Bladder and Ureteral Cancer
About 70,000 people are diagnosed with bladder cancer in the United States every year. Most patients are older (above the age of 60) and the disease is much more common in men (by a ratio of 3 to 1). However, the incidence of female bladder cancer is increasing, probably as a result of the increase of smoking among women.
Ureteral cancer is a cancer that arises in the ducts that transport urine from the kidneys to the bladder (the ureters). It is essentially the same kind of malignancy as bladder cancer.
Symptoms and DiagnosisThe most common symptom of bladder or ureteral cancer is visible (or microscopic) blood in the urine. Occasionally, bladder irritability and frequent urination can be symptoms of these malignancies. People who notice blood in the urine or other symptoms should be evaluated by a physician immediately, because outcomes are correlated with the length of time between symptom onset and treatment.
Bladder/ureteral cancer arises in the cells that line these organs. The disease appears to be caused by carcinogens excreted in the urine. Inhaled tobacco is the most common source of these carcinogens, but occupational exposure to certain industrial chemicals can also play a role. In addition, there may be a link between vitamin D deficiency and incidence of bladder cancer.
Patients with symptoms of bladder or ureteral cancer may have select lab tests to rule out other causes:
- Many patients undergo a CT urogram, a CT scan of the urinary tract using a contrast medium.
- Another common diagnostic procedure is cystoscopy, in which a flexible endoscopy telescope is inserted into the urethra and used to inspect the lining of the bladder.
Bladder Cancer TreatmentThe goal of treatment for bladder cancer and ureteral cancer is to cure the disease while maintaining the patient’s urinary function. Achieving these goals requires a team approach (“interdisciplinary care”). In the Prostate and Urologic Cancer Program, physicians who specialize in surgical, radiation oncology, medical oncology (drug and hormone therapies) and reconstructive surgery work together to devise an optimal treatment plan for each patient.
The right treatment for bladder cancer depends on how far the tumor has penetrated the wall of the bladder. Cancers on the surface of the bladder lining and cancers that have not spread far into the bladder wall can largely be managed using minimally invasive techniques. The deeper the cancer has spread into the bladder wall, the greater the need for aggressive therapy.
Non-Invasive Bladder CancerAbout 80 percent of bladder tumors have not yet penetrated the muscle layer of the bladder wall. The earliest of these cancers are confined to the surface of the bladder lining and are almost like warts inside the bladder. An intermediate group of bladder cancers are tumors that have started to penetrate the bladder wall but have not yet reached the muscle layer.
These non-invasive tumors are treated using minimally invasive procedures. An endoscope is carefully inserted into the urethra and guided to the bladder. Using special instruments, the physician scrapes the tumor off the bladder wall. (The tissue is sent to pathology to determine the grade and stage of the cancer.) In some cases, the physician will apply a chemotherapy drug directly to the site to help prevent recurrence of the cancer. Some patients may undergo repeated endoscopic applications of the drug over an extended period.
This treatment approach is very effective for non-invasive bladder cancers. About 95 percent of patients with these early-stage tumors experience a long-term cure.
Muscle-Invasive Bladder CancerTumors that have penetrated the muscle layer of the bladder put the patient in a much higher risk group. For these patients, treatment aims at preventing the cancer from spreading to other organs.
- Cystectomy: The standard treatment for muscle-invasive bladder cancer in the United States is surgical removal of the bladder (cystectomy) coupled with surgical reconstruction (see below). For many patients, cystectomy also includes removal of lymph nodes and other nearby organs. Select patients are eligible for a robot-assisted cystectomy, a less invasive technique that can result in faster recovery.
- Chemotherapy before surgery: Bladder cancer is relatively chemo-sensitive. When a tumor has invaded the muscle layer of the bladder, giving chemotherapy prior to bladder removal improves survival rates. A combination of agents is used to shrink the tumor, increasing the chance that the surgeon will be able to remove all of the diseased tissue and reducing the chance of the cancer spreading outside the bladder.
- Chemotherapy after surgery: Patients who have had the bladder surgically removed (and have not yet received chemotherapy) can benefit from post-surgery drug therapy. A combination of chemotherapy agents has been shown to improve outcomes for patients with higher-risk disease.
- Radiation therapy: Some cystectomy patients also receive external beam radiation therapy and/or brachytherapy radiation to help kill cancer cells that remain following surgery.
- Radiation therapy and chemotherapy to spare the bladder (organ preservation) is another option for muscle invasive bladder cancer. This is a non-surgical approach, and for well-selected cases, offers a good chance for curing the cancer and keeping good bladder function. Froedtert & The Medical College offer an excellent team approach for coordinating this option for bladder cancer patients.
- Partial cystectomy: Certain patients with muscle-invasive bladder cancer are eligible for an organ-sparing approach that combines surgical removal of the tumor with radiation and drug therapy. In this treatment approach, the bladder tumor is removed using endoscopic instruments inserted through the urethra. Then, over the course of several weeks, the patient receives a combination of chemotherapy and external beam radiation therapy. Typical side effects include loose stool, frequent urination and some suppression of the immune system, all of which resolve eventually.
Bladder removal (in combination with other appropriate therapies) can lead to long-term cure for approximately 60 percent of patients with muscle-invasive bladder cancer.
Surgical ReconstructionFroedtert & The Medical College of Wisconsin offer patients with bladder cancer a unique team-based approach to bladder surgery. The surgical care team includes a fellowship-trained cancer surgeon and a fellowship-trained reconstructive surgeon who is skilled in a variety of techniques for restoring urinary function. The specialists carefully coordinate treatment to help ensure each patient achieves the best outcome — cancer control with successful reconstruction.
