What is bladder cancer?

It is the uncontrolled multiplication of the cells that line the inner part of the bladder, the part that comes into contact with urine.

What are the symptoms of bladder cancer?

It can cause the presence of blood and clots in the urine without pain. If it leads to obstruction in the channel where the kidneys open into the bladder, it may cause pain similar to that of a kidney stone.

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Is bladder cancer a common disease?

According to the 2017 national data from the Ministry of Health, bladder cancer is the 4th most common cancer in men in our country. In one year, 20.1 out of every 100,000 men are diagnosed with kidney cancer, while in women, this rate is 2.8 per 100,000.

Bladder cancer is the 4th most common cancer in men. In Turkey, 7.5% of all cancers observed in men in 2017 were bladder cancers. In women, however, urological cancers are not among the top 10 most common cancers.

How is bladder cancer diagnosed?

Patients presenting with blood in the urine, especially those over 50 years old and who smoke, should be thoroughly evaluated. The initial evaluation is done through ultrasound. If a mass is detected in the bladder during the ultrasound, the patient should be taken for surgery without delay to confirm the diagnosis.

Even if ultrasound does not detect any problem causing the bleeding, the bladder should be examined using a camera (cystoscopy) to check for small tumors that might have been missed by ultrasound.

How is cystoscopy performed?

It is the process of directly visualizing and evaluating the urethra and bladder using a long, narrow telescope equipped with light and optical systems. In women, this procedure does not require anesthesia, while in men, cystoscopy can be comfortably performed under local (topical) anesthesia with the application of an anesthetic into the urethra. During this procedure, biopsy samples can also be taken from areas suspected of having tumors using biopsy tools. The pathological evaluation of these biopsy samples is definitive for diagnosis.

What should be done when a mass is detected in the bladder?

Unless proven otherwise by pathological evaluation, all bladder masses should be approached as bladder cancer. Benign bladder tumors are rarely encountered. The first step in treatment is the removal of the tumor via scraping under camera guidance (cystoscopy) (TUR-B) and sending it for pathology. After this surgery, the next steps in treatment will be determined based on the pathology report.

How is the stage of bladder cancer determined?

The bladder is a three-layered organ. From the inside out, the first layer is the epithelium, the second layer is muscle, and the third layer is the outer serosa. The samples taken during the first surgery (TUR-M) are evaluated by a pathologist. If the tumor has not exceeded the first layer (Ta, T1), the disease can be controlled in the short term with medication inside the bladder, without the need for a second surgery. However, if the cancer has extended beyond the inner layer and reached the underlying muscle layer (T2), or has spread beyond the muscle layer to the outer serosa (T3), or has invaded the surrounding organs (T4), the first surgery (TUR-B) will not be sufficient for treatment.

Carcinoma in situ (Tis) is a separate type of bladder cancer. Even though this type of cancer may not have spread to deeper layers, it is highly prone to progression, and TUR-M surgery alone may not be sufficient for treatment.

What is done after TURB surgery in early-stage bladder cancer (Ta, T1)?

Within the first 24 hours after surgery, chemotherapy may be administered into the bladder to kill cancer cells floating in the bladder that cannot be seen with the camera.

After TUR-M surgery, chemotherapy or BCG (Bacillus Calmette-Guérin) is administered once a week for 6 weeks, starting 2-3 weeks after the surgery. BCG attracts the body’s immune system cells to the bladder, helping to kill cancer cells that cannot be detected by the camera.

To prevent recurrence, this intravesical drug treatment is continued for 1 year or 3 years, depending on the disease's potential for progression, with treatments given every 3 months for 3 weeks (or once a month). In addition to this treatment, cystoscopy (camera examination of the bladder for cancer control) is performed at regular intervals, depending on the tumor's stage and aggressiveness.

What is done after TURB surgery in Tis-stage bladder cancer?

Tis (Carcinoma in situ) bladder cancer is a dangerous subtype with a very high likelihood of recurrence and spread. It is very difficult to distinguish cancerous areas from normal bladder tissue. The appearance of Tis in cystoscopy is very similar to normal bladder tissue, and as a result, the surgeon may mistakenly consider these areas as normal, potentially leaving cancerous tissue behind. Therefore, if Tis is detected in the pathological evaluation, it suggests that there is a high probability of remaining cancer cells in the bladder.

If carcinoma in situ (Tis) is detected in the pathology, BCG treatment is administered into the bladder once a week for 6 weeks, starting 2-3 weeks after TUR-M surgery. BCG draws immune system cells into the bladder, helping to kill cancer cells that cannot be detected by the camera.

To prevent recurrence and progression of the cancer, this treatment is continued for 1 year or 3 years, with treatments given every 3 months for 3 weeks (or once a month). Along with this treatment, the tumor is monitored through periodic cystoscopy (camera examination of the bladder for cancer control).

What can be done to avoid missing Tis-stage bladder cancer?

In this type of bladder cancer, it can sometimes be impossible to distinguish between normal bladder tissue and cancerous tissue using white light cystoscopy. To avoid missing cancerous areas that are not visible with white light, different colored lights can be used with special chemicals. Before cystoscopy, the bladder is treated with HAL (hexaminolevulinate), and the bladder is examined under blue light. This procedure is called fluorescence cystoscopy. Fluorescence cystoscopy is superior to white light cystoscopy in detecting cancerous areas, although not every detected area may be cancerous. Sometimes, inflammatory areas may appear similar to cancer.

How is the follow-up for bladder cancer patients who have not advanced to deeper layers performed?

In patients where the bladder is not removed, recurrence monitoring is done through periodic cystoscopy (camera examination). Unfortunately, ultrason, tomography, or MRI cannot provide the same detailed evaluation as cystoscopy.

If a new cancer is detected during follow-up, the same procedures performed during the initial diagnosis will be repeated.

What is done after TURB surgery in advanced-stage bladder cancer (T2, T3, T4)?

At this stage, there is a risk that the disease may spread to the body, so imaging of the lungs and abdominal cavity (CT or MRI) is performed to check for metastasis. If there is no metastasis (the disease has not spread to the body), a second surgery to completely remove the bladder (cystectomy) may be required.

Is any treatment given before bladder removal?

Chemotherapy (neoadjuvant chemotherapy) may be administered based on the possibility of metastases that are not detectable by imaging methods and are still too small to be detected.

Is treatment with methods other than bladder removal not possible?

There is no better treatment option than bladder removal for disease that has progressed into the muscle layer or deeper. However, for patients who wish to avoid losing their bladder, multiple treatments may be used. In this approach, a deeper and wider TUR-M surgery is performed again to remove any cancer cells that may still be present in the bladder wall. Afterward, radiation therapy and chemotherapy are administered.

It is important to note that this method is not highly recommended for controlling the disease.

How is urine output managed after bladder removal?

After the bladder is removed, two methods can be used to divert urine outside the body:

Neobladder (Constructed from the intestine): In this method, a 40-45 cm segment of the small intestine is removed and shaped into a sphere. The upper part of the sphere is connected to the ureters (the urine ducts coming from the kidneys), and the lower part is connected to the urethra, allowing the patient to urinate through their own urinary tract. While patients with a neobladder do not feel the usual sensation of urination as they would with a normal bladder, the filling of the neobladder can be felt as abdominal bloating. Patients can urinate by contracting their abdominal muscles and applying some pressure to the lower abdomen.
Ileal Loop: In this method, the ureters are connected to a 10-15 cm segment of the small intestine, and the other end of the bowel is stitched to the abdominal skin. The urine from the bowel is collected in a waterproof bag attached to the skin, and this bag is replaced daily.