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Urology - Surgery > Bladder Cancer > Flashcards

Bladder Cancer Flashcards

1
Q

How common is bladder cancer?

A

Most common cancer of the renal system

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2
Q

What are the risk factors for bladder cancer?

A
  • Age > 80yrs
  • Men (3:1)
  • Smoking
  • Exposure to aeromatic hydrocarbons (e.g. industrial dyes or rubbers)
  • Schistosomiasis infection (specifically causing the SCC subtype)
  • Previous radiation to the pelvis.
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3
Q

What are the different types of bladder cancer & what proportion of cases do they make up?

A
  • Transitional cell carcinoma (>90% of cases)
  • Squamous cell carcinoma ( 1-7% - except in regions affected by schistosomiasis)
  • Adenocarcinoma (2%)
  • Sarcoma (rare)
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4
Q

What is a transitional cell carcinoma?

A

Cancer of the transitional epithelium (urothelium) of the bladder.

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5
Q

What are the 4 layers of the bladder wall (from inside to outside) ?

A
  • Transitional epithelium (Urothelium)
    • Inner lining of bladder
  • Lamina propria
    • 2nd layer made up of connective tissue
  • Muscularis propria
    • 3rd layer
  • Fatty connective tissue
    • Outer layer
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6
Q

How does TCC present?

A
  • Painless haematuria (Visible / Non-visible)
  • Recurrent UTIs
  • Lower urinary tract symptoms (LUTS)
    • Frequency
    • Urgency
    • Feeling of incomplete voiding.
  • Systemic symptoms (e.g. weight loss or lethargy)
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7
Q

What signs may be present on examination of a patient with TCC?

A

In early disease examination is typically unremarkable can show signs such as:

  • Urinary retention

In metastatic disease may present with

  • Enlarged pelvic lymph nodes – lymphatic spread
  • Hepatomegaly – liver metastases
  • Bone pain – bony metastases
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8
Q

What are your differentials?

A
  • UTIs
  • Renal calculi
  • Prostate / renal cancer
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9
Q

What investigations are used to investigate suspected bladder cancer?

A
  1. Usual haematuria work-up
  2. Urgent flexible cystoscopy (under local anaesthetic)
    * All cases of haematuria should be investigated with cystoscopy
  3. Rigid cystoscopy (after initial cystoscopy)
    * For more definitive assessment under general anaesthetic
  4. Biopsy
    * If tumour identified on rigid cystoscopy

+/- transurethral resection of bladder (TURBT)

  • If found to be superficial
    4. CT urogram
  • For any suspected muscle-invasive bladder cancer, prior to any resection performed at TURBT
    5. Urine cytology
  • To identify cancerous cells (has poor sensitivity and so not routinely done)
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10
Q

Why is urine cytology not routinely done?

A

It has poor specificity & sensitivity

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11
Q

What is a CT urogram?

A

CT imaging with contrast used to evaluate urinary tract including kidneys, bladder, ureters

  • · Different to CT KUB which doesn’t use contrast
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12
Q

When would you do TURBT on initial assessment vs. after biopsy?

A

If the growth is superficial - Do TURBT on initial assessment

If growth seems invasive - Do TURBT after biopsy results

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13
Q

What is a TURBT?

A

Resection of bladder tissue by diathermy during rigid cystoscopy

  • To remove cancerous tissue
  • Performed under general / regional anaesthetic
  • Can be used for biopsy to stage disease
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14
Q

How is bladder cancer staged?

A
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15
Q

What is non-muscle-invasive bladder cancer?

A

Bladder cancer that does not penetrate into the deeper layers of the bladder wall (around 70-80% cases)

  • TNM staging = Tis / Ta / T1
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16
Q

What is muscle-invasive bladder cancer?

A

Bladder cancer that penetrates into the muscular layers of the bladder wall (deeper)

  • TNM staging = T2, T3
17
Q

What is locally advanced / metastatic bladder cancer?

A

Bladder cancer that is spreading through the bladder wall to distal structures

(e.g. local / distant structures or to lymph nodes)

  • TNM = T4 , N1/2, M1
18
Q

How do you manage non-muscle-invasive bladder cancer?

A
  1. TURBT
    * For CIS or T1 tumours

+/- Adjuvant intravesical therapy (e.g. BCG / Mitomycin C)

  • Cases with deemed higher risk disease, even in non-invasive
    2. Radical cystectomy
  • High-risk disease / limited response to initial treatments.
    3. Routine follow-up with regular surveillance via cytology and cystoscopy.
19
Q

What is the recurrence rate for superficial bladder tumours? & How does this impact management?

A

They have a high rate of recurrence with around 70% recurring within 3 years & these recurrences are more likely to be more invasive.

This is why all patients require regular surveillance w/ cytology & cystoscopy

20
Q

How do you manage muscle-invasive bladder cancer?

A
  1. Radical cystectomy

with urinary diversion via:

  • Ileal conduit w/ urine draining via urostomy
  • Bladder reconstruction from a segment of small bowel (Neobladder)
  1. Neoadjuvant chemotherapy
    * Typically with a cisplatin combination regimen.
  2. Regular follow-up w/ CT imaging
    * To monitor for local and distant recurrence.
21
Q

What is radical cystectomy?

A

Surgical procedure in which bladder & surrounding organs removed:

  • In men – bladder, prostate, seminal vesicles and surrounding lymph nodes are removed
  • In women – bladder, ovaries, Fallopian tube, uterus, cervix and part of the vagina and surrounding lymph nodes are removed
22
Q

What are the different types of urinary diversion?

A
  1. Ileal Conduit
    * Allows urine to drain through stoma and into external bag affixed to abdomen
  2. Continent diversion / Indiana pouch
    * Harvested intestine used to form internal pouch that collects urine which is then drained using catheter through stoma (small opening) on abdomen
  3. Neobladder
    * Harvested intestine used to form internal pouch that collects urine which is voided normally though urethra
23
Q

What are the 2 options for urine drainage after formation of a neobladder?

A

Urine can drain either:

Urethrally or via catheter

24
Q

What follow up is essential with patients who recieve a neobladder? & why?

A

Routine bloods, B12 and folate levels should be checked at least annually

Macrocytic anaemia can develop due to B12 deficiency as resection of part of ileum will affect B12 absorption

25
Q

How do you manage patients with locally advanced / metastatic muscle-invasive bladder cancer?

A
  1. Chemotherapy
    * Cisplatin‑based regimen

or

  • Carboplatin plus gemcitabine-based regime.
    2. Manage symptoms of the disease (e.g. pelvic pain, ongoing bleeding, or urinary frequency) with specialist advice and input through the MDT.
    3. Discuss palliative options with patient when appropriate
26
Q

What is the prognosis for patients with bladder cancer?

A
  • Patients with superficial disease
    • Five-year survival 80-90%
  • Muscle-invasive disease
    • Five-year survival 30-60%
  • Metastatic disease
    • Five-year survival 10-15%
27
Q

What malignancies does bladder cancer increase the patient’s risk for?

A

Upper urinary tract & urethral tumours.

28
Q

What are the common sites of metastases of TCC?

A
  1. Via direct invasion:
    * Peritoneum
  2. Lymphatic (Lymph nodes)
  3. Haematogenous
    * Liver, Lungs, Bone, Brain

Urology - Surgery (12 decks)

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