Bladder neoplasm

Kawa Omar, Nawal Shamim Khan, Muhammad Shamim Khan

    Research output: Chapter in Book/Report/Conference proceedingChapterpeer-review

    2 Citations (Scopus)

    Abstract

    Bladder cancer is the most common urothelial malignancy. More than 90% arise from the transitional cell lining of the urinary tract. The remainder of the histological variants include squamous cell cancer, adeno carcinoma, and other rare tumours. Urothelial cancer is associated with smoking and exposure to industrial carcinogens. This cancer generally affects people who are older and who have many comorbidities, which makes their management more challenging. More than two-thirds of the urothelial cancers are non-muscle-invasive bladder cancer (NMIBC) confined to the mucosa or submucosal layers of the bladder wall and remainder are muscle-invasive bladder cancer (MIBC). NMIBC have tendency to recur, and the risk of recurrence varies between 15 and 80% and the majority of the recurrences occur within 6-12 months. Hence, intensive surveillance with cystoscopy and imaging of the urinary tract is required, which in turn incurs a high cost to the healthcare systems. The NMIBC cancers are classified based on their risk of recurrence and progression into low, intermediate, and high risk to tailor subsequent management and surveillance. In addition to the initial transurethral resection, intravesical therapies in the form of chemotherapy, immunotherapy, or a combination are used to reduce recurrence or progression of the disease. For MIBC or high-risk NMIBC, radical cystectomy and urinary diversion is the mainstay of treatment. Radical cystectomy is a life-changing operation and is associated with significant perioperative morbidity and mortality. Therefore, experts in the field are striving to minimise the morbidity of the procedure by using minimal invasive techniques of laparoscopy or robotic surgery in combination with enhanced recovery pathways to expedite recovery. There remains a risk of recurrence even after radical cystectomy due to micrometastasis. Various chemotherapy regimens have been used to decrease this in the neoadjuvant and adjuvant settings. Neoadjuvant chemotherapy has so far provided 5-8% absolute survival benefit at the expense of significant morbidity. In patients unfit or unwilling to undergo radical cystectomy, bladder preservation is an alternative which includes external beam radiotherapy and chemotherapy after transurethral resection. There is not enough evidence to prove the equivalence of this to radical surgery. In those with advanced or metastatic disease, patients are put on palliative care pathway because the natural history of the disease is poor with four to six months expected survival. However, some newer immuno-therapies that inhibit the interaction between programmed death ligand 1 (PD-L1), present on the surface of tumour or antigen-presenting cells, and programmed death 1 (PD-1), present on the surface of activated lymphocytes, are offering new hope to the patients with advanced disease. In some cases of locally advanced cancer, palliative cystectomy can be performed for control of recurrent bleeding.

    Original languageEnglish
    Title of host publicationBlandy’s Urology
    PublisherWILEY-BLACKWELL
    Pages409-446
    Number of pages38
    ISBN (Electronic)9781118863343
    ISBN (Print)9781118863374
    DOIs
    Publication statusPublished - 1 Jan 2019

    Keywords

    • Bladder cancer
    • Diagnosis and management of bladder cancer
    • Muscle-invasive carcinoma
    • Non-muscle-invasive bladder cancer
    • Transitional cell carcinoma

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