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The bladder is lined with cells called transitional cells. The majority of bladder tumours arise from these cells and are called transitional cell carcinoma (TCC). TCC is a type of cancer and represents about 90% of bladder tumours. Other types of bladder cancer include squamous cell carcinoma and adenocarcinoma. There are also benign (non-cancerous) tumours of the bladder, which generally do not come back after they are removed.
Symptoms and Diagnosis
[Illustration: Bladder and bladder neck, front view, with bladder tumour on sidewall, same as TURBT discharge but more smooth muscle]
Although the exact cause of bladder cancer is unknown there are certain risk factors associated with the disease. The use of tobacco is a major risk factor as cigarette smokers are more likely to get bladder cancer. Pipe and cigar smokers are also at risk. Some workers have been found to be at higher risk of bladder cancer because of toxin exposure in their workplace.
Bladder tumours are often diagnosed during the investigation of blood in the urine (haematuria). Occasionally, these tumours can cause urinary problems with pain or increased frequency and urgency to void.
The diagnosis of bladder tumours is made after visual inspection of the bladder (Cystoscopy). At times, they are identified on ultrasound examination of the bladder or CT Urogram or on inspection of the urine for cancer cells (cytology) or other urinary markers. These test take place in our rapid access heamaturia clinic.
Once a tumour has been discovered it can be biopsied at the time of cystoscopy to make a diagnosis. More often, your urologist will recommend a surgical procedure to have the tumour scraped away using an instrument passed through the urethra (trans-urethral bladder tumour resection or TURBT).
What is a transurethral resection of a bladder tumour (TURBT)?
A TURBT is the standard treatment for bladder tumours. The tumour or tumours are cut away from the bladder wall and sent for further analysis that will enable your Urologist to see whether the tumour cells are cancerous and if more treatment is needed.
What do I need to do before a TURBT?
You should take your normal medication as before the procedure. If you are on aspirin or clopidogrel (Plavix), these drugs will need to be stopped 10days before the operation. In addition, if you are on warfarin, this will need to be stopped and the appropriate alternative will be suggested. So ensure this is discussed with your urologist.
It is important to exclude a urinary tract infection before your procedure. The urine should be checked by a health professional.
No food should be eaten 6 hours before but clear water only can be consumed 3 hours before the planned time of TURBT.
What happens during a TURBT?
Under general anaesthesia (i.e. asleep), a telescope examination is made of the bladder using a camera mounted on the end of a tube passed through the water pipe (urethra). TURBT involves resecting the tumour using an electrical loop inserted into the urethra via a telescope. It cuts tissue and seals blood vessels as it removes the tumour. These are washed out at the end of the operation and sent for histological analysis. The procedure usually lasts between 30-60minutes and involves no incisions on the outside. A catheter is inserted for 24 hours, through which irrigation fluid flows into the bladder to rinse any blood in it.
Administration of Hexvix for photodynamic diagnosis (PDD)
There is current school of thought that bladder tumours can be missed at the time of normal white light endoscopic resection. In order to improve the visibility of the bladder tumours within the bladder a fluorescent dye (called Hexvix) is sometimes introduced into the bladder prior to the operation. Hexvix causes bladder tumours to appear bright pink when the bladder is examined using a blue light TURBT. This allows otherwise invisible tumours to be seen so that a more thorough resection can be achieved. 1 in 5 patients with bladder tumours may receive more appropriate treatment through the use of Hexvix fluorescence cystoscopy
If we plan to use PDD, Hexvix will be introduced into your bladder through a urinary catheter. Once the Hexvix is in your bladder, the catheter is removed. You should not pass urine for at least one hour after removal of the catheter. This allows the tumour(s) to take up this dye and thus improve the images of the tumour(s) during blue light cystoscopy.
|Standard white light Cystoscopy
At the end of the operation, a catheter (drainage tube) may be placed into the bladder through the urethra. A water solution may be used to flush the bladder to wash out any blood in which case you may remain in hospital for a day or two. The doctor may prescribe Mitomycin C chemotherapy drug to be placed in the bladder soon afterwards in order to decrease the chance of the tumour coming back. Discharge usually occurs 24 hours after the operation. In some cases, the patient may be discharged on the day of surgery. Most patients should be able to resume usual activities and return to work in a few weeks.
The raw area in the bladder lining remaining after such a scraping will heal over, initially with a scab and, eventually, with normal lining tissue. It is not unusual to have increased frequency and urgency of urination for a few weeks after bladder tumour resection. There may also be some burning with urination. There may be a bit of blood visible in the urine for a few weeks after bladder tumour resection. Occasionally, a few blood clots may be seen, particularly after about two to four weeks when the scab comes away.
Most bladder tumours are confined to the bladder lining and are described as superficial. Even these superficial tumours however have a tendency to recur. It is important to monitor the bladder closely with regular bladder inspections (surveillance cystoscopy).
In some cases the urologist may recommend additional treatments in order to decrease the chance of tumour recurrence. These treatments may involve placing a drug directly into the bladder through a small catheter. There are several medications available including BCG and mitomycin.
Occasionally, more aggressive tumours may invade into the muscle of the bladder wall or spread to other parts of the body. This requires more intensive investigation and treatment, which may include surgery (removal of the entire bladder), chemotherapy or radiotherapy.
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