Bladder tumor is a common disease in urology, and most bladder tumors are epithelial tumors. Bladder cancer can occur at any age, but it is mostly seen in middle-aged and elderly people; adolescents and adults within 20 years of age have more superficial bladder cancer with better differentiation and better prognosis.
I. Causes of bladder cancer
1.Smoking
Smoking is the most certain risk factor for bladder cancer, about 30-50% of bladder cancers are caused by smoking smoking can increase the risk rate of bladder cancer by 2-4 times. The risk is related to the number of cigarettes smoked, the duration and the depth of inhalation when smoking. The risk of developing the disease can be reduced after quitting smoking.
2.Long-term exposure to industrial chemical products
About 20% of bladder cancer is caused by occupational factors. Aniline, benzidine, aminobiphenyl, diaminobiphenyl, dichlorobenzidine, etc. are carcinogenic substances. Occupations that increase the risk of bladder cancer include: dye industry, rubber, tanning, painting, printing, drilling, coal mining, dry cleaning, hairdressing, dentistry, etc.
3.Coffee
Some epidemiological studies have found that coffee consumption can increase the incidence of bladder cancer, but if smoking and artificial sweeteners are also taken into account, there is no clear evidence that coffee can promote the occurrence of bladder cancer.
4.Analgesic drugs
Finasteride is a derivative of aniline. Long-term application of large amounts of finasteride analgesics can increase the incidence of uroepithelial cancer, and the latency period of bladder cancer is longer than that of renal pelvis cancer, which can be up to 25 years. There is no clear relationship between other types of analgesics and the occurrence of bladder cancer.
5.Artificial sweeteners
In rodent experiments, high doses of artificial sweeteners, including benzoylecgonine phthalate (saccharin) and cyclohexane aminosulfonate, were found to be bladder carcinogens. However, epidemiological surveys have found that consumption of artificial sweeteners does not significantly increase the incidence of bladder cancer, and it is now believed that consumption of artificial sweeteners by nonsmoking women and heavily smoking men can increase the incidence of bladder cancer.
6.Chronic cystitis and other infections
Chronic cystitis caused by indwelling catheters or stones can increase the incidence of squamous bladder cancer. The incidence of bladder cancer in people with long-term indwelling catheters due to paraplegia is 2-10%, 80% of which are squamous cell carcinoma. The incidence of squamous cell carcinoma of the bladder is high in schistosomiasis endemic areas, and the incidence of migratory cell carcinoma is also elevated. Human papilloma virus infection in the bladder is also closely related to the occurrence of squamous cell carcinoma of the bladder.
7.Pelvic radiotherapy
Patients with cervical cancer treated with pelvic radiotherapy have an increased risk of bladder metastatic cell carcinoma and are mostly highly staged and locally infiltrated at the time of diagnosis.
8.Cyclophosphamide
Patients treated with cyclophosphamide can have a 9-fold increase in the incidence of bladder cancer, and muscle infiltration of the bladder occurs more often at the time of diagnosis. It is now believed that the metabolite of cyclophosphamide in the urinary tract: acrolein, is associated with the development of hemorrhagic cystitis and bladder cancer. The incubation period of bladder cancer caused by cyclophosphamide is 6-13 years.
Clinical manifestations of bladder cancer
1.Hematuria
Hematuria, especially intermittent painless carnal hematuria, is the most common symptom of bladder tumor. For middle-aged and elderly people with unexplained hematuria, cystoscopy should be performed to exclude bladder cancer.
The degree of hematuria depends on the amount of bleeding and may appear as a washout, with irregular or flaky blood clots, or even a large amount of blood clots filling the bladder. The time and degree of hematuria are not consistent with the differentiation, stage, size, number and morphology of tumor cells, and hemorrhagic anemia may occur in severe or repeated bleeding.
2.Bladder irritation symptom
Bladder irritation symptoms, i.e. urinary frequency, urinary urgency and painful urination, are the second common symptoms of bladder cancer. Any bladder cancer with bladder irritation symptoms or discharge of “rotting flesh” is mostly advanced or infiltrative and has poor prognosis.
3.Other manifestations
The cancer of bladder neck or prostate gland, the cancer of the neck and the large necrotic cancer tissue can block the neck opening and cause urinary retention.
If the cancer involves the ureteral orifice, distension and pain in the kidney area, hydronephrosis, infection and renal function impairment may occur.
Patients with advanced bladder tumor may develop lower abdominal mass, renal insufficiency, wasting, severe anemia and other cachectic manifestations.
If metastasis occurs, corresponding symptoms of metastatic sites may appear, and the commonly occurring metastatic sites are bone, liver and lung.
Diagnostic analysis of bladder cancer
The main symptom of bladder cancer is hematuria. Any person above 40 years old who has painless hematuria should think of the possibility of bladder cancer. Those who have microscopic hematuria or no hematuria with urinary tract irritation symptoms should undergo comprehensive and in-depth examination.
Early diagnosis of bladder cancer is very important. All patients who die from bladder cancer are due to distant metastases, and patients who develop distant metastases are accompanied by or have bladder muscle infiltration. Early diagnosis is the key to improve the treatment effect of bladder cancer.
