Information on bladder cancer

What is bladder cancer?

Bladder cancer is a malignant tumor disease of the bladder mucosa. A distinction is made between invasive and non-invasive bladder tumors, with the invasiveness referring to whether the muscles beneath the mucosa are also affected. Around two thirds of tumors have not yet infiltrated the muscles when they are diagnosed.

Bladder cancer leads to around 30,000 new cases in Germany every year, with men being affected twice as often as women. It is primarily a disease of older people, so that men develop bladder cancer at an average age of 72, and women at an average age of 74.

Function of the bladder

Our kidneys are organs with an extremely high blood supply that constantly produce urine. So that we don't have to constantly run to the toilet, our body is equipped with a kind of urine reservoir, the bladder. This can expand greatly in size and collects urine until we excrete it voluntarily.

Excess body water, acids and bases and water-soluble pollutants are removed from our body through urine. The urine reaches the bladder via the two kidneys and ureters and then leaves the bladder via the urethra. In men, the urethra also runs through the prostate. However, the fact that urine sometimes stays there for hours also gives pollutants the opportunity to have a negative effect on the mucous membrane of the bladder.

The urinary tract is equipped with a special type of mucous membrane, the so-called transitional epithelium (urothelium). The height and cell shape of this can vary depending on how full the bladder is. In around 98% of cases, the cancer develops in this layer, which is why it is referred to as urothelial carcinoma. Other types of tumor such as squamous cell carcinoma only occur very rarely.

What are the causes of bladder cancer?

As with many types of cancer, the exact development process of bladder cancer is unknown. However, certain risk factors have been identified over the years.

The strongest negative influencing factor is tobacco smoke. Around 30-70% of bladder tumors are caused by this. The pollutants contained in smoke enter the blood via the lungs and are filtered by the kidneys and excreted in the urine. The carcinogenic pollutants not only lead to an extremely high risk of lung cancer, but also to not insignificant cases of bladder cancer.

Certain chemical substances, so-called aromatic amines, can also cause bladder cancer. Many of these substances were used in industry and are now banned. Because they take a long time to appear, these variants, which are classified as occupational diseases, can still lead to bladder cancer today. Former painters or employees in the rubber industry, for example, are particularly at risk.

A tropical pest can also lead to bladder cancer by causing schistosomiasis (disease caused by the pest). This parasitic disease is mainly found in parts of Africa and Arab countries.

It is also suspected that frequent irritation of the bladder, for example from catheters, can lead to bladder cancer via chronic cystitis.

Ultimately, cancer always develops when certain cells degenerate and change in such a way that they grow and multiply independently of external signals. In doing so, they displace or infiltrate surrounding tissue. If the cancer cells gain access to the blood or lymphatic system, the cells can reach other organs and form colonies there, known as metastases.

What symptoms can occur with bladder cancer?

Initially, bladder cancer is associated with uncharacteristic symptoms. These are often misinterpreted as cystitis. These include an increased urge to urinate combined with little urine when urinating (polyuria), impaired bladder emptying (dysuria) with dribbling and pain when urinating or unclear pain in the flank area. Cystitis, especially in men, should therefore always be subjected to a thorough examination.

A clear warning signal is always blood in the urine, causing it to take on a reddish to brownish discoloration. Around 80% of bladder cancer patients are first noticed because of this symptom. The patients do not feel any pain, so it is referred to as painless hematuria. This should always result in a visit to a urologist, as there is usually a good chance of recovery if treatment is started as early as possible.

In advanced stages, bladder cancer can also cause general symptoms such as weight loss, fever and night sweats. Depending on the location of any metastases, these can also cause symptoms. For example, upper abdominal or bone pain can occur.

How is bladder cancer diagnosed?

The suspicion of bladder cancer can arise from the first patient interview. Occupational exposure, smoking and specific complaints can confirm the suspicion. Various tests then follow.

As a rule, the first measures are a urine test for blood and cancer-like cells and a blood sample. This can either be done by examining the spontaneous urine or by taking a so-called bladder lavage sample, in which the bladder is first rinsed with a little saline solution. The cells obtained are then examined in the laboratory.

To rule out kidney disease as the cause of the hematuria, the kidney values are checked and an ultrasound examination of the kidneys and abdominal organs is often carried out.

This is followed by imaging tests such as an excretory urogram. The patients receive a contrast agent that is excreted via the kidneys. In order to be able to visualize the excretion process, several X-rays or CT images are taken in which the contrast agent is clearly visible.

A cystoscopy provides a reliable diagnosis. The urologist inserts an endoscope into the bladder to examine the mucous membrane. The endoscope consists of a flexible tube with a small camera and a light source. It also has a working channel through which instruments can be inserted. This allows the examiner to take tissue samples directly from suspicious areas using small forceps.

If the bladder cancer is deeper (invasive), secondary tumors can form in the body (metastases). CT, MRI and skeletal scintigraphy are used to detect these. If the bladder cancer spreads via the lymph vessels, metastases are primarily found in the lymph nodes of the pelvis and groin. However, metastases can also form in the lungs, liver or bones via the bloodstream.

How is bladder cancer treated?

