The bladder is a hollow muscular organ whose twin functions are to store and to empty urine produced by the kidneys. Bladder cancer referred to the uncontrolled growth of cells in the lining of the bladder wall, and occurs most commonly in chronic tobacco smokers. Occupational exposure to chemicals, such as benzidine and 2-naphthylamine, are also well-known risk factors.
Bladder cancer classically presents with painless blood in the urine (known as haematuria). Other symptoms may include frequent or painful urination. Cystoscopy of the bladder, wherein a flexible endoscope is passed through the urethra into the bladder under local anesthesia, is the most accurate way to determine if cancer is present and to obtain samples for biopsy. Once confirmed, accurate staging of the bladder cancer would include (1) computer tomography of the urinary tract, popularly known as a CT urogram; (2) endoscopic removal of the bladder tumour under general anesthesia, to ascertain the grade of cancer and whether it has invaded into the muscular wall (Figure 1); and (3) chest X-ray and bone scan to determine if there is spread of cancer to distant organs (known as metastasis).
Figure 1: Staging of bladder cancer, based on depth of invasion into the muscular wall of the bladder.
Most bladder cancers are detected early and are confined to the epithelial lining of the bladder (stage pT1). Endoscopic removal of these tumours alone is curative (Figure 2), and all that is required is regular surveillance with cystoscopy to detect any recurrence. However, cancers that have invaded into the muscular wall of the bladder (stage pT2-T4) are more aggressive, and without definitive surgical treatment, the c ancer will quickly spread to the lympatic system outside the bladder and then to distant organs. Once the cancer cells have invaded into the muscular wall, the only effective cure lies chiefly in radically removing the whole bladder and its surrounding lymph nodes, and diverting the urine outwith of the body through either an artificial conduit using a loop of intestine, or fashioning a new pouch from intestine (known as a neobladder). Agreeing to proceed with surgery is a difficult decision for patients with muscle-invasive bladder cancer, as they cannot accept the loss of their natural urination and the need for a permanent pouch for urine to leave the body. Many MIBC patients go into denial when faced with this diagnosis and do not follow-up with their doctors, resulting in loss of valuable time and the opportunity for curative surgery.
Figure 2: Reconstruction of the urinary tract on multi-phasic computer tomography to visualize the kidneys, ureters and bladder.
In the last decade, three significant advances have occurred in the treatment of muscle-invasive bladder cancer: (1) the use of neoadjuvant chemotherapy before radical surgery; (2) meticulous removal of pelvic lymph nodes; and (3) minimally invasive approaches for surgical removal of the bladder.
In recent years, urologists have been pushing the envelope and developing new techniques for performing the same surgery through small incisions using the da Vinci® surgical robot (Figure 3). This affords the surgeon improved vision and dexterity during the surgery, leading to significantly less blood loss and perioperative complications, quicker recovery of bowel function, and shortened hospital stay. Recently published studies have demonstrated that using the da Vinci robot to perform this surgery is safe in older patients above seventy years of age – this is widely attributed to the benefits of less blood loss encountered during robotic surgery. More and more centres worldwide are now adopting robotic surgery to deliver improved outcomes for this challenging surgery.
Dr Tan Yau Min, Gerald
is a consultant urologist at Mt Elizabeth Hospital with over 17 years of clinical experience. He is internationally renowned for his expertise in minimally invasive and robotic surgery for prostate, kidney and bladder diseases. Dr Tan was one of the first surgeons to pioneer robotic nephron-sparing surgery in Asia, having performed the largest number of such surgeries in Mt Elizabeth Novena and Tan Tock Seng Hospitals to date. He was named the Outstanding Young Urologist of Asia by the Urological Associations of Asia in 2012. He may be contacted via email at firstname.lastname@example.org.