Bladder Cancer

The human bladder is the part of our body that stores urine after it has been filtered by the kidneys. The inside of the human bladder is lined by transitional cells. Over 90% of the time bladder cancer is caused by the abnormal growth of these cells. This type of cancer is called transitional cell carcinoma. Bladder cancer is frequently curable if it is diagnosed while it is still confined to the inside of the bladder. The majority of bladder cancer (approximately 70%) is detected in this early stage.

Most patients with bladder cancer present with blood in the urine (hematuria), but other patients can present with painful urination, and frequent urination. There are some people that present with no obvious symptoms, yet their urinalysis shows traces of blood in the urine (microhematuria).

Bladder cancer is commonly associated with people who smoke. It is estimated that smoking has been the causative agent in over 50% of bladder cancers detected in the United States. Other risk factors for bladder cancer include:

  1. Family history
  2. Work exposure to toxic chemicals seen in paint, textile, leather and rubber industries
  3. Males – men are 3-4 times more likely than women to develop bladder cancer. This may have to do with the fact that more men than women have historically had a smoking history. This is changing over the last 10-20 years.
  4. Schistosomiasis haematobium infection

During an evaluation for hematuria most patients will undergo an evaluation, which includes the following:

  1. Urine tests, such as a urinalysis and urine culture
  2. Cystoscopy – a small lighted scope is placed into the bladder through the urethra (using anesthesia) to evaluated the lining of the bladder
  3. Radiologic evaluation of the urinary tract
    1. Intravenous pyelogram (IVP) – an x-ray study to evaluate the kidneys and the lining of the urinary tract draining the kidneys OR
    2. CT scan (CT urogram, Triple phase CT) – to evaluate the kidneys, the pelvis, ureters and bladder OR
    3. Renal US – this evaluates the kidneys ONLY. An additional test in the OR may be necessary to clear the collecting system – a cystoscopy with retrograde ureteropyelograms.
  1. Urine cytology or NMP- 22
    1. Urine cytology – a "PAP" smear of the urine looking for abnormal cancerous cells
    2. NMP22 – a urine screening test that detects abnormal cancer cells. This evaluation is necessary to evaluate the entire urinary tract. Transitional cell carcinoma can occur anywhere from the urethra (tube that empties the bladder), to the prostate, the bladder, and ureters, all the way up to the renal pelvis within the kidney.

Once a bladder cancer has been diagnosed it is important to determine the size of the tumor, the grade of the tumor, and the depth of invasion into the bladder wall. This is accomplished by performing a Transurethral Resection of the Bladder Tumor (TURBT), with bladder biopsies. The specimens are evaluated by the Pathologist, who determines the depth of invasion of the cancer. The risks of TURBT include, but are not limited to bleeding, infection, and damage to the bladder, urethra, prostate, and ureters.

If the pathology shows no evidence of invasion the bladder cancer is treated depending on the number of tumors. If the tumor was small and solitary, the patient is treated with observation and follow up cystoscopies. If there were multiple bladder tumors, or this particular tumor was a recent recurrence (a repeat or returning tumor), then the patient is treated with intravesical chemotherapy, such as BCG or mitomycin.

If the pathology shows invasion of the cancer, then further diagnostic testing be necessary, to include:

  1. CT scan (noted above) – this is helpful in determining the clinical depth of invasion, to evaluate the lymph nodes, and to rule out spread to other organs in the body.
  2. Chest x-ray – to rule out spread to the lungs
  3. Liver function tests – to see if it has spread to the liver
  4. Bone scan – this is done only if the alkaline phosphatase blood test is elevated to determine if the cancer has moved to the bones

The stage of the bladder cancer is determined from the findings of the tests noted above. There are 3 parts to the staging, and the staging system is referred to as the TNM cancer staging system.

  1. T = Tumor size and extent
  2. N = Nodal involvement
  3. M = Metastasis outside the nodal system, involving other parts of the body.

The treatment of patients with invasive bladder cancer depends of the stage and grade of the cancer, as well as the overall health of the patient. This decision making process will require a lengthy discussion with your urologist. Treatment options include:

  1. Surgery– to remove the cancer. Surgery can be done alone or in combination with chemotherapy, and radiation therapy. If the cancer is aggressive, and demonstrates a strong tendency to invade the wall of the bladder, most patients are treated with removal of the bladder (radical cystectomy – NOTE: please link to radical cystectomy), and the lymph nodes around the bladder. Once the cancerous bladder has been removed, a new bladder needs to be made to handle the urine. This is accomplished by using bowel to form a urinary diversion (NOTE: Please link to urinary diversion), which can be a simple as a urinary conduit, or as complex as a urinary reservoir, or a neobladder (or "new bladder"). All of these options are available with the Urologic Surgeons of Washington:
    1. Ileal conduits use 10-15 centimeters of your small intestine to create a conduit of urine from the ureters, which drain the urine from the kidneys, to a stoma on the outside of the body. The urine then drains into a stoma bag attached to the skin.
    2. Continent urinary reservoir uses a longer segment of the small and/ or large bowel to create a pouch that stores urine inside the abdomen or pelvis. The ureters are attached to this pouch and the pouch needs to be drained periodically. There are 2 major ways this can be accomplished:
      1. Continent urinary reservoir with a stoma - The urine is drained every 4 to 6 hours by the patient placing a catheter into a small stoma in the skin.
      2. A bladder substitution or "neobladder" – the urine is drained using your own urethra. So the urine passes out of the body just as you did prior to surgery. Sometimes the patient has a pass a urinary catheter into the "new" bladder to drain this type of reservoir.
  2. Radiation therapy – which destroys the cancer cells using high energy X rays. This may be used before, or after surgery. It has even been used in more recent years in conjunction with chemotherapy as an alterative to surgery.
  3. Chemotherapy – this destroys cancer cells using medication.

The risks of surgery include, but are not limited to: Infection, bleeding, bowel obstruction, bowel injuries, damage to the vessels, nerves, liver, spleen, bowel, rectum, urinary and bowel fistula, sexual dysfunction

Once the bladder cancer has been successfully treated, the follow up care depends on the stage and grade of the cancer. We recommend a detailed discussion with the Urologist to determine the best procedure for follow up after completion of the therapy.

  1. For superficial disease treated with observation of intravesical therapy:
    1. Cystoscopy and urine tests will be required every 3 to 6 months during the first and second years after your treatment
    2. A cystoscopy and urine test will be required every 6 months during the 3rd through 5th years after treatment.
    3. Annual cystoscopy after the fifth year.
    4. An IVP may be required to ensure that cancer does not develop in other parts of the urinary tract. This can occur in 3-5 % of patients.

  1. For invasive bladder cancer, follow up includes:
    1. Urine tests – Urinalysis, and cytology every 3 to 6 months
    2. An IVP, renal ultrasound and/or a CT scan will be done periodically to monitor for any recurrent cancer.
    3. Blood tests to monitor the salts and acid/base balance in the bloodstream.
    4. A periodic Vitamin B12 evaluation.

Telephone (202) 223 1024 / FAX (202) 223 2152


Address Urologic Surgeons of Washington 2021 K St. NW, Suite 408, Washington D.C. 20006

© 2006-2011 Urologic Surgeons Of Washington

Website development: Salem Mountain design group