Urinary bladder cancers are the second most common tumor of the genitourinary system. Transitional cell carcinoma accounts for 90% of cases. Risk factors include smoking, industrial exposure to chemicals, and prior chemotherapy or radiation treatment. Clinical presentation varies from painless hematuria to irritative bladder symptoms. Diagnostic evaluations include urine cytology, cystoscopy, CT/MRI, and biopsy. Treatment depends on tumor stage but may include transurethral resection, intravesical BCG or chemotherapy, radical cystectomy, or radiation therapy. Follow up care involves regular cystoscopy and urine cytology to monitor for recurrence.

1. URINARY BLADDER CANCERS
S.V.BHARTI
1ST YR RESIDENT
GEN.SURGERY

2. Introduction
• 2nd most common tumor of genitourinary
• Benign - Papilloma
• Malignant -Trastitional cell ca 90%
-Squamous cell ca 5-10%
-Adeno carcinoma <2%
-Undifferentiated <2%
-Mixed ca 4-6%

3. Other tumors
• Small cell carcinomas
• Carcinosarcomas
• Primary bladder lymphomas
• Rhabdomyosarcomas
• Carcinoid tumor
• Melanomas
• Pheochromocytomas
• choriocarcinomas

4. • Mean age 65 yrs
• TCC-69yrs male
• 71years female
• 2.5 times more common in male
• Male
4th most common tumor
6.2%of all cases
• Female
8th most common tumor
2.5% of all cases

5. Clinical presentation
• 60-90% - painless gross hematuria.
• 3p’s
painless haematuria
profuse haematuria
paroxymal haematuria
• 20-30%- irritative bladder symptoms
Dysuria
Urgency
Frequency of urination
• 10-15% asymptomatic
Palpable Mass
• Advanced cases
Pelvic or bony pain
Flank pain 30% from ureteral obstruction
Hepatomegaly

6. The World Health Organization classification
• low grade (grade 1 and 2) 55-60% of
patients have low-grade superficial
disease
• high grade (grade 3).
• Carcinoma in situ (CIS) is a flat,
noninvasive, high-grade urothelial
carcinoma.

7. Tumors are also classified by growth patterns
• Papillary
• Sessile
• Mixed
• Nodular

8. Transitional cell ca
• 90% bladder ca
• Most commonly-papillary and exophytic may
be sessile or ulcerated
• Bladder is 30-50x common site of the
tumor than ureter or renal pelvis
• Synchronous (simultaneous) transitional cell
carcinomas are common

9. Squamous cell carcinomas (SCCs)
• 5%-10% bladder cancer
Associated with persistent inflammation from long-
term indwelling Foley catheters and bladder stones.
• Associated with bladder infection by Schistosoma
haematobium (bilharzial inf)

10. Adenocarcinomas
Less than 2% of primary bladder tumors.
These tumors are observed most commonly in
exstrophic bladders
Respond poorly to radiation and
Chemotherapy.
Three types
primary vesicle
urachal
metastatic

11. Etiology
• Smoking 50%.
[Nitrosamine,2-naphthylamine,and 4- aminobiphenyl
are carcinogenic agents found in cigarette smoke].
• Industrial exposure to aromatic amines in dyes, paints,
solvents, leather dust, inks, combustion products,
rubber, and textiles.
• Higher-risk occupations –[ painting, driving trucks, and
working with metal]

12. Contd…
• Chemotherapy with cyclophosphamide
Increase risk 9 fold
• Radiation treatment of ca carvix,ovary-
increases risk 2-4 fold
• Spinal cord injuries
Indwelling catheters 16- 20 fold

13. Contd…
• Mutations of the tumor suppressor gene for p53,
found on chromosome 17, are associated with
high-grade bladder cancer and CIS.
• Mutations of the tumor suppressor gene for p15
and p16, on chromosome 9, are associated with
low-grade and superficial tumors.
• Retinoblastoma (Rb) tumor suppressor gene
mutations