The reconstructive surgeon works with each patient to explain options, understand preferences and set realistic expectations. In general, there are three ways to reconstruct urinary function following bladder removal:
- Urinary conduit: A urinary conduit provides a simple means for bringing urine outside the body. First, the surgeon detaches a short segment of the small bowel from the rest of the intestines. The ureters are surgically attached to one end of the bowel segment, and the other end is brought out through an opening made in the lower abdomen. The patient wears a urostomy bag, which must be emptied periodically. Urinary conduit is the most common urinary reconstruction. In general, a urinary conduit is the best option for elderly patients or those with significant health issues.
- Neo bladder: A neo bladder is a “new bladder” constructed using the patient’s own tissue. First, the surgeon takes a segment of the small bowel (approximately 22 inches) and fashions it into a spherical pouch. The ureters and the urethra are then attached to the pouch. Urine flows from the kidneys, through the ureters, to the “new bladder” and is expelled normally through the urethra. With a neo bladder, patients do not feel the same urge to urinate as they are used to. As the bladder fills, the patient will experience a sensation like bowel cramping. Expelling urine requires a combination of relaxing the pelvic muscles and slightly straining the abdominal muscles. Almost all patients are incontinent following surgery. As a patient builds up the strength of his or her pelvic muscles with Kegel exercises and works on extending the time between urinations, the neo bladder will expand. After about one year, more than 80 percent of patients are able to regain daytime continence. Reestablishing nighttime continence can take a few years, with approximately two-thirds of patients able to achieve complete nighttime dryness. In general, younger and healthier patients are the best candidates for this reconstruction. A neo bladder is not possible for patients whose cancer has spread to the urethra or ureters. In addition, patients with chronic kidney disease are not good candidates for the procedure.
- Catheter pouch: This reconstruction creates a urine “reservoir” that the patient drains with a catheter. First, the surgeon constructs the reservoir using a portion of the large bowel. Next, the ureters are attached to the reservoir. The terminal portion of the small bowel is then used to form a channel from the reservoir to an opening created in the lower abdomen. The patient inserts a catheter into the opening to drain the urine. Most patients need to drain their reservoir pouch every four to six hours. At first, patients may need to drain it more frequently, but many are eventually able to reduce frequency to four times a day. Potential problems include difficulty inserting the catheter and leaking. In addition, the pouch needs to be rinsed periodically to prevent mucus build-up. Like the neo bladder reconstruction, the catheter pouch is more suitable for younger and healthier patients, and chronic kidney disease rules out this option. In addition, patients with colitis and colonic polyps are not good candidates for a catheter pouch.
Metastatic Bladder CancerBladder cancer can spread to other parts of the body. When this disease metastasizes, it can cause pain and result in functional impairments.
- Radiation therapy for pain control: Radiation therapy can reduce pain by shrinking painful bone metastases. Options include external beam radiation or the injection of a radioactive drug that collects in bone tissue. In some instances, metastases to the spine can put pressure on the spinal cord, resulting in impaired arm or leg movement. Shrinking these metastases can help restore physical function.
- Drug therapy for metastatic disease: Several drug regimens are able to extend survival for patients with bladder cancer that has spread to other parts of the body. There are also several chemotherapy clinical trials available for patients with metastatic bladder cancer.
Ureter Cancer TreatmentThe ureters are the ducts through which urine passes from the kidneys to the bladder. The key to treating cancer of the ureter is tailoring the right therapy to the patient’s specific risk. Since ureter cancer is very rare, it is important to receive treatment from physicians who have experience with this malignancy.
Management of ureteral cancer depends on both the grade of the tumor and where it is located. Tumors located higher up in a ureter — closer to the kidney — have a greater chance of recurrence. Because of this increased likelihood of developing new tumors, it is important whenever possible to use treatment strategies that will preserve the kidney and ureter.
Endoscopic Urologic ManagementSome ureteral cancers can be treated using minimally invasive surgical techniques. These procedures involve inserting a flexible tube through the urethra or a small incision in the abdomen. A laser deployed at the end of the tube is used to destroy the tumor.
UreterectomySome cases of ureter cancer require the surgical removal of the ureter, also known as ureterectomy. Surgical removal can sometimes be limited to just the segment of the ureter involved in the tumor. For advanced cancers, removal of the entire ureter, the entire kidney and a section of the bladder may be necessary.
Chemotherapy OptionsPatients with a ureter cancer in a higher risk category who have undergone surgery can benefit from drug therapy. A combination of drugs can reduce the chance of the cancer recurring after surgery. Ureter cancers that have spread to other parts of the body are treated the same as metastatic bladder cancer. Several chemotherapy agents are able to extend survival even after the patient’s primary cancer has spread.
Radiation OptionsSome patients with ureter cancer benefit from radiation to the area of the tumor. This is usually done in combination with surgery and chemotherapy.
Clinical Trials for Bladder and Ureteral CancerFor appropriate patients, Froedtert & The Medical College of Wisconsin offer several investigational therapies for bladder and ureteral cancers. These rigorously controlled clinical trials focus on finding new ways to prevent the return of cancer after surgery and slow down the progression of advanced disease. Trials are available for both non-invasive and muscle-invasive cancers as well as advanced metastatic disease. View our full listing of current clinical trials.
|Medical Reviewer: ||Colleen Lawton, MD|
Last Review Date: June 26, 2013
Online Editor(s): Andy Monigal