Dr. Green:  The bladder is a muscular organ of the body that is part of the midportion of the urinary tract.  Its main function is the temporary storage of urine. 

Q.  What are tumors of the bladder? 

Dr. Green:  Bladder tumors are uncontrolled growth of bladder cells.  Why these cells express themselves as tumors is unknown and is at the very roots of all cancer research, i.e., how does cancer develop? 

Q.  Are there different types of bladder tumors? 

Dr. Green:  Yes; however, for the purpose of this article we will confine our discussion to "transitional papillary tumors".  Other types of bladder tumors are: 1) inverted papilloma, 2) nonpapillary carcinomas, such as adenocarcinoma, 3) bladder cancer associated with other disease, e.g., bladder stones, diverticula, 4) metastatic cancer to the bladder, 5) cancer in situ, 6) involvement of ureters, urethra, and renal pelvis, and 7) sarcomas. 

Q:  What are the signs or symptoms of bladder cancer? 

Dr. Green:  The cardinal or principal sign is gross painless blood in the urine.  This occurs in about 2/3 of cases and is usually total (occurring throughout urination).  In 1/3 of cases blood is seen only under the microscope (microscopic hematuria) or with a chemical qualitative test.  The most common symptom is frequency and urgency with decreased bladder capacity and pain.  One must be cognizant of the fact that bladder cancer may occur without any symptoms or visible blood in the urine. 

Q. Do bladder tumors occur in children? 

Dr. Green:  Bladder tumors are rare in children.  Bladder tumors occur primarily in adults in the 6th decade of life and beyond; however, I and with other urologists have seen bladder tumors in individuals in their early 40s.  Historically bladder tumors occur more frequent in men than women (2:1); however, that may change due to the increased smoking habits of women over the last 30 years.  Black men and women have a lower incidence rate of bladder cancer than their white counterparts (approximately three fourths)... the reasons are unknown. 

Q.  What are some environmental or occupational risk relationships to bladder cancer? 

Dr. Green:  Smokers develop bladder cancer at 2 to 3 times the rate of non-smokers.  Employees who work with dyes, metal, paints, leather, textile, and organic chemicals have been suggested to be at risk.  These risks are likely to be causal.  Many of the occupational findings are preliminary and require collaboration.  A number of other drugs and chemicals have been suggested as being linked to bladder cancer, but none have proven to be responsible for bladder cancer when put to scientific scrutiny.  I mention them casually as theyhave all appeared in the news media over the last two decades, e.g., coffee, artificial sweeteners (saccharin and cyclamate), phenacetin, hair dye, and diet (low Vitamin A).  Also, the use of a common cancer drug, Cytoxan, has been linked to bladder cancer as has "chronic bladder infections".  

Q.  How does one diagnose bladder cancer? 

Dr. Green:  Cystoscopy, inspecting the bladder with a lighted telescope-like instrument, and bladder biopsy remains the primary diagnostic procedure. 

Q.  Are all bladder tumors malignant (cancerous)? 

Dr. Green:  No; however, 90% are. 

Q.  What does staging of the bladder cancer mean and consist of? 

Dr. Green:  Staging of bladder cancer means determining the extent of growth and spread, i.e., is the cancer confined to the inner lining of the bladder or does it extend into the muscle, or has it spread to other tissues or organs, e.g., lungs and liver.  Conventional staging consists of the following:  Bimanual examination, Transurethral resection or tumor biopsy, Excretory Urogram (IVP), Computed Tomography (CT), Liver and Bone Scans, Chest x-ray and possible CT of the chest, and Liver and renal function blood test.  Staging is very helpful in planning treatment.     

Q.  Is there a screening test for early detection of bladder cancer similar to the PSA blood test used in the early detection of prostate cancer? 

Dr. Green:  Unfortunately, no. 

Q.  How do you treat bladder cancer? 

Dr. Green:  Treatment of bladder cancer involves many different factors (age, health status, stage); however, surgery is the cornerstone of treatment.  The critical issue to be determined is the stage of the cancer... is it superficial, i.e., in the lining of the bladder, or does it extend into the muscle?   

For superficial bladder tumors... transurethral resection and intra-vesical pharmacotherapy, e.g., BCG.  

For invasive (deep) bladder tumors... surgical removal of the bladder and urinary diversion if total bladder removal is required.                 

Q.  Should all patients with hematuria be referred for urologic evaluation? 

Dr. Green:  Usually.  If there is no known reason for the hematuria and if the hematuria is total painless and the patient is 50 years of age or older.  You should have a high degree of suspicion in smokers.  The old urologic adage that "gross total painless hematuria in an adult represents bladder cancer until proven otherwise" is a good rule to follow.

1) to eradicate existing disease     

2) to provide prophylaxis against tumor recurrence     

3) to avoid deep invasion into the muscle layers of the bladder or metastases to regional lymph nodes.  Transurethral resection (TUR) is the primary treatment to eradicate stage T1, Ta and Tis lesions.  However, within 6-12 months 40%-80% of these tumors recur after initial treatment.  Due to this high recurrence rate, adjuvant intravesicular pharmacotherapy with cytotoxic and immunomodulatory drugs is currently being used to decrease the recurrence rate of these superficial tumors.  Adjuvant intravesical pharmacotherapy has varying potential beneficial effects for patients.  At present the agent demonstrating the most beneficial effect is BCG.  Approximately 10%-25% of patients treated with TUR alone will develop muscle-invasion or metastatic tumors, necessitating more aggressive therapies, e.g., surgery and/or irradiation and/or systemic therapies.  Other common active pharmacologic agents include doxorubicin, mitomycin C, thiotepa, etc. 

Invasive
In the United States "radical cystectomy" (total removal of the bladder) is standard treatment for muscle-invading bladder cancer.  This operation involves removing the pelvic lymph nodes, the bladder, and the prostate and seminal vesicals, and the construction of some form of urinary diversion to manage urinary drainage.  Five year survival rates are between 50%-80% depending on the grade, depth of bladder penetration, and nodal status.  Treatment failures occur most commonly due to distant metastasis and not local recurrences.  There are a limited number of treatment options for invasive bladder cancer:    

A. Transurethral Resection (TURB).  In general, TURB is considered potentially applicable to the local control of small low grade T2 lesions with limited muscle invasion.   

B. Segmental Resection.  Limited to patients with a localized small tumor allowing at least a 2 cm margin.   

C. Simple Cystectomy.  Rarely done today; provides no information on node status.   

D. Neoadjustment Therapy.  May prove to be beneficial in improving survival.