Bladder cancer – Diagnosis and treatment with Ass dr Uroš Babić

29-10-2019

We talked with Ass. Dr. Uroš Babić about bladder cancer, which is a very common form of malignant tumor that urology specialists encounter.

Ass. Dr. Uroš Babić is a urology specialist, a consultant at Atlas General Hospital and a PhD at the Clinic for Urology at the Clinical Center of Serbia.

dr Uroš Babić - Atlas bolnica

What is bladder cancer?

It is a very severe malignant disease that very often ends in death. Bladder cancer is a capricious and unpredictable disease with a pronounced malignant potential. Patients who approach us with this problem in most cases do so very late. We cannot then speak of healing but of survival. What is very important for bladder cancer is early detection of the disease. It is vital and determines the prognosis of treatment.

 

Bladder cancer: Statistics 

It seems to me that every year there are more and more patients. It is something that is common to all malignant diseases of the urinary tract:  the incidence is increasing, especially in developed countries. We do not have very precise data for our country, but I have data from the European Union. Bladder cancer ranks 7th in frequency compared to other cancers in men and 11th in women. These are very high places and in numbers it is about 19 men per 100,000 patients – newly discovered. In Belgium, there are even more and it amounts to 31 patients on a sample of 100,000 people. We do not have accurate data for Serbia, but we do not have a dilemma that the number is the same or even worse, considering: habits or risk factors that are present in our country, as well as patterns of behavior that characterize our environment.

Bladder Cancer: Risk Factors 

We do not know all the risk factors, for some they are just guesses, but what we know for sure is that smoking is recognized as the main and basic reason for the occurrence of the disease and during the treatment for the recurrence of the disease. The first and foremost thing when it comes to patients with bladder cancers is to ask through conversation if they are smokers. This is something that fits into the clinical picture, that is, into the assumption that there is a bladder cancer if symptoms already appear. Then we know we need to apply a diagnostic and treatment algorithm.

One of the main tips when planning bladder tumor treatment is to suggest an immediate smoking cessation.

In addition to cigarettes, aromatic amines have also been identified as risk factors. These are substances that are present in various industries of paint, textiles and rubber. It is a work exposure and people who are employed in such industries are exposed to risk.

It has been determined that there is no pronounced hereditary basis for bladder cancer. So if one of your relatives (brothers, sisters, parents) had a cancer, it does not necessarily mean that you will get sick too. But when it comes to smoking, it is the only undoubtedly and clearly recognized risk factor.

Are there clear symptoms that indicate the presence of a bladder cancer?

The cardinal sign of this disease is the so-called total painless hematuria – the presence of blood in the urine. Most of the patients show this symptom, sometimes it is caused by an infection and they receive antibiotic therapy and that symptom passes. After that, they appear in the Emergency Center with profuse hematuria, massive bleeding. Such a symptom requires a detailed examination. In addition to such symptoms, we often see symptoms of advanced disease if patients are in a situation where there are already morphological changes in the bladder caused by cancer, kidney failure, poor kidney emptying, accumulation of nitrogenous substances, kidney infection, general weakness and bleeding as the first diagnosis occurs in clinical practice, because in our country, unfortunately, the medical education is at a really low level, so neglected patients are often seen in practice. 

Urologic cancers: Diagnosis

We take anamnesis of a patient and understand that the bleeding happened one or more times, that it lasted for some time and that the bleeding was not accompanied by pain in the bladder, burning when urinating, and it turns out that the patient is a smoker, then we apply diagnostic tests .

The first and basic examination is ultrasound, with which we can verify the largest number of cancers, and then we will propose an examination called cystoscopy.

What is cystoscopy?

Cystoscopy is an endoscopic examination that enters the bladder through the urethra, where the presence or absence of a cancer can be examined. We also examine the characteristics of the cancer, the size, localization and, depending on such a finding, we plan further treatment. In addition to these diagnostic methods, we also use more complex methods such as a MRI or a scanner, and then we define a treatment model.

In most patients, almost always the disease is detected when the cancer is localized, when a complete cure can be discussed. In the other 25%, which is a huge number, there are patients in whom the cancer has progressed locally or it is a metastatic disease, so it is a very painful and unpleasant situation for both the patient and the doctor, and we must point out that the entire treatment goal only to prolong life, no long-term survival.

The idea of ​​oncology therapies is to make the disease, if possible, a chronic condition such as diabetes or hypertension that can be lived with. But it is a slightly pretentious plan for my area because this is a disease that has a pronounced malignant potential and we are obliged to inform patients about it immediately. Patients are constantly waiting from one therapy to another, whether there has been a recurrence, what is the recurrence, what is the quality of life of patients who have become ill… and this quality is very low when it comes to bladder cancers.

