Tumour

The commonest bladder cancer type is a TCC. In countries where schistosomiasis is endemic, squamous carcinoma of the bladder is common. Adenocarcinoma is rare.

Transitional cell carcinoma

Classically, a TCC presents with painless haematuria, although urine infection is also commonly seen. Cystoscopy allows a biopsy to confirm the diagnosis and a resection biopsy of the base of the tumour will allow the pathologist to stage the tumour, by determining whether muscle invasion has occurred.

Treatment depends on the tumour stage and the general fitness of the patient. If the tumour is superficial (i.e. has not invaded muscle), simple endoscopic resection may be sufficient. This may be combined with adjuvant intravesical instillation of mitomycin C or epirubicin to reduce recurrence rates. Nevertheless, recurrence of new tumours in the bladder is common and so repeat check cystoscopies are

necessary. The majority of superficial bladder cancers (>80%) will not progress to muscle invasion. However, they do have a tendency to recur over a period of many years. If a superficial bladder cancer is poorly differentiated and invasion of the lamina propria is demonstrated histologically (G3 pT1), the disease may be treated as though it were muscle invasive, as the disease tends to run a more aggressive course with an increased likelihood of progression to muscle-invasive disease.

If the tumour has invaded the muscle of the bladder wall (>pT2), it is termed invasive. Local resection is unlikely to remove the entire tumour and the options for cure are radical radiotherapy or total removal of the bladder by surgery (cystectomy) and a urinary diversion procedure. If staging by CT or MRI scans reveal the disease has spread to lymph glands or beyond, the tumour is incurable and it is managed symptomatically. Adjuvant chemotherapy may be used in an attempt to improve long-term survival following cystectomy.

Adenocarcinoma

Adenocarcinoma of the bladder and squamous carcinoma of the bladder are both treated by cystectomy, if they are not metastatic, as they are both resistant to radiotherapy.

Urine diversion

In the UK, the most commonly performed urine diversion is an ileal conduit (Fig. 19.10). A segment of small bowel is isolated, along with its blood supply. The divided ends of the remaining ileum are anastomosed to maintain bowel continuity. The cut ends of the ureters are implanted into one end of the ileal conduit and the other end brought out as a stoma (urostomy) on the right side of the abdomen. A stoma bag is then applied to collect the urine (Fig. 19.10).

Alternatively, it is possible to use bowel to create a new reservoir, or neobladder. This 'orthotopic bladder' can be anastomosed to the urethra and if the sphincter mechanism is preserved, controlled voiding in the normal way is usually possible. Alternatively, the bowel urine reservoir can be drained onto the abdominal wall via a narrow lumen tube such as the appendix. Its closing pressure is such that the urine storage reservoir is continent and it is drained by the patient catheterizing the reservoir, via the stoma.

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