14. AJCC STAGE
• TX: Primary tumor cannot be assessed
• T0: No evidence of primary tumor
• Ta: Noninvasive papillary carcinoma
• Tis: Carcinoma in situ: "flat tumor"
• T1: Tumor invades subepithelial connective tissue
• T2: Tumor invades muscle
T2a: Tumor invades superficial muscle (inner half)
T2b: Tumor invades deep muscle (outer half)
• T3: Tumor invades perivesical tissue
T3a: microscopically
T3b: macroscopically (extravesical mass)
• T4: Tumor invades any of the following:
T4a: Tumor invades the prostate, uterus, vagina
T4b: Tumor invades the pelvic wall, abdominal wall

15. • Nodal involvement (N)
• NX: Regional lymph nodes cannot be assessed
• N0: No regional lymph node metastasis
• N1: Metastasis in a single lymph node, 2.0 cm or less in
greatest dimension
• N2: Metastasis in a single lymph node, more than 2.0 cm
but not more than
– 5.0 cm in greatest dimension;
– or multiple lymph nodes, none more than 5.0 cm in greatest
dimension
• N3: Metastasis in a lymph node more than 5.0 cm in
greatest dimension
• Distant metastasis (M)
• MX: Presence of distant metastasis cannot be assessed
• M0: No distant metastasis
• M1: Distant metastasis

16. staging

17. AJCC Stage Groupings
• Stage 0a Ta, N0, M0
• Stage 0is Tis, N0, M0
• Stage I T1, N0, M0
• Stage II T2a, N0, M0
T2b, N0, M0
• Stage III T3a, N0, M0
T3b, N0, M0
T4a, N0, M0
,
• Stage IV
T4b, N0, M0
Any T, N1, M0
Any T, N2, M0
Any T, N3, M0
Any T, any N, M1

18. Investigations

19. • Routine investigations
Hb%,Tc,Dc,ESR
urine RE/ME
LFT
Urine C/s
urea ,creatinine
blood sugar
Na/K

20. Urinary cytology
• Exfoliated cells from urinary sediment or
bladder wash
• Fixing these exfoliated cells on glass slide and
staining
• More sensitive in high grade tumor and CIS
• More sensitive in bladder wash than voided
urine
• 10-50% accuracy. for low-grade carcinoma ,
• 95% accuracy , high-grade carcinoma and CIS

21. Urine tumor markers
• NMP22,(nuclear matrix protein)
positive predictive value of 81.1%.
• Bladder cancer antigen (BCA) testing measures cytokeratins
8 and 18,
positive predictive value of 85%.
• CYFRA 21-1 testing detects cytokeratin 19. Cytokeratin 20
positive predictive value of 80.5%.
Other markers telomerase, epithelial growth factor, fibrinogen
products, and p53.

22. Ultrasonography
Tumor size,location,
shape,
– help identify
bladder wall
thickening and
bladder diverticula.
– detect
obstruction,metasta
sis

23. intravenous urogram
radiolucent filling
defect 50-75%
obstructive
features
hydronephrosis

24. Cystoscopy
• Direct visualisation
– Superficial low grade
tumor are typically sigle
or multiple papillary
lesion mainly <3cm
– High grade tumor are
sessile and large
– CIS may appear as an
erythematous, velvety
lesion,and mucosal
irregularities.

25. Cystoscopy
• Mucosal biopsy
--Should take biopsy from
area adjacent to the tumor
--Opposite bladder wall
--Bladder dome
--Trigone
--Prostatic urethra

26. CT scan
-Extension of tumor
-Depth of penetration
Pelvic and paraaortic
lymphnode status
-staging accuracy 40%-85%

27. MRI
• Nodal mets can be
dectectd better than
CT,MRI can help define
small tumors in the
renal pelvis and ureter.
• Staging accuracy 50%-
90%

28. Contd...
• Chest x-ray
• Radionuclide bone scan

29. Treatment

30. • Tis- complete TUR followed by intra vesicle BCG
• Ta (single low to moderate grade not
recurrent)
complete TUR
• Ta (large ,multiple,high grade or recurrent)
complete TUR ,followed by intra
vesicle BCG or chemo
• T1 complete TUR ,followed by intra
vesicle BCG or chemo

31. Contd…
• T2-4 Radical cystectomy
Neoadjuvent chemo followed by radicalcystectomy
Radical cystectomy followed by adjuvent chemo
Neoadjuvent chemo followed by concomitant
chemo and radiotherapy
• Any T,N+,M+ systemic chemo followed by selective surgery
or radiotherapy

32. • Intravesical immunotherapy (Bacillus
Calmette-Gueurin [BCG]
– superficial TCC and CIS,
– residual tumor,
– prophylactic in recurrent superficial tumor
• most effective intravesical therapy
• live attenuated strain of Mycobacterium
bovis.

