High Risc Bladder Cancer

Bladder cancer is the predominant malignancy of urinary tract -kidneys, ureters, bladder and urethra- and is the 7th most common cancer in men and 17th in women.

Cigarette and tobacco smoking is a well-known risk factor for the development of bladder cancer and accounts for at least half of the patients.

“Aromatic Amine and Polycyclic Hydrocarbons” that exist in cigarette are very dangerous carcinogens and are excreted in urine. Carcinogenesis may develop as this urine stored in bladder may affect the cells lining the inner part of bladder. Exposure to certain environmental factors as dyes, paints, heavy metals and petroleum in chemical, metal and textile industry workers are also associated with bladder cancer.

Preliminary diagnostic work-up in patients with these symptoms include radiologic studies as bladder ultrasonography or a computerized tomography (CT) of pelvis or whole abdomen.

Subsequently an endoscopic procedure, cystoscopy combined with resection of the tumor, referred as Trans Urethral Resection-Bladder (TUR-BT) is performed by inserting special instruments through urethra into the bladder. This provides confirmation of diagnosis and quantification of the number, size (over 3 cm ?) and location of tumor and yields pathologic evaluation for ultimate management.

Figure 1. A high risk bladder cancer diagnosed on computerized tomography

Pathologic evaluation demonstrates the depth of cancer through bladder layers and invasion to the bladder muscle as well as the grade (malignant potential) of the tumor; all these features are vital in management options of bladder cancer. Thus, as bladder cancer should be dealt by surgeons specialized on urologic cancers, pathologic evaluation demands pathologists focused on urologic malignancies.

All the effort to manage bladder cancer appropriately and duly depends on accurate evaluation of the presence of bladder muscle invasion by malignant cells. In cases of muscle invasive bladder cancer, delay of radical cystoprostatectomy (removing the bladder, prostate, seminal vesicles and adjacent lymph nodes) sacrifices patient’s life because cancers invading muscle layers of bladder have high potential to disseminate in distant organs (metastases) easily and quickly.

Bladder tumors invading muscle layer are referred to T2 and they are definitely High Grade (G3) tumors. Muscle invasive bladder cancers are stated as Pt2 High Grade in pathology reports after initial TUR-BT procedure. When such a pathologic assessment is entertained removal of bladder, radical cystoprostatectomy, must be considered. Management of Ta low grade tumors (Ta G1) reported after initial TUR-BT differs because these are low-risk tumors.

Bladder Tumors With High Risk

These tumors are those that have not invaded muscle layer of bladder, not as T2 High Grade but are in the proximity of bladder muscle and reported as T1. All T1 Tumors are High Grade (G3) tumors.

It is essential to be certain whether the tumor is T1 or T2 in those patients who have T1 High Grade bladder cancer after initial TUR-T. In forty percentage of T1 High Grade tumors actual stage of the tumor is known to be T2; that is muscle invasion. Hence it is necessary to perform a re-TUR-BT in these T1 High Grade bladder cancer patients 2-6 weeks after primary TUR-BT and confirm definite pathologic stage.

If we are not aware that the tumor stage reported as T1 is in fact a T2 tumor we mishandle the disease by not removing out the bladder and mistreat by instillations of BCG. That is why a re-TUR-BT (second TUR-BT) after a T1 reported bladder cancer is mandatory. It is not possible to treat a T1 tumor appropriately excluding a re-TUR-BT. When there are no residual cancer cells on second pathology in re-TUR-BT patients (pT0), BCG instillations into bladder is commenced.

In some cases, initial TUR-BT may yield a pT1 tumor without muscle layer of bladder. The incidence of under staging in T1 tumors after TUR-BT may be as high as 40%. If no muscle layer is present on initial TUR-BT where pathology is reported as T1, a re-TUR-BT (second TUR-BT) is necessary for proper staging.

Which Patients Are Candidates For a re-TUR-BT?

  1. All patients with a T1 pathology result after initial TUR-BT
  2. If there is no muscle layer in specimens of initial TUR-BT
  3. If a pTa High Grade (G3) cancer is reported after initial TUR-BT
  4. If there is a tumor greater than 3 cm on initial TUR-BT
  5. If there are more than 3 tumors on initial TUR-BT

Re_TUR-Bt is a widely accepted procedure.

Biological behavior of T1 tumors is not easy to predict and both patients and physicians may simply have conflicts over management. Contradictions may arise due to concerns for unnecessary removal of bladder in actual T1 patients and/or for delay in those patients misbelieved to be T1 and yet in fact having T2 tumors.

Management of actual T1 bladder tumors (according to pathology of re_TUR-BT) is designed as follows: Following a re_TUR-BT a solitary tumor, less than 3 cm in size and proved to be T1, is treated by weekly instillations of BCG into bladder after 2 weeks and followed by cystoscopy+biopsy at 3 months intervals. Weekly BCG instillations are continued for a year.

To Which T1 (Without Muscle Invasion) Patients Removal Of Bladder (Radical Cystectomy) Should Be Offered? Who Are Candidates for Early Radical Cystectomy?

  • Patients with actual T1 tumor which is greater than 3 cm in size or more than 3 in amount
  • Residual T1 tumor in re_TUR-BT. (This subtype of patients carries an 80% possibility for progression to muscle invasive disease)
  • Actual T1 patients who received BCG instillations and yet found to have recurrent tumor on follow-up cystoscopy (BCG unresponsive patients)
  • Actual T1 patients with “lymphovascular invasion”
  • Actual T1 patients with diffuse “carcinoma in-situ”
  • Aggressive variants of bladder cancer as “Micropapillary”, “Nested Cell”, “Sarcomatous”, “Small Cell”, “Plasmacytoid” and “Bladder Sarcoma”
  • Actual T1 tumors with obstruction in one or both kidneys (hydronephrosis) as diagnosed on ultrasound or computerized tomography
  • Existence of similar tumor in prostatic stroma (inner zone of prostate)
  • Actual T1 patients who are allergic to BCG or in whom BCG instillations is unsuitable due to side effects or in patients with a deficient immune system

In 10 Years Follow-Up, Patients with Actual T1 Tumors:

  • 1/3 of patients are managed successfully and no recurrence is observed
  • 1/3 of patients show progression into muscle layer and necessitate removal of bladder
  • 1/3 of patients are lost due to conflicts in management

Urinating with an Neobladder

Spontan voiding with new bladder (neobladder). He is 64 years old male After 2 months from surgery he is able spontan peeing and he can control. His urine, he is not incontinent, no leak of urine.