Non-muscle Invasive Bladder Cancer

Blood in the urine is the most common symptom of bladder cancer. It is generally painless. Often, you cannot see blood in your urine without a microscope. If you can see blood with your naked eye you should tell your health care provider right away. Even if the blood goes away, you should still talk to your doctor about it.

Blood in the urine does not always mean that you have bladder cancer. There are a number of reasons why you may have blood in your urine. You may have an infection or kidney stones. For some people a very small amount of blood might be normal, but this should be determined by a doctor.

Frequent need to pass urine and pain when you pass urine (dysuria) are less common symptoms of bladder cancer. If you have these symptoms, it is of great value to see your health care provider. They will find out if you have a urinary tract infection or something more serious, like bladder cancer.

If any of these tests suggest that you have bladder cancer, the next step to confirm the diagnosis is a transurethral resection of a bladder tumor (TURBT) described below. This procedure will be done in the operating room and you will likely be put to sleep for this procedure. During a TURBT the doctor will both try to remove all visible tumors and take tissue samples. This is a very important procedure for accurate tumor typing, staging and grading. The tissue sample will be sent to a laboratory where they will find out important information about your cancer. They will also see whether the cancer has spread. This will help with choosing the right treatment.

Other additional imaging tests: These tests may help your doctor diagnose and stage bladder cancer.

• Retrograde pyelogram. This test uses x-rays to look at your bladder, ureters and kidneys. The test is done during a cystoscopy or TURBT.

• Magnetic resonance imaging (MRI). These tests use a powerful magnetic field, radio waves and a computer to produce detailed pictures of the inside of your body.

Bladder cancer is described by how far into the wall of the bladder the cancer has grown (which is the clinical stage). Non-muscle invasive bladder cancers are found in the inner layer cells of the bladder. These cancers do not invade the muscular wall. These tumors are staged from Ta (lowest stage) to T1 (highest stage for NMIBC).

Stages of Bladder Cancer

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Tumor recurrence is common in patients with low-grade Ta cancer. Some patients will progress to a higher stage without further treatment.

Once diagnosed, the survival rates for patients with NMIBC are good. But, it is of great value that the disease is diagnosed early. This helps doctors predict the course of the disease and choose the best treatment to stop it from coming back and becoming more aggressive.

Transurethral resection of bladder tumor (TURBT)

Transurethral resection of bladder tumor (TURBT) is performed under anesthesia. The surgery is done through the urethra using a cystoscope, so there is no cutting into the abdomen. You will be given general or spinal anesthesia.

A rigid cystoscope is what your doctor will use for this procedure. This scope is straight and does not bend. It has a light at the end and is bigger and allows surgical instruments to pass through it. Your doctor is able to see inside the bladder, take tumor samples and resect (cut away) the tumor.

If a tumor is clearly seen, the doctor will attempt to remove it all. The doctor may also remove very small samples of other areas of the bladder that may look abnormal. These samples will also be checked for grade and stage. You may be left with a Foley catheter in your bladder after this procedure to allow your bladder to heal.

Your doctor may decide to use Blue light cystoscopy with TURBT. For this test, a catheter is placed prior to surgery and an imaging solution is put into your bladder through your urethra. The solution is left in the bladder for about an hour. The doctor then uses the cystoscope to inspect the bladder with regular white light and then with blue light to identify certain types of bladder cancer. The bladder cancer cells may show up better with blue light.

You may need to have a TURBT more than once to remove all potential tumor. During your follow-up examinations your doctor will check to make sure all the cancer is removed.

Intravesical Therapy

Intravesical ("within the bladder") therapy, is when a treatment drug is put directly into your bladder. The drug is put into the bladder with the help of a catheter (a thin tube that is placed through the urethra). You will hold the drug in your bladder for one to two hours and then pass it out. Intravesical chemotherapy is sometimes given immediately after TURBT. Most intravesical therapy is given after the results from pathology of the tissue taken at TURBT based on risk group.