Auxiliary examination of bladder cancer
1.B-ultrasound examination
Ultrasound examination of bladder tumor has the advantages of simple operation, painless and repeatable.
The ultrasound image of bladder tumor is mainly a bulging superfluous organism on the bladder wall toward the lumen, with different sizes, various shapes or irregularities, moderate echogenic intensity and no sound shadow in the deep part. The basic images such as size, number, location and width of the base of the tumor can be obtained by tomography scan of the bladder through the abdominal route.
2.Pelvic CT scan + enhancement scan
CT examination can clearly show the location, size, number of days, depth of infiltration and the presence of metastasis of bladder wall tumor. For patients diagnosed with bladder cancer, one of the purposes of CT examination is to determine the tumor stage.
CT examination can clearly show the enlarged lymph nodes in the pelvis.
3.Intravenous pyelogram
Migratory epithelial tumors have characteristics of implantation and multi-organ pathogenesis, and bladder cancer may be accompanied by ureteral cancer of the renal pelvis.
The significance of intravenous pyelogram.
① Exclude upper urinary tract tumors;
② To understand the function of both kidneys.
4.MR examination
To determine the extent of tumor and surrounding fatty tissue infiltration. To clarify the prostate lesion and its surrounding relationship, and to judge the lymphatic metastasis. It shows deep muscle infiltration and has high sensitivity and specificity for cancer infiltration outside the bladder wall.
5.Cystoscopy
Cystoscopy can provide a comprehensive view of the bladder and directly observe the size, location, number, growth pattern, base and surrounding conditions of the cancer.
Biopsy can clarify the nature of the lesion, the degree of infiltration and other biological characteristics.
Carcinoma in situ appears as a red area with velvety protrusions on the mucosa, and the presence of bladder irritation or spasm is often a sign of extensive carcinoma in situ.
Papillary carcinomas are mostly Ta and T1 stage tumors with single or multiple tumors, light red in color, with elongated tips, limited to the mucosal layer, with good mobility and elongated branching surface villi. Nodules and masses of papillary carcinoma are often T2 and T3 stage tumors with short and fused papillae, dark red or brown with grayish-white necrotic tissue, broad-based or short tissues, poor mobility, thickened, edematous and congested nearby mucosa, infiltration of superficial muscle layer or lymph node obstruction.
Infiltrative carcinoma is often T3 and T4 stage tumor, non-tipped, indistinct, focal elevation, brown or gray-white surface, covered with gray-green pus moss or phosphate deposits, ulcerated tumor with elevated and outgrown edges, thickened and stiffened surrounding bladder wall, or satellite tumor. The bladder urine is cloudy and mixed with “rotting flesh-like necrotic tissue.
IV. Staging of bladder cancer (analysis by urologist)
Superficial bladder cancer (non-muscle invasive bladder cancer)
Infiltrative bladder cancer (muscle invasive bladder cancer)
V. Treatment of bladder cancer
1.Transurethral bladder tumor electrosurgery (TURBT)
Transurethral resection of bladder tumor (TURBt) is both an important diagnostic method and the main treatment for superficial bladder tumor.
A repeat transurethral resection of bladder tumor is recommended after 2-6 weeks in the following cases
(i) Incomplete resection of the tumor.
②No muscle layer in the specimen.
(iii) T1 stage tumor.
2.Bladder perfusion chemotherapy
The recurrence rate is 10-67% within 12 months after transurethral bladder tumor electrosurgery, and the peak recurrence period is 100-200 days after surgery and 600 days after surgery. Postoperative recurrence may be related to incomplete resection of the primary tumor, tumor dissemination and implantation, and new tumor development.
Bladder perfusion chemotherapy regimen.
① Immediate postoperative bladder instillation chemotherapy is instilled within 24 hours postoperatively.
②Early postoperative bladder perfusion chemotherapy once a week for 4-8 weeks after surgery.
③Maintenance postoperative bladder perfusion chemotherapy once a month for 8-12 months.
Commonly used bladder perfusion chemotherapy drugs
Pirarubicin, mitomycin, epirubicin, hydroxycamptothecin, gemcitabine, etc.
Precautions during instillation
①The chemotherapeutic drug is instilled into the bladder through the catheter and kept for 0,5-2 hours (refer to the instructions for details).
②Avoid drinking water before instillation to avoid dilution of drugs by urine.
③The main side effect of bladder perfusion chemotherapy is chemical cystitis (mainly manifested as urinary frequency and urgency), which can mostly improve on its own after stopping the drug.
The chance of tumor recurrence after immediate postoperative bladder infusion chemotherapy for low-risk non-muscle invasive bladder cancer is very low, so bladder infusion chemotherapy can not be continued after immediate infusion chemotherapy.
3.Radical cystectomy
Indications for surgery
①T2-T4aN0M0 invasive bladder cancer.
②T1G3 non-muscle invasive bladder cancer.
③Recurrent non-muscle invasive bladder cancer.
Scope of surgery (complete and total removal of the bladder and tumor lesions)
①Bladder and its surrounding tissues.
②Distal ureter.
③Pelvic lymph nodes.
④Prostate gland, seminal vesicles (male).
⑤Uterus, adnexa (female).
Surgical method
①Open surgery.
②Laparoscopic surgery (less blood loss, less postoperative pain, faster recovery, but longer operation time).