Bladder Cancer - Types and Staging
Bladder cancer staging is the critical determinant of treatment path - the distinction between non-muscle-invasive and muscle-invasive disease fundamentally changes management.
Cell types:
- Urothelial (transitional cell) carcinoma: 90-95% of bladder cancers; arises from the urothelium lining the bladder
- Squamous cell carcinoma: ~5%; associated with chronic irritation or schistosomiasis
- Adenocarcinoma: rare; may be primary or secondary
Staging:
| Stage | Description | Treatment Approach |
|---|---|---|
| Ta | Non-invasive papillary: confined to urothelium | TURBT + surveillance |
| Tis (CIS) | Carcinoma-in-situ: flat high-grade | TURBT + BCG intravesical therapy |
| T1 | Into lamina propria (not yet muscle) | TURBT - BCG; re-TURBT for high-risk |
| T2 | Muscle-invasive | Radical cystectomy - neoadjuvant chemo |
| T3-T4 | Perivesical fat / adjacent organs | Radical cystectomy - neo + adjuvant chemo |
| N+/M+ | Lymph node or metastatic | Systemic platinum-based chemotherapy - surgery |
Diagnosis:
- Haematuria (blood in urine) - the cardinal symptom; visible (macroscopic) or microscopic
- Cystoscopy: direct visualisation of the bladder with biopsy
- CT urogram: upper urinary tract and bladder staging
- MRI pelvis (VIRADS score): determines depth of invasion
- TURBT: both diagnostic and therapeutic for NMIBC
TURBT and Non-Muscle-Invasive Treatment
TURBT (Transurethral Resection of Bladder Tumour): The primary treatment for non-muscle-invasive bladder cancer. A resectoscope is passed through the urethra under spinal or general anaesthesia; the tumour is resected using an electric loop with sampling of the muscle layer to confirm invasion depth.
Procedure:
- 1-2 hours depending on tumour number and size
- 1-3 night hospital stay
- Catheter in situ for 24-48 hours post-op
- Post-TURBT immediate intravesical instillation of mitomycin C (reduces early recurrence)
- Specimen sent for histopathological analysis and grade/stage confirmation
BCG (Bacillus Calmette-Gu-rin) intravesical therapy: For high-risk NMIBC (high-grade T1, CIS, multiple or recurrent tumours), BCG immunotherapy is instilled weekly into the bladder for 6 weeks (induction course), followed by maintenance courses.
BCG mechanism: BCG is an immune stimulator - causes localised immune activation in the bladder wall that eliminates residual tumour cells and prevents recurrence and progression.
Schedule: Induction 6 weekly instillations; then maintenance schedule - 3 years (EAU guidelines)
Surveillance: NMIBC has a high recurrence rate (50-80% at 5 years depending on risk group) - regular cystoscopy surveillance is mandatory:
- High-risk: cystoscopy every 3 months for 2 years; every 6 months to year 5; then annually
- Intermediate risk: every 3-6 months to year 1; then annually
- Low risk: cystoscopy at 3 months and 12 months; then annually
BB Global Health can coordinate the TURBT in Turkey and then support ongoing surveillance cystoscopy planning (can be performed in home country with result sharing).
Radical Cystectomy for Muscle-Invasive Disease
Radical cystectomy removes the whole bladder along with pelvic lymph nodes and (in men) the prostate and seminal vesicles; in women the uterus, ovaries, and anterior vaginal wall are typically also removed. It is one of the most complex urological operations.
Surgical approaches:
- Laparoscopic (keyhole): standard approach; 4-5 port incisions
- Robotic-assisted (da Vinci): enhanced precision; available at BB Global Health partner hospitals
- Open: large midline abdominal incision; for complex or converted cases
Urinary diversion options: After cystectomy, a new way to pass urine must be created:
| Diversion Type | Description | External Bag? | Continent? |
|---|---|---|---|
| Ileal conduit | Small bowel segment brought to skin; urostomy bag | Yes | No |
| Orthotopic neobladder | Ileal pouch connected to urethra; patient voids normally | No | Mostly |
| Continent cutaneous pouch | Internal reservoir with stoma; self-catheterise | No | Yes |
Neobladder is preferred when technically feasible and patient is motivated - allows voiding without an external bag. Requires pelvic floor rehabilitation post-op.
Outcomes (radical cystectomy):
- 5-year cancer-specific survival for pT2N0: 60-70%
- pT3N0: 40-50%
- Node-positive: 20-30% (chemotherapy significantly improves outcomes)
- Robotic cystectomy achieves comparable oncological outcomes with lower blood loss and faster recovery
Recovery:
- Hospital: 5-7 nights
- Hotel: 10-14 days before flight home
- Full recovery: 4-6 weeks
- Follow-up: CT scan at 3 months, 6 months, and annually