bladder cancer

Question 1

what type of cancers arise in the bladder?

Answer 1

80% are transitional cell carcinomas

20% are squamous cell carcinomas

adenocarcinomas are rare

Question 2

what are the risk factors for transitional cell carcinomas?

Answer 2

smoking

occupational aromatic amine exposure

Question 3

what are the risk factors for squamous cell carcinomas?

Answer 3

long term catheters
recurrent UTIs
bladder stones

(irritate bladder lining = more mitosis to replace cells = more chance of neoplasia)

Question 4

what is the initial treatment for bladder cancer?

Answer 4

transurethral resection of the bladder
it allows assessment of histology, grade and stage of tumour

allows tumour to be divided into non detrusor muscle invasive (Ta/T1) or detrusor muscle invasive (T2+)

Question 5

what are the further treatment options for bladder cancer?

Answer 5

low risk(g1/2) = cystoscopic surveillance only

intermediate risk = 6x week mitomycin instillations followed by surveillance (mitomycin reduces recurrence)

high risk(G3) = BCG regime, high risk might chose cystectomy upfront

Question 6

what is the BCG regime?

Answer 6

used for high risk G3 cases of bladder cancer TCC

Used for TB inoculation but also if given intravesically, stimulates a hypersensitivity reaction type IV that reduces progression.

Question 7

what are the side effects of the BCG regime ?

Answer 7

• dysuria, frequency, urgency
• UTI
• Haematuria

If BCG fails treatment is a cystectomy

Question 8

how does treatment differ in muscle invasive disease between organ confined and metastatic?

Answer 8

metastatic = palliative chemotherapy

organ confined = neoadjuvant chemotherapy and cystectomy and chemoradiotherapy

Question 9

how does a radical cystectomy differ between a male and female?

Answer 9

in a male = cystoprostatectomy
removal of bladder and prostate

in female = anterior exenteration
remove bladder, uterus, tubes, ovaries and anterior vaginal wall

both get pelvic lymph node dissection

Question 10

what are the types of urinary diversion after cystectomy?

Answer 10

ileal conduit = ureters are connected to section of small bowel brought out as a stoma into a stoma bag (a urostomy)

neobladder = ureters are connected to a new bladder made of small bowel and connected to urethra

continent diversion = pouch fashioned e.g right hemicolon, patient passes catheter into it to release urine into stoma bag when needed.

Question 11

when is a continent diversion contraindicated?

Answer 11

in renal impairment, hepatic impairment, inadequent small bowel e.g crohns, not able to be catheterised

Question 12

when is a neobladder contraindicated?

Answer 12

if tumour extends to prostatic urethra (urethrectomy required)

Question 13

what are the issues with continence diversions?

Answer 13

• hyperchloraemic metabolic acidosis
• incontinence
• stones
• mucus
• perforation
• must get up every 3 hours at night to empty at start

Question 14

how to patients with bladder cancer present?

Answer 14

painless haematuria, either visible or non-visible. Patients may also present with recurrent UTIs or lower urinary tract symptoms (LUTS), such as frequency, urgency, or feeling of incomplete voiding.

Question 15

how is bladder cancer diagnosed?

Answer 15

initially via a flexible cystoscopy under local anaesthetic.

However, if a suspicious lesion is identified from initial cystoscopy, a rigid cystoscopy will be required (typically done under general anaesthetic) for more definitive assessment.

then biopsy

Question 16

For a patient presenting with new visible haematuria, what is the recommended first-line investigations (after routine bloods and urine dipstick testing)?

Answer 16

CT scan KUB + flexible cystoscopy