Diagram of Intravesical Therapy

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Intravesical Immunotherapy

Immunotherapy is a treatment that boosts the ability of your immune system to fight the cancer. Bacillus Calmette-Guerin (BCG) is the immunotherapy drug that is used for bladder cancer. BCG also has been used as a tuberculosis vaccine.

Your BCG therapy will probably last about six weeks for the first course. It is usually done in your doctor's office, not in the hospital or operating room. You may get BCG treatment more than once and some patients need many courses.

The BCG drug is inserted into the bladder through a catheter. The therapy triggers the immune system to attack bladder cancer cells. It is one of the most effective treatments for bladder cancer, especially carcinoma in situ (CIS). It is not recommended if you have a weak immune system or certain symptoms. Side effects can include:

• Passing urine often
• Pain when passing urine
• Flu-like symptoms
• Joint pain
• Fever or chills
• Bacteria infecting whole body (less common)

Intravesical Chemotherapy

Intravesical chemotherapy is usually given immediately after surgery. With intravesical chemotherapy, drugs that are known to kill cancer cells are placed directly into the bladder, not in the bloodstream. As a result, many common side effects of chemotherapy, like hair loss, can be avoided. Because the drugs only reach the bladder lining, this type of treatment is only recommended for NMIBC.

Mitomycin C and gemcitabine are the most common chemotherapy drugs used for intravesical therapy. It is usually given after the initial TURBT. It helps stop cancer cells from going to another place and growing. It also lowers the recurrence rates. It can also be given as a six-week induction course similar to BCG and some people need more than one course.

Common side effects include:

• The need to pass urine often
• Pain when passing urine
• Skin rash

Repeat Intravesical Therapy

Some patients may respond to repeat therapy if the cancer returns. If you have high-grade Ta or T1 cancer or CIS, or you tried BCG and it did not work, you may need something else to control the cancer. In this case, you should talk to your doctor about surgery to remove the bladder as well as alternative bladder preserving options.

Maintenance Intravesical Therapy

After the bladder is free of disease, your doctor may suggest more treatment with the same drugs to keep the tumor from coming back. This may happen at the first three-month appointment after treatment.

Maintenance therapy is a good choice for people who have had BCG, less so for those who have had chemotherapy drugs. It is given for up to three years after treatment, and generally about every three to six months for three weeks at a time.

Your doctor will talk to you about whether you are a candidate for maintenance therapy. They will also talk about whether intravesical chemotherapy or BCG are good options for you.

Surgery to Remove the Bladder

If you have NMIBC, you may have to remove your bladder if intravesical BCG therapy fails. You may also need to remove it if you are at a greater risk of getting the cancer again or of it spreading. Cystectomy is considered and recommended for tumors that are high-grade T1, T1+CIS (carcinoma in situ) and T1+LVI (lymphovascular invasion).

Diagram of the Bladder and Urethra

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Partial Cystectomy (removal of part of the bladder)

Partial cystectomy is a good choice for some patients if the tumor is located in a specific part of the bladder and does not involve more than one spot in the bladder. It is only useful in very specific situations. The surgeon removes the tumor, the part of the bladder containing the tumor, and nearby lymph nodes. After part of the bladder is removed, you may not be able to hold as much urine in your bladder as before surgery. You may need to empty your bladder more often.

Radical Cystectomy (removal of the whole bladder)

For NMIBC, radical cystectomy is usually done if other therapies fail. The surgeon removes the entire bladder, nearby lymph nodes and part of the urethra. In men, the surgeon may remove the prostate as well. In women, the surgeon may remove the uterus, ovaries, fallopian tubes and part of the vagina. Other nearby tissues may also be removed.

Urinary diversion after bladder removal

When your bladder is removed or partly removed, your urine will be stored and made to leave your body by a different route. This is called urinary diversion. If you have a radical cystectomy, you will need to know about urinary diversion options.

