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Bladder cancer
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Bladder cancer

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CANCER

Urinary Tract

From MayoClinic.com

Treatment

Like many people with cancer, you may choose to take an active role in the decisions affecting your medical care. If so, try to learn as much as you can about bladder cancer and the treatment options that exist. As part of this process, you may want to consider getting a second opinion from a bladder cancer specialist, such as a urologist, medical oncologist or urologic oncologist.

In many cases, your primary care doctor may refer you to one or more specialists. You can also get the names of specialists from a nearby hospital or medical school.

Ultimately, the best treatment for you will depend on a number of factors, including the type and extent of bladder cancer you have, as well as on your age, overall health and personal preferences. Below are some of the treatment options:

Surgical procedures

Surgical treatments are usually the best option for people with bladder cancer. The most common procedures include:

  • Transurethral resection (TUR). This is often used to treat superficial bladder cancer. During TUR, your doctor inserts a cystoscope — an instrument with a special lens and fiber-optic lighting system — into your bladder through your urethra. The cancer is removed with a small wire loop and any remaining cells are burned away with an electric current. In some cases, a high-energy laser may be used instead. TUR itself causes few problems. You're likely to have some blood in your urine or pain when you urinate for a few days following the procedure. But because superficial bladder cancer commonly recurs, you'll need to see your doctor for a cystoscopic exam every three to six months.

  • Segmental cystectomy. This procedure may be an option when a tumor has invaded just one part of the bladder wall. It removes only the portion of the bladder that contains cancer cells. The main side effect of this surgery is more frequent urination. Although the problem is often temporary, it may become permanent in some people.

  • Radical cystectomy. This extensive operation may be used for invasive bladder cancer or for superficial cancer that affects a large portion of the bladder. It involves removing the entire bladder, as well as nearby lymph nodes and part of the urethra. In men, the prostate gland, seminal vesicles — which produce some of the fluid in semen — and a portion of the vas deferens (a conduit for sperm) also are removed. For women, radical cystectomy usually means removing the ovaries, fallopian tubes and part of the vagina.

  • Radical cystectomy can be life altering, affecting not only your ability to urinate normally but also your sexuality. Women who lose their ovaries and fallopian tubes are no longer able to become pregnant and enter menopause immediately. In addition, removing part of the vagina during surgery can affect the ability to have sexual intercourse.

  • In the past, the vast majority of men became impotent after a radical cystectomy. Now, new surgical procedures may prevent this problem in a very select group of men. Still, removing the prostate gland and seminal vesicles means that semen is no longer produced and sperm aren't released during ejaculation. Bladder cancer usually occurs in men after the years of active reproduction, but some men who have a cystectomy early in life choose to bank their sperm before surgery. Others may later decide on a procedure in which sperm are removed from their testicles.

Radiation therapy

This therapy uses high-energy X-rays to destroy cancer cells and shrink tumors. It's most often used after an operation to treat any remaining cancer cells. When surgical treatment isn't an option, radiation may sometimes be used instead, but it's much less effective than surgery.

In treating bladder cancer, radiation may either come from outside your body (external radiation) or from radioactive materials placed directly into your bladder (internal radiation). Internal radiation is rarely used for this condition, but until recently was a popular treatment in Europe.

External radiation is usually performed as an outpatient procedure, with treatments occurring five days a week for five to seven weeks.

You may find that you become tired during radiation therapy, especially during the last weeks of treatment. External radiation can also cause your skin to become red, tender and itchy — just as if you had sunburn. Women may also experience vaginal dryness, and men may have problems with impotence. Radiation may also cause bladder or bowel incontinence, impotence in men and irritation of the rectum, leading to diarrhea. These side effects are usually temporary. In the meantime, your doctor may be able to offer measures to make them more manageable.

Chemotherapy

This treatment uses drugs to destroy cancer cells. Your doctor may suggest having chemotherapy after an operation to eliminate any remaining traces of cancer, but sometimes you may have it before a surgical procedure in an effort to spare the bladder.