33. CONTRAINDICATION
• GROSS HEMATURIA
• BACTERIAL INFECTION
• IMMUNOCOMPROMISED PTS

34. SIDE EFFECTS
• DYSURIA,URINARY FREQUENCY,URGENCY,
• HEMATURIA 30%
• GRANULOMATOUS PROSTATITIS
ASYMTOMATIC 20-30%
SYMPTOMATIC 1%
LOW GRADE FEVER /MALAISE
• BCG SEPSIS 0-4% -TRIPLE DRUG THERAPY WITH STEROIDS
• BLADDER CONTRACTURE

35. Other Intravesical chemotherapy
Mitomycin c
Most commonly used chemotherapeutic agent.
Inhibit DNA synthesis
Dose 20-60mg
Install for 6-8 wks
Response rate
CIS -58%
papillary -43%
Decrease recurrence 19-42%

36. Intravesical chemotherapy
• Doxorubicin
– Intercalating agent,anthracycline antibiotics
– Inhibit protein synthesis
– response rate –mean 38%
-Epirubicin
-Thiotepa
Alkylating agent
Response rate-up to 55%
Use 30 mg weekly
-Valrubicin
-Ethoglucin
-Gemcitabine a prodrug that requires activation by intracellular
phosphorylation
1500-2000 mg in 50 mL of saline wkly for 6 wks
complete responses in 50% of patients with CIS

37. LASER THERAPY
• Neodymium yttrium aluminium garnet
(ND:YAG)
-COAGULATE LESION
USED IN
recurrent
low grade lesion

38. New modalities
• Photodynamic therapy:Involves the intravenous
injection of a porphyrin derivative(Porfimer Na 1.5
to 2 mg/kg)
followed 24 hours later with exposure of the bladder
surface to laser light
• Other alternatives:
• Vitamins
VitA , vit B6 , vitC , vit E
Effective in low grade Ta lesion

39. Contd…
• Difluoromethylorinithine
- irreversible inhibitor of orinithine decarboxylase
- SOY products soy isoflovane chemoprotective
- Cycloxinase inhibitor
Cox1,cox2

40. Partial cystectomy
• Only tumor taken out
• Local reccurance-40-70%
• Sexual and bladder function retaind
Indication
• Normal function bladder and good capacity
• 1st time tumor reccurance/solitary tumor
• Tumor Location that allow 1-2 cm margin of resection such
as dome

41. Radiation Therapy
Who refuse cystectomy after intravesical
chemotherapy
Unsuitable to major surgery
local micrometastasis
Downstaging
External beam irridation (5000-7000Gy)
• overall 5-year survival rate
20-40%

42. neoadjuvant chemotherapy
• Given before definate local
treatment
Allow tumor
chemosensitization
Potential downstage
Micrometastasis
Used
Methotrexate
Cisplatin
Vinblastin
Doxorubicin
• Used combination
MCV
MVAC

43. Perioperative chemotherapy
• Two cycle of MVAC before OT then
4 cycle after OT

44. Radical cystectomy
• Men:bladder with surrounding fat,peritoneal
attachements,prostate,seminal vesicles
• Women:bladder with surrounding
fat,peritoneal attachments,cervix,utreus,ant
vafginal vault,urethra and ovaries

45. Contraindications:
(1) Bleeding diathesis,
(2) Evidence of gross, unresectable metastatic
disease (unless performed for palliation), and
(3) Medical comorbidities that preclude operative
intervention (eg, advanced heart disease, poor
pulmonary mechanics, advanced age).

46. Follow-up care:
,
• patients are monitored at regular intervals
with cystoscopy and urine cytology.
• every 3 months for the first 1-2 years
• every 6 months thereafter.
• IVP is also usually performed every 6-12
months. This follow-up continues for a
minimum of 5 years.

47. THANK YOU