Because the surgeon uses tissue from your intestines for bladder reconstruction, you must have sufficient bowel tissue for them to create your urinary diversion method. Before this is done, your surgeon will explain the procedure to you so that you can understand what will be done and the changes you will need to make. Here are some of the urinary diversion options your surgeon may offer:

• Ileal conduit: To make an ileal conduit, the surgeon will take a piece of your upper intestine and use it to create an opening (stoma) on the surface of your abdomen. The ureters are connected so that the urine leaves your body by the opening. A bag will be attached to collect the urine, and you will "dump" the bag several times a day. This is the most simple, and most commonly used diversion after bladder surgery.
• Continent cutaneous reservoir: Your surgeon creates a pouch inside your body and you will learn to use a catheter to remove the urine.
• Orthotopic neobladder: Your surgeon creates an internal pouch, much like your bladder, to store urine. Your ureters are connected to this new "bladder" and you are able to empty through your urethra the same way you did before the surgery. In some instances, you may need to use a catheter to remove the urine.

Talk with your doctor about your options for a urinary diversion. Having a urinary diversion will greatly impact your quality of life.

If your health care provider stages you as low-risk for cancer progression, then you will be asked to return, usually in three months at first (spaced out further with time), just for a surveillance scope of your bladder.

If you are an intermediate-risk patient, then your health care provider may ask you to return for a cystoscopy with cytology every three to six months for two years, then 6-12 months for three to four years, and then every year after. Cytology is the examination of cells from the body under a microscope. If you are intermediate- to high-risk, your urologist may place you on maintenance therapy as described before.

If you are high-risk for cancer progression, your health care provider may bring you back every three to four months for two years, then six months for three to four years, and then every year after.

You may also be given imaging tests as your health care provider sees fit. These imaging tests will be done to look for cancer in your kidneys and ureters.

If you had bladder removal surgery, it takes time to heal. The time needed to recover is different for each person. It is common to feel weak or tired for a while. But, like any other major surgery, bladder surgery may have complications. Older patients and women are more likely to get complications after cystectomy.

There are some things you can do before surgery to help your recovery. If you smoke, try to get help so that you can quit before and after surgery. You also need to make sure you eat right so that your body can heal and can cope with the changes.

Here are some possible problems you may have after treatment:

• Gastrointestinal (GI) problems: Your bowel function may return more slowly after your surgery. This often happens after abdominal surgery. Your surgeon and other health care providers will take steps to monitor bowel function and avoid GI problems.
• Urinary diversion: Urinary diversion following bladder surgery may present challenges for which you should prepare yourself. You may need to learn how to remove urine from your body with a catheter. There also is potential for leakage from the stoma (opening) that is made to take away urine. Infections related to urinary diversion may occur, as may infections related to the kidneys. It is of great value for you to learn as much as you can about the urinary diversion method that you will use, and how to manage changes to your body. Before you leave the hospital, your health care providers will ensure that you get the education you need so you can manage your new way of life.
• Hormonal changes: For females who are not yet menopausal, you may have hot flashes after your ovaries are removed.
• Reproductive health: When the prostate is removed, a man can no longer father a child. Also, a man may be unable to have sex after surgery. When the uterus is removed, a woman can no longer get pregnant. If the surgeon removes part of a woman's vagina, then sex may be difficult.
• Sexual dysfunction: In reality, bladder cancer surgery is likely to affect your sex life. If you have a partner, you may be worried about maintaining sexual intimacy and your relationship. It may help you and your partner to talk about your feelings. You can find other ways to be intimate after you had treatment. If you do not have a partner, you may want to explore how to manage your dating life after bladder cancer surgery. Either way, you (and your partner) may benefit from the advice of a counselor who specializes in discussing sexual issues. Your health care provider may be able to refer you to medical professionals and counselors who specialize in sexual issues after cancer treatment.

• Managing Pain: You may have pain or discomfort for the first few days following bladder surgery. Medicine can help control your pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain control.

Remember that each person is unique and each body may respond differently to therapy. It is of great value that you take care of yourself and remain in contact with your health care provider. Try to adopt healthy lifestyle habits including exercise, a well-balanced diet and no smoking. Your health care provider also may recommend a cancer support group or individual counseling.