In most cases, two or more drugs are used in combination. They sometimes may be inserted directly into your bladder through your urethra — a procedure known as intravesical therapy. This treatment is commonly used following TUR to help prevent a very superficial cancer from recurring. You are likely to have intravesical therapy once a week for several weeks.

This isn't an option if cancer cells have penetrated deep into the bladder wall or spread to other organs. In that case, chemotherapy drugs are given intravenously so that they travel through your bloodstream to every part of your body (systemic chemotherapy). This treatment is given in several cycles, which gives your body a chance to recover between sessions.

Even so, the side effects of chemotherapy — hair loss, nausea, vomiting and fatigue — can be severe. They occur because chemotherapy affects healthy cells — especially fast-growing cells in your digestive tract, hair and bone marrow — as well as cancerous ones. Not everyone has these side effects, however, and there are now better ways to control them if you do.

Systemic chemotherapy may also reduce the number of white and red blood cells in your body, making you temporarily more prone to infections and bruising. In addition, some drugs used to treat bladder cancer may cause kidney damage. To help prevent kidney problems, you may be given intravenous fluids during your treatment and advised to drink lots of fluids.

Biological therapy

Biological therapy stimulates your body's own immune system to fight cancer. It's usually used after TUR to help prevent superficial bladder cancer from recurring. Bacillus Calmette-Guerin (BCG) is the most commonly used immune stimulant. It binds to your bladder, where it triggers a response that inhibits the formation and growth of tumors. BCG is administered directly into your bladder using a small, flexible tube (catheter) for two hours once a week. Treatment may last six or more weeks.

During treatment with BCG, you may have some bladder irritation or blood in your urine and feel as if you have the flu. Your doctor may suggest a medication to help reduce some of these signs and symptoms.

Other treatments

Standard therapies for bladder cancer may not always be effective, or you may not be able to tolerate the side effects. In that case, several more recently developed treatments may be an option. They include:

  • Interferons. These naturally occurring compounds can help slow the growth of tumors. They're administered directly into the bladder through a catheter, just as BCG and chemotherapy drugs are. Side effects include bladder infections, blood in the urine and signs and symptoms similar to those of the flu. In a small number of cases, people treated with interferons have developed serious lung or liver infections.

  • Keyhole-limpet hemocyanin (KLH). This shellfish-based compound is used to stimulate the immune system. It causes few side effects and may help prevent tumors from recurring, but its exact role in the treatment of bladder cancer is still the subject of experimental studies. KLH is currently used primarily in Europe.

  • Photodynamic therapy (PDT). This two-part treatment helps destroy bladder cancer cells. Initially you receive an injection of a chemical (Photofrin) that is taken up by cancer cells but not by healthy ones. The cells with Photofrin are then exposed to light from a laser, which kills or severely damages them. PDT may produce serious side effects, such as chronic bladder infections, bladder shrinkage and long-term sensitivity to sunlight.

Bladder reconstruction

In radical cystectomy, your bladder is completely removed. Immediately afterward, your surgeon reconstructs your urinary system so that you can eliminate urine effectively. Several options for bladder reconstruction exist. The best approach for you depends on a number of factors, including your overall health and the extent to which the cancer has spread. In all cases, the goal is to maintain your quality of life as much as possible. Some reconstructive procedures include:

  • Urinary conduit. This is the simplest operation with the least risk of complications. It involves isolating a segment of your small intestine and attaching one end of it to your ureters. The other end is connected to an opening (stoma) in your lower abdomen through which urine drains into a small bag. You wear the bag outside your body and empty it three or four times a day. In the evening you can use a larger bag that allows you to sleep through the night.

  • Catheterizable stoma. This type of reconstruction eliminates the need for a bag. Instead, your surgeon fashions an interior pouch capable of holding three or four cups of urine. You drain the urine from the pouch several times a day using a catheter. Because the size of the pouch remains the same, you must also drain your urine during the night.

  • Neobladder. During this complex reconstructive procedure, your surgeon literally recreates a bladder. This is accomplished by connecting the same type of internal pouch used in a catheterizable stoma to the tube that carries urine from