| What are risk factors for bladder cancer? | - Smoking: Major causative factor
- Exposure to toxin (like benzene)
- Age
- Oncogenes
A patient who does not smoke and has cancer is more aggressive than in people who smoke because it is often due to genes predisposition. |
| How is clinical manifestation of bladder cancer? | Bladder cancer is a mass or polyp in the bladder, these is 3 major symptoms:
Urgency
Dysuria
Frequency
Major Sign: Painless Macrohematuria
Hematuria: >5 RBCs in urine analysis
(Microhematuria, we see it only in urine analysis)
If it’s metastatic cancer: systemic manifestation. |
| How is bladder cancer workup? | Uroscan/CT urography (3 phases: 1st w/o contrast detect stones, 2nd 2 mins after IV contrast detect kidney tumors parenchyma, 3rd 10-15 mins after IV contrast collecting system dx filling defect most likely a mass)
CI (Kidney failure due to nephrotoxicity by contrast)
Cystoscopy (enter urethra go to bladder, look polyps and cancer)
Urine Cytology (atypical urothelial cells, urinate 3 times on 3 separate days in morning useful for urethelial cancer high specific for high grade TCC, do it after - cystoscopy w/sus) |
| How is tx of urothelial cancer? | Resection: TURBT (transurethral resection of bladder tumor) (Diagnostic cause we can send it to Ana pathology (might be benign) and Therapeutic (for Low grade))
-Depth of the tumor plays an important role during resection; we should take the base and the muscle underneath it to be able to do staging and the corresponding treatment.
-Male and Female same procedure. |
| What are types of urothelial cancer? | Can be:
-Urothelial carcinoma (Most common)
-Squamous carcinoma (More aggressive, secondary to Chronic inflammation of the bladder (frequent in Egypt due to bilharzia) (However, the most common is urothelial cancer)
-Small cell carcinoma (More aggressive)
Polyps have 2 forms: Pedunculated (=having one root) or Sessile (=having a large base); Sessile is usually more aggressive than pedunculated) |
| How is staging for urothelial cancer? | Ta, CIS (T0):
Ø Ta: Superficial, tumor is limited to the mucosal/ submucosal (but doesn’t reach the lamina propria) layer, can be low or high grade (statistically, more likely it’s low grade)
Ø CIS: T0: in situ (only in urothelium), we don’t resect it, high grade, very aggressive, poor prognosis, it can metastasize at any instant (if it metastasizes, we simply can offer symptomatic
treatment)
Ø T1 : Invades lamina propria
Ø T2: Muscles are invaded.
Ø T3: Peri vesical fat
Ø T4: Edges of organs
Ta, T1 are superficial.
T2, T3, T4 are deep |
| How is grading of urothelial cancer? | Grading: low or high grade of malignancy
Ta, statistically speaking, is most likely low grade, but it can be a high-grade cancer discovered early.
Ta is superficial cancer that can be either high or low grade
CIS: ALWAYS HIGH-GRADE, low-grade CIS doesn’t exist.. |
| How is tx and prognosis of Ta low grade urothelial cancer? | Since 3 years, this is no more considered a malignant tumor, but a benign lesion {low malignant potential urothelial cancer}
It is a superficial, low-grade lesion with low recurrence rate.
Patients diagnosed with low grade Ta can be cured after resection.
But if the patient is heavy smoker, we must follow up him because of the presence of risk factor {smoking, exposure to toxins.}
Bladder {urothelial} cancer, polyp, is multifocal cancer, so we must examine the whole bladder, one resection is not enough most of the time.
Smoking is one of the causes of progression |
| How is tx and prognosis of T1 low grade urothelial cancer? | The treatment is usually bladder instillation with chemotherapy agents which the most common is mitomycin (mixed with normal saline and then infused in the bladder) to reduce the progression (local treatment, no needle).
we already did urine cytology, if it’s high grade: 90% it’s positive because the test is very sensitive. If the urine cytology is negative, and we found a tumor in surgery, we perform a resection and we give him mitomycin or clindamycin right after surgery
Follow up for T1 low grade: 3 times cystoscopy every for 3 years, then twice the 4th year, then once the 5th year to check for recurrence, if all are negative, our patient has become cancer free.
T1 low grade: 60% risk of progression (become T2) and 85% of recurrence.
With treatment, recurrence becomes 40% and progression 20%. |
| How is prognosis and tx of T1 high grade urothelial cancer CIS? | Intravesical infusion of BCG (vaccine of tuberculosis): Immunotherapy to destruct all cancer
cells: BCG induce immunological reactions in bladder (Macrophages and mastocytes phagocyte cancer cells and recurrence/progression rate is much lower).
