Surgical management

1. BLADDER CANCER
BY
DR. H. ATAWURAH

2. Bladder urothelium

3. The Urothelium
1. It is the epithelium that lines the urinary
tract-from renal papillae to the urethra.
2. From basement to lumen- basal cells,
intermediate cells, and umbrella cells.
3. It is the most impermeable of all human
epithelia and also very inert- predisposition
to malignant transformation.

4. Histology of the urinary bladder

5. Histology

6. Bladder Cancer-epidemiology
 The 2nd
most common urological malignancy
 Peak age 70 yrs
 Male to female ratio is 4:1
 4th
most common cancer in men and 8th
most
common in women
 It is the 4th
most common cancer in men and 5th
most common overall.

7. Type of bladder cancers
1. Primary cancers
 Transitional Cell Carcinoma (TCC) : they form 90% of all
urinary bladder cancers.
 Squamous Cell Carcinoma (SCC) : they are about 7% of
all bladder cancers. 75% in areas endemic with
schistosomiasis.
 * Adenocarcinoma : about 2%
 * Rare one include melanoma, lymphoma,
Phaeochromocytoma, sarcoma.
2. Secondary cancers
are mostly metastatic from gut, prostate, kidney, ovary.
* these are not urothelial tumors.

8. Pathogenesis of bladder cancer
 There are two major groups-1) low grade, non-
invasive (pTa/T1) about 70-80%. Carcinoma in
situ(CIS) is by definition noninvasive but is a high
risk lesion, so treated as invasive.
 Invasive tumours are invasive at diagnosis with poor
prognosis( 20%).
 Multifocality and frequent recurrence.

9. Etiology of bladder cancers
1. Acquired Factors
 Tobacco Smoke- 50-60% of bladder cancers are caused by smoking(cigarette
smoke contains arylamines)
 Chronic Cystitis and other infections
 indwelling catheters
 Schistosoma haematobium cystitis
 Analgesic abuse (5-15kg over a 10-year period). Phenacetin which is similar in
structure to aniline dyes increase risk of TCC
 Pelvic irradiation.
 Chlorinated byproducts and arsenic in water
 Genetic- Hx of 1st
degree relatives with bladder Ca have double risk of Ca Bladder.
 Chemotherapy with cyclophosphamide.

10. Etiology of bladder cancers(cont)
2. Occupational Exposures:
 Aromatic hydrocarbons eg. Benzene, coal
tar, bitumens, diesel exhaust.
 Aromatic amines(arylamines) eg. Aniline
dyes encountered in textiles, hairdresser,
chemical plant.

11. Carcinogens causing bladder cancers
 Memonic – Pee SAC
-Phenacitin ( a banned analgesic
-Smoking
-Analine( rubber and dyes)
-Cyclophosphamides(medication for cancer Rx)

12. Signs and symptoms
 Haematuria-total, gross and painless
 Bladder storage symptoms such as frequency,
urgency and nocturia. There would be no
voiding spymtoms

13. Signs
1. Pallor- this indicates anaemia due to blood loss or
chronic renal impairment.
2. Suprapubic mass- in the case of locally advanced
disease or tumour causing BOO.
3. If metastasis is present, then systemic symptoms eg.
Anorectia , weight loss, pelvic pain or weakness
4. Digital Rectal Examination(DRE) can reveal a mass
if prostate is involved.

14. Signs and symptoms cont.
Microhaematuria- RBC per hpf more than
50
assymptomatic microhaematuria occurs in
about 13%
of the population but only 0.4% have been found
to
be due to urothelial tumours.
Indications for urological evaluation is not clear
cut,
however with the presence of frequency,
urgency,

15. Diagnosis
1. Physical examination-usually
unremarkable. DRE may reveal
infiltration of the prostate
2. Urine test-(Microscopy) there should more
than 3 RBC per HPF, urine cytology, cytometry
would show aneuploid , hyperploid cells
3. Cystoscopy
4. Ureteroscopy
5. Biopsies
6. Imaging- USG, IVU, CXR, CT scan, MRI
7. Isotope bone scan

16. Cystoscopic view of bladder cancer

17. Description
T Primary tumor
Ta Neoplasm confined to mucosa
Tis Carcinoma in situ (confined to mucosa)
T1 Tumor invades submucosa/lamina propria
T2a Tumor invades superficial muscle
T2b Tumor invades deep muscle
T3 Tumor invades perivesical fat
T4a Tumor invades prostate, uterus, or vagina
T4b Tumor invades pelvic or abdominal wall
N Lymph nodes
N1 Single regional lymph node, <2 cm in diameter
N2 One or more lymph nodes, none >5 cm
N3 One or more lymph nodes, >5 cm
M Metastases
M1 Distant metastasis
TNM Staging Classification American Joint Committee on Cancer

20. Surgical Management
Management –carefully individualized
1. Stage – superficial or muscle invasive.
2. Grade:
Well differentiated ( 10% will be invasive)
Moderately differentiated ( 50% invasive)
Poorly differentiated ( 80% will be
invasive)
3. Presence of carcinoma in situ (Tis)

21. Superficial Bladder Cancer
Stage Ta to T1 and CIS– Transurethral resection is
curative in most cases
1. Stage Ta ( confined to mucosa)- recurrence is 50%
and
progression 3%
2. Stage T1 (invasion of lamina propria)- recurrence
is 75%
and progression 30%
* CIS is a flat high grade transitional cell carcinoma
Tumor recurrence is managed by repeated TUR and
prophylactic intravesical chemotherapy

22. Intravesical Therapy
1. BCG ( preparation of attenuated tubercle
bacillus)- this is immunotherapy.
2. Mytomycin C- obtained from
Streptomyces spp. – inhibits DNA synthesis
3. Thioptera an alkylating agent.
4. Doxorubicin- anthracycline

23. Complications of TURB
1. Bleeding
2. Bladder perforation.
3. UTI.
4. TUR syndrome
5. Incomplete resection
6. Urethral stricture due to accidental
injury to the urethra

24. Muscle-Invasive ( Stage T2)
1. Radical cystectomy and pelvic lymphadenectomy.
2. Radiation- unsuccessful as a sole mode. It is
reserved for those who refuse cystectomy.
Preoperative irradiation followed by cystectomy
is advantageous.
3. Chemotherapy (M-VAC): methotrexate,
vinblastin, andriamycin and cisplatin- for T3/T4.

25. Carcinoma in Situ(Tis)
1. It is a superficial lesion but very aggressive.
2. 50% t0 75% will progress to advance
disease skipping directly to dissemination
Treatment here is RADICAL CYSTECTOMY
with urinary diversion.

26. Complications after cystectomy
1. Bleeding
2. Thromboembolism
3. Sepsis
4. Wound infection
5. Intestinal obstruction or prolonged ileus
6. Rectal injury
7. Erectile dysfunction

27. Patient education and health maintenance
 Advice Pt that irritative and voiding symptoms
and intermittent hematuria are possible several
weeks after TUR
 Importance of vigilant adherence to follow-up
schedule-cystoscopy every 3 months for the 1st
year, then every 6 months for the next year,
thereafter yearly for the rest of life
 70% of superficial tumours recur

28. Goals of therapy
 Superficial- prevent recurrence
 Muscle-invasive- Maximize chances of cure
 Metastatic- prolong survival, improve symptoms

29. Summary
 Structure of the urothelium
 Type of bladder cancers
 Risk factors ( causes) of bladder cancers
 Diagnosis and staging
 Surgical management and complications thereof