Treatment for non-invasive bladder cancer
In the case of superficial (non-invasive) bladder cancer, the primary treatment is cystoscopy. The urologist removes the visible tumor using an electric loop. This procedure is called transurethral resection (TUR) of the bladder.
The removed tissue is then examined by the pathologist. If the cut edges are tumor-free, treatment ends here. If they are not, another TUR of the superficial bladder carcinoma is performed within six weeks. This procedure can completely remove 70% of the tumors in the bladder.
After the cystoscopy, at the latest 24 hours after the operation, a local chemotherapy drug should also be initiated in the bladder for approx. 2 hours. This is primarily used to destroy tumor cells that were overlooked or ground down during the operation. In many cases, recurrence prophylaxis is also recommended. Local chemotherapy is repeated at regular intervals for a certain period of time. Weekly intervals are typical at first, but can then be extended.

Alternatively, as part of immunotherapy, a certain substance (BCG) is repeatedly introduced into the bladder to sensitize the body to fight the cancer cells.

Bladder tumors that have only been treated locally should be checked at regular intervals. Cystoscopy is recommended, initially every three months and later every six months.

Treatment of invasive bladder cancer

If the patient is suffering from invasive bladder cancer, either surgery or radiation therapy is required. Both can be combined with chemotherapy. With the latter, it is often possible to preserve the bladder.

Surgical treatment consists of removing the bladder (cystectomy). This involves removing all the organs involved (lymph nodes, prostate, seminal vesicles or uterus, ovaries, parts of the vagina). However, in rare cases, partial removal of the bladder is sufficient. Different procedures are used to replace the bladder, which depend greatly on the patient's state of health, age and wishes.

Intestinal tissue can be used to construct a new bladder (neo-bladder) that resembles the old one, but also a reservoir that must be emptied independently via the abdominal wall. Your treating urologist will discuss the options that are particularly suitable for you in detail with you.

In rare cases, muscle-invasive bladder cancer can also be treated without surgery with radiation and/or chemotherapy. This is a good alternative, especially for patients with very serious pre-existing conditions. However, this form of therapy is usually not recommended for younger patients with few risk factors, as it is associated with a high recurrence rate.
How long do you have to stay in hospital after bladder surgery?
The operation for bladder cancer can be performed under partial or general anesthesia and usually takes no longer than 15-30 minutes, although the duration depends largely on the findings. Afterwards, the patients are given a bladder catheter through which the urine is drained. Therefore, a short inpatient stay of 2-3 nights is usually necessary. The stay is also due to the fact that local chemotherapy is usually carried out after the tumor is removed. This means that the patient does not have to return to the hospital for this procedure.

After a few days, the bladder catheter is removed and the patient can urinate independently. If there are no problems with this, there is nothing to stop the patient being discharged home. The subsequent check-ups and discussion of the results of the tissue samples can then take place either in the clinic or with a specialist in private practice.
Follow-up treatment for bladder cancer
Like any operation, bladder removal also carries risks such as inflammation, bleeding, injury to neighboring organs or the formation of blood clots.

If the bladder is replaced, it can take a while for the intestinal tissue to adapt to its new task. You also need time to get used to handling the respective urinary diversion and to integrate it into your everyday life.

Men may experience erection difficulties after the prostate has been removed, but these can usually be managed well with various modern medical methods.

The most important thing, however, is consistent and regular tumor follow-up care. If you have any further questions about treatment and prognosis for bladder cancer, please contact your treating urologist.

Prognosis and life expectancy

The prognosis for bladder cancer depends largely on the size and spread of the tumor tissue. The chances of recovery are better the sooner adequate therapy is initiated. If no therapy is given, rapid metastasis must be expected.

Statistically, around 25% of all patients with bladder cancer develop another urothelial carcinoma in the upper urinary tract. Regular follow-up examinations are therefore particularly important.

The 5-year survival rate varies with the tumor stage. With smaller tumors, around 75% of patients survive a period of 5 years after diagnosis; with larger tumors, this figure decreases, so that with very large tumors or the presence of metastases, the 5-year survival rate is less than 5%.

How can bladder cancer be prevented?

The prevention of cancer is always very important. It mainly consists in avoiding the risk factors that can be influenced. In the case of bladder cancer, this is primarily smoking. Consistent abstinence from nicotine is therefore strongly recommended. The decision to stop smoking has a positive effect on health at any age. It is therefore worthwhile to adapt your lifestyle accordingly, even in old age.

Another important measure is the consistent treatment of any infections in the urogenital area. Since recurrent inflammation can promote the development of cancer, appropriate measures should be taken here. A change in diet can also have a positive effect on bladder health. In any case, you should ensure that you drink enough and see a doctor as soon as possible if you have any complaints.

Which doctors and clinics are specialists in bladder cancer?

Urologists specialize in the treatment of bladder cancer and in performing operations on the bladder. Clinics that have been certified as uro-oncology centers by the German Cancer Society generally have a great deal of experience in the treatment of urological cancers. Doctors from different disciplines often work together here to provide patients with an interdisciplinary treatment concept. Bonn University Hospital is one of the best university hospitals for bladder cancer treatment.