Clinic Location & Map

#09-40 Mt Elizabeth Novena Specialist Centre
(located within Mt Elizabeth Novena Hospital)
38 Irrawaddy Road
Singapore 329563

Phone: +65 6235 1180
Fax: +65 668 41310
Emergency: +65 6535 8833
Email: drchin@ccmurology.com
 

Clinic Hours

Monday - Friday 9:00am - 5:30pm
Saturday 9:00am -12:30pm
Sunday / Public Holiday Closed

Bladder Cancer

Picture of blood Cancer
Picture of blood in the urine

Fig 1: Blood in the urine is the most common sign

Bladder cancer is now the 7th most common cancer in Singapore. Men are affected 3 times more commonly than women and it occurs mostly in those above 50 years old. The causes for bladder cancer are ageing, chemical agents and cigarette smoking.

The most common presentation is painless gross haematuria (blood in the urine) [Fig 1]. It can also present with irritative bladder symptoms, eg. frequency and urgency of urination. Quite commonly, the diagnosis is delayed because the haematuria is intermittent or wrongly attributed to other causes esp. urine infection.


Diagnosis

a) Xray


Since haematuria can arise from any part of the urinary tract, the standard initial investigation is an xray called Intravenous Urogram (IVU). It involves the injection of contrast material which is excreted by the kidneys to outline the urinary tract. A bladder tumour may show up as a ‘filling defect’ if the tumour is large enough [Fig 2].

Sometimes, the bladder tumour can also be seen on an ultrasound examination if it is > 1 cm [Fig 3].

A negative IVU or ultrasound does not rule out bladder cancer as small tumours < 1 cm may not be obvious. As such, cystoscopy is mandatory even if the IVU or ultrasound is reported as “normal”.

Picture of tumour

Fig 2. IVU showing a huge tumour over the right side of the bladder

Picture of Bladder Tumour

Fig 3. Ultrasound may also detect a bladder tumour if it is > 1cm


Picture of Flexible cystoscopy

Fig 4. Flexible cystoscopy is easily done under local anaesthesia in the clinic

b) Cystoscopy

This is easily done under local anaesthesia in the clinic using a flexible scope without causing much discomfort [Fig 4]. The advantage is that even small tumours can be seen and biopsy taken to confirm if the bladder tumour is indeed cancerous as some 5% of bladder tumours may in fact be benign.

c) Cytology

Although the urine can be sent for cytologic examination to look for presence of cancer cells, its accuracy is limited by low sensitivity (< 50% pick-up rate). Hence, the result is not to be relied on when deciding whether a patient does or does not have cancer.


Treatment

i) Early (superficial) Stage

a) Surgery

Once the diagnosis of a bladder lesion is confirmed, endoscopic surgery using a resectoscope instrument to cut away the tumour (called TURBT). Biopsies of normal looking bladder are also done so as not to miss early tumours of the bladder lining (carcinoma-in-situ or CIS). Staging of the cancer is also done during the surgery by taking separate muscle biopsies and feeling the bladder with both hands. General anesthesia is usually preferred and it may take up to 1 hour to resect a large tumour. The pathologist assesses the cancer according to its grade and the depth of invasion [Fig 5].

Picture of bladder cancer stage

Fig 5. The staging of bladder cancer

At the time of diagnosis, 80% of bladder tumours are superficial, i.e. confined to the bladder lining. The other 20% are invasive (i.e. penetrated the muscle layer of the bladder). Superficial tumours carry a good prognosis but have a tendency to recur frequently. If so, they have the real risk of becoming invasive in the future, especially if the pathological grade is of the aggressive type or if CIS is present. Invasive tumours will eventually spread to the lymph nodes and distant organs, especially the lungs, bones and liver. Prognosis for invasive disease is poor, hence it is important to treat bladder cancer at its early stage (stage 1) before it penetrates into the muscle layer.

After endoscopic tumour resection of superficial bladder tumours, periodic surveillance cystoscopies are needed to pick up recurrences. The regime is 3-monthly for the first year, then 6-monthly to yearly depending on the behaviour / recurrence of the tumours. It is important to note that bladder cancers may look the same but may not behave the same.

b) Chemotherapy

Those at high risk of recurrence, eg. multiple tumours, high-grade and those with CIS disease are additionally treated with a choice of cytotoxic agents or immune-enhancing agent (BCG) instilled into the bladder (intravesical therapy) to prevent recurrence. A typical treatment protocol would consist of weekly instillation for 6 weeks followed by a booster over 3 weeks. The most common cytotoxic agent used is Mitomycin C. BCG is considered to be superior for tumours that are likely to recur and those with CIS disease.

ii) Advanced (Invasive) Stage

a) Surgery

Picture of Leal Conduit Drains

Fig 6. Ileal conduit drains the urine via a segment of small intestine

Treatment of patients with invasive bladder cancer has to be individualised according to the general status of health, extent of cancer and personal preferences. Total removal of the bladder (radical cystectomy) for muscle-invasive cancer (Stage 2 and 3) provides the best chance of cure. Partial cystectomy is seldom done as most bladder tumours are of the transitional cell type and may recur in the remaining bladder. After a radical cystectomy, the urine from the kidneys and ureters is diverted into a short segment of small bowel (called an ileal conduit) which opens as a stoma on the abdominal wall [Fig 6]. Urine is collected in an external collection bag (urostomy). This type of diversion remains the most popular choice as it is relatively easy and quick to construct. For younger patients, and those who wish to remain continent or avoid a urostomy, a “new bladder” can be constructed using a long intestine segment. This neobladder is reconnected to the native urethra so that the patient cn void normally. Although there is no need to wear an external bag, self intermittent catheterisation may still be needed as the neobladder may not empty well or become blocked with mucus produced by the intestine lining. Nocturnal incontinence (bed-wetting) is often a problem too. As a neobladder operation are more difficult and takes longer to perform, only motivated and fit, young patients are suitable candidates.

b) Radiotherapy

Although radiotherapy is a safer option and allows bladder conservation, the 5 year survival for bladder cancer with muscle invasion is only 20%-40%. The limitation with radiotherapy is that it may not kill the cancer cells completely and there will be cumulative side-effects on the bladder and bowel, causing irritation and incontinence. Also, the radiotherapy has to be delivered daily for a period of 6 weeks.