TUR surgery

What are the treatment options for bladder cancer?

If it is a localized cancer, a disease that is limited to the bladder mucosa, and that is in the majority of the cases, then the gold standard for them is TUR of bladder tumors – transurethral resection of bladder tumors. It is an endoscopic procedure and the device with which we enter the bladder and we try to completely remove the cancer that we verified earlier, if possible, from the urinary bladder. Whenever that tumor is removed, a part of the healthy tissue is removed and we send all that tissue for pathohistological analysis (the idea is to remove the entire preparation) where we get very good indicators regarding the malignant potential of the cancer. Whether it is a cancer that has a pronounced potential or is it something that allows us a wider space for maneuver and waiting for some other therapies… We get the most important data concerning the degree of the disease. We don’t know if it is a cancer that is localized or reaches deeper into the bladder muscle.

When the bladder muscle is punctured, it is a clear indication that the disease has progressed locally, and then TUR of the urinary bladder is no longer a method of treatment. If the tumor is localized, after the first resection, patients come for check-ups; cystoscopies are required every 3 months and so on for a couple of years. At the examinations, we notice whether there are recurrences, and after that we go for resection again, and so on for as long as possible. At one point, the cancer either stops appearing or it progresses to a higher degree, so the treatment model changes.

Radical surgical treatment of bladder tumors?

Radical surgical treatment is reserved for patients whose muscle has been punctured by a tumor. In addition to this indication, patients who have localized carcinoma stopped in the mucosa but the tumor is large, tumors that return frequently, multilocular – in several places, or carcinoma in situ, patients who respond poorly to BSJ therapy given locally in the bladder , we opt for radical surgery.

We are forced to perform a radical operation, that is, to remove the entire bladder in patients whose lives are being saved by this surgery. In patients with a neglected, advanced disease, who are bleeding, who have a kidney failure, in poor general condition, we are forced to remove the entire bladder and save the patient’s head.

Life after bladder removal – bladder removal surgery

Radical surgery involves removing the bladder, prostate, seminal vesicles, and the final parts of the urethra. In women, this operation involves resection of the uterus, ovaries and one part of the vagina, as well as extensive removal of lymph glands. It is a very large, mutilating, difficult operation, difficult for the patient to endure. Sometimes they can last a very long time and are related to blood loss.

The quality of life depends on the way the operation goes, whether there were pronounced perioperative morbidities and what kind of urine derivation was done because after the operation the patient is without a bladder and we have to conduct urine somewhere.

A urinary conduit after bladder removal surgery

There are several ways in which urine is conducted and this measure largely determines the quality of life and depends on the local finding. They say in the book that it is a compromise between the medical and socio-economic characteristics of patients. Here, the selection of more complex urine derivations requires a strong cooperation of the patient so that the patients are able to abstract the entire pathology.

Ways are to perform urinary tract on the skin, it is the simplest derivation. What is the gold standard, what we usually do is to isolate a part of the small intestine from a part of the small intestine of the ileum. We implant canals in that part and then that part of the intestine is performed on the skin, that is the so-called ilear conduit or ilear reservoir – urinary stoma. The patient carries the bag as with the first derivation, which is the most convenient option from the medical aspect, but patients reluctantly accept it. Of course, it is a very unpleasant realization and emptying the bag, which in itself is not difficult, but when we talk about the quality of life, it is an inconvenient solution.

We have a possibility concerning continental bladders – making bladders from intestines. There, the bladder was made as a native one that existed, but of course it can never be of the same quality. These surgeries are reserved for patients who have an oncologically good prognosis and a good general condition. These operations are not performed often; they are also associated with great complications. Although they sound good to patients, it often turns out that this solution is not a happy one. Complications, apart from the fact that they are life-threatening, there is no question of quality of life in that case, it is a pure arrangement of life, both qualitative and functional in every sense.

Check-ups or laboratory tests

Laboratory analyzes, so-called tumor biomarkers are very popular and we have been working on their development for years. However, none is sensitive and specific enough to detect bladder cancer early on that basis. There is urine cytology – malignant cells are diagnosed from the urine from a simple urine test. This is possible and very sporadically is done, mainly in patients who have advanced disease, larger cancers. Tests are not for the general population. The only thing left is an ultrasound examination. A large number of patients are diagnosed accidentally, at a routine examination. There is no screening in the general population, although today people are examined by ultrasound on their own initiative and then cancers can be detected.