Bladder Cancer

Bladder cancer is the 9th most common cancer in Singapore. It affects both men and women, and is most often detected after investigation for blood in the urine. Early bladder cancer can be treated with minimally invasive surgery.

Smoking is the main risk factor for bladder cancer. Other risk factors are exposure to industrial chemicals and long-term urinary catheters.

The most common symptom of bladder cancer is that of blood in the urine. When the cancer is more advanced, pain in the pelvis, frequent urge to pass urine, loss of weight and leg swelling can occur.

Initial evaluation is performed using a flexible cystoscope, under local anaesthesia or intravenous sedation. Once the tumours are identified, the patient should undergo a rigid cystoscopy under general anaesthesia, during which the tumour can be removed and sent to the laboratory for confirmation.

Flexible cystoscopy confirms a tumour in the bladder

If necessary, a CT scan is also performed to check the rest of the urinary system for tumours and also to check if the tumour has spread.

For purpose of treatment, bladder cancers can be divided into 2 main groups:

Superficial bladder cancer – where the cancer is confined to the lining of the bladder and has not involved the muscle layer

Muscle-invasive bladder cancer – where the cancer has invaded into the muscle layer. This type of cancer is more likely to spread to surrounding organs and lymph nodes.

Stages of bladder cancer

The treatment options for bladder cancer are:

Transurethral resection of bladder tumour (TURBT)
This is a minimally invasive surgery. The tumour is removed using a rigid cystoscope, under general anaesthesia. This is the initial treatment once the patient has been diagnosed to have cancer. The cancerous tissue is removed and sent to the lab for examination. Complete removal of the tumour is possible if the tumour is superficial. The advantage of this treatment is that the rest of the bladder is preserved so the patient can continue function normally.

Removing a bladder tumour using a rigid cystoscope

Intravesical therapy
Medication is instilled into the bladder through a catheter. Some patients need to undergo this treatment after removal of the bladder tumour through TURBT, in order to reduce the risk of the tumour recurring. This is carried out once a week for 4 to 6 weeks, and then repeated at specific intervals for up to 1 to 3 years, depending on the severity of the disease.

For a particular type of bladder cancer called carcinoma-in-situ, intravesical therapy is the recommended treatment as well.

Radical cystectomy
If the tumour has involved the bladder muscle, the patient is usually recommended to go for radical cystectomy, which means complete removal of the bladder and the prostate for male patients, and the bladder and uterus for female patients. This is a major surgery which requires hospitalisation for at least one or two weeks.

Radical cystectomy (image from Cancer Research UK)

After this surgery, in most cases the patient will have his urine come out of an opening  in the abdomen (ileal conduit). A special urine bag is attached to the stoma to collect the urine. Alternatively, a new bladder can be created from intestine (ileal neobladder)  so that the patient can pass urine in the normal fashion.

Is there an alternative to radical cystectomy?
If the patient is unfit for surgery due to age or other medical problems, or the tumour is not advanced, it may be possible for the patient to be treated with a combination of transurethral resection of bladder tumour, radiotherapy and chemotherapy.

What if the cancer has already spread?
If the bladder cancer has already spread to the lymph nodes or distant organs, the patient will require chemotherapy or immunotherapy as surgery will not be enough to cure the patient.