Chemotherapy does not work on CIS even though it’s superficial (Exam question)
N.B: It is a misconception that superficial tumors we always give chemotherapy |
| How is tx of superficial tumors? | Chemotherapeutic agents and usually local treatment because metastasis are still controlled (risk of metastasis is still 5% so no need to any workup of metastasis= PET scan)
T1 rarely causes metastasis, f/uEvery 3 months we do cystoscopy for the first 3 years.
Then every 6 months till the 4th year
Then one cystoscopy per year |
| How is management of T2 tumors? | Deep tumors (T2 or more)
What determines whether a tumor is superficial or deep is the involvement of muscularis propria (detrusor muscle)
Metastatic workup: First step in T2 tumors
When the tumor is t2 or more we should look for metastasis
=total body PET scan |
| What are most common sites of metastasis? | 1. Lymph Nodes
2. Bone
3. Lung
First, we rely on a nuclear or pet scan. It isn’t always available, so we use total body MRI with a previous lung CT scan and bone scintigraphy (bone metastasis) + uroscan (Abdo and pelvis CT scan). However, now we use a total body PET scan |
| What is tx plan in case of + metastasis? | difficult case even in terms of chemotherapy response. We usually use cisplatin, a chemotherapy drug used to treat testicular, ovarian, bladder, head and neck, lung and cervical cancer and now we could use immunotherapy. Not the best result as they could die within a year or few. No indications for any surgeries (many complications, the patient will not live long with the metastasis anyways) |
| What is tx plan in case of - metastassi? | a. Radical cysto-prostatic surgery: (better survival rate), urethral cancer is multifocal, and its recurrence does not always happen in the exact same place, so for the surgical resection, we remove any possible recurrence areas such as the entire bladder and the prostate (urine moves from the bladder towards the prostate). We also remove the seminal vesicles.
b. Radical lymph node dissection: the main site is the iliac node and the surrounding nodes (we evaluate and usually perform this dissection even if pet scan is negative)
We should perform both |
| What are complications of surgery of bladder cancer? | In this case we can perform urinary diversion. There are 2 adapted methods:
1- Ileal conduit
2- Neobladder |
| What are types of surgeries for bladder cancer? | We can perform the surgery either open or via laparoscopy. However, open surgery is mostly the surgery of choice.
Urinary diversion is done because the bladder is resected with its surrounding nerves, vessels… => No place for urine accumulation |
| What is ileal conduit procedure? | Ileal conduit = We take a segment around 20 cm of the ileum from its distal part 10 cm away from the ileocecal valve which is left unchanged, and we open a stoma to the exterior. We implant the ureters inside it, the right and the left. The segment is stapled on one the side of digestive system and remains open on the external side. The open part is connected to a bag on the exterior. This method is also called Bricker procedure. This procedure is the incontinence surgical procedure after radical surgery |
| What are risks of complications of ileal conduit and neobladder? | We preserve the vessels of the used segment to avoid necrosis. The difference of pressure and peristalsis promotes emptying to the exterior. Overall, complications (Stenosis, Hernia, Fistula) risk of ileal conduit is 25%. Neobladder risk of complications is 50%.
First few days, there is a risk of fistula between digestive and urinary systems.
Ileal conduit is the best procedure. Ureterostomy (Anastomosis with the skin) is another easier method, but the problem is that the ureter is narrow, which leads to recurrent stenosis. It is done for patients unable to undergo surgery |
| What is neobladder procedure? | Neobladder is a new bladder The best neobladder is made from ileum, we take 60cm, open it, and reconstruct it in the shape of a sphere, we connect it to the urethra and ureters. It is a continent procedure since we keep the sphincter intact |
| What are issues of neobladder? | However, reflex is lost. Incontinence and pressing the stomach from pain. There is more risk of complications (Longer procedure).
Another issue is in the level of the liquid:
-if too low, the patient will spend a life in the bathroom as being incontinent
-if too high, there will be residual urine, which will then be absorbed, leading to hyperkalemia and uremia (buildup of waste products in your blood) |
| What are CI of neobladder? | Contraindications for Neobladder Reconstruction:
- low IQ level
-Creatinine > 2
7 to 10 years of survivability using modality 1 (surgery) |
| What is 2nd modality of tx of bladder cancer? | Resection of the tumor + systemic chemotherapy and radiotherapy without surgery (bladder sparing modality).
less survival rate and less quality of life → urinate blood and spend long periods urinating and urine infections. |
