A biopsy for bladder cancer is usually done during cystoscopy. It may be possible to remove the entire tumor during the biopsy.

Urine cytology

A urine cytology is an examination of urine under a microscope to check for abnormal cells.

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Stages of Bladder Cancer

Definition of Staging

A staging system indicates if cancer has spread and to what extent. Staging describes the extent or severity of cancer based on the size of the original tumor and the extent it has spread in the body or the affected organ. With bladder cancer, t he stage of the cancer refers to the location of the tumor within the bladder or, more specifically, the speed of growth and the tumor’s penetration into the bladder

While there are different staging systems for bladder cancer, the most widely used system in the United States is called the TNM System. It is also known as the Staging System of the American Joint Committee on Cancer. 1

General Information on Staging

Staging is based on knowledge of how cancer develops. Cancer cells divide and grow to form a mass of tissue called a tumor. As the tumor grows, it can invade nearby organs and tissues. Cancer cells may also break away from the tumor and enter the bloodstream or lymphatic system. By moving through the bloodstream or lymphatic system, cancer can spread from the primary site to form new tumors in other organs. The spread of cancer is called metastasis. 2

Purpose of Staging

Staging helps the cancer diagnosis and treatment process in important ways.
Staging helps doctors plan a patient’s appropriate treatment.
The stage can be used to estimate the person’s prognosis (likely outcome or course of the disease).
Knowing the stage helps to identify clinical trials that may be suitable for a patient. 3

Staging also helps researchers and health care providers exchange information about patients, provide a common language for diagnosis, treatment and clinical trials.

Tests to Determine Bladder Cancer Stage

The following tests and procedures may be used in the staging process:
Cystoscopy : A procedure to look inside the bladder and urethra to check for abnormal areas. A cystoscope is inserted through the urethra into the bladder. A cystoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples that are checked under a microscope for signs of cancer.
CT scan (CAT scan) : A procedure that makes several detailed pictures of areas inside the body taken from different angles. The pictures are created by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computerized tomography, or computerized axial tomography.
MRI (magnetic resonance imaging) : A procedure that uses a magnet, radio waves, and a computer to take several detailed inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
Physical exam and history : An exam of the body to check general signs of health, including signs of disease such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
Chest x-ray : An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making an image of areas in the body.
Bone scan : A procedure to check for rapidly dividing cells such as cancer cells in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones and is detected by a scanner .

Staging Bladder Cancer

Your treatment options will depend on the stage of your disease. The following is a description of the various stages of bladder cancer:

 

Stage 0 – In this stage, abnormal cells are found in tissue that lines the inside of the bladder . These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is divided into stage 0a and stage 0is, depending on the type of tumor . Stage 0a is also called papillary carcinoma and may look like tiny mushrooms growing from the lining of the bladder . Stage 0 is also called carcinoma in situ and is a flat tumor on the tissue lining the inside of the bladder .

Stage I – In stage I , cancer has formed and spread to the layer of tissue under the inner lining of the bladder .

Stage II – In stage II , cancer has spread to either the inner half or outer half of the muscle wall of the bladder .

Stage III – In stage III , cancer has spread from the bladder to the fatty layer of tissue surrounding it, and may have spread to the reproductive organs ( prostate , uterus , vagina ).

Stage IV – In stage IV , cancer has spread from the bladder to the wall of the abdomen or pelvis . Cancer may have spread to one or more lymph nodes or to other parts of the body.
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1. “Staging: Questions and Answers”, National Cancer Institute, www.cancer.gov, URL: http://www.cancer.gov/cancertopics/factsheet/Detection/staging
2.Ibid.
3.Ibid.

While clinical studies support the effectiveness of the da Vinci® System when used in minimally invasive surgery, individual results may vary. Surgery with the da Vinci Surgical System may not be appropriate for every individual. Always ask your doctor about all treatment options, as well as their risks and benefits.