Clinical Urology for Interns – Bladder Cancer in 10 minutes or less (2)

This video has been designed to remind myself of the clinical knowledge I picked up during my Urology term at Ballarat Base Hospital during rotation 3 of 2014.

In this topic, I talk about bladder cancer. I feel that out of the four topics that I talk about, this is my weakest topic. Nevertheless, I’ll try and give a short summary of what this 10 minute video goes through.

Bladder cancer tends to present either as painless haematuria, or as a completely incidental finding. Painless hameaturia wise, it’s often a good principle that “If there is bleeding from somewhere, find out where the bleeding is coming from.” PR bleeding – colonoscopies; Haematemesis – endoscopy; haematuria – flexible cystoscopy. The number one concern you have with painless haematuria, is that the cause is a urothelial cancer/transitional cell cancer (TCC).

These tumours can arise anywhere along the renal tract – up high in the kidney, or ureter; or sometimes in the bladder as well. A flexible cystoscopy will help visualise the bladder, but will not visualise the upper tracts. The upper tracts can be pseudo visualised with a CT IVP (CT with contrast). Any parts of the upper tract which does not ‘fill’ with contrast is known as a filling defect. A filling defect is indicative of something there, usually a stone, or tumour. In old, crumble pie patients with poor kidney function, a CT IVP will not be tolerated. In this setting, a retrograde pyelogram can be given instead.

Once a tumour has been identified, the next step is to cut it out. For simplicity, we are just going to consider the bladder. Resecting a bladder tumour is known as a TURBT or transurethral resection of bladder tumour. This tumour is sent off for histopathology, and can be broadly classified into three groups:

1. Low grade – non invasive tumour: this is usually treated with intravesical mytomycin. ‘Vesical’ refers to bladder, so it’s a therapy where mytomycin is instilled into the bladder.

2. High grade – muscle non invasive: this is the nastier stuff that is usually treated with BCG. BCG is the vaccine for tuberculosis, so cannot be given to immunocompromised patients.

3. High grade – muscle non invasive: this disease has a poor prognosis, unless a cystectomy is performed. This is where the bladder is taken out. The bladder is then replaced with either an ileal conduit (where they take out a portion of bowel, and make a fake bladder) or a neobladder (I didn’t see any of these being put it in).

And that’s bladder cancer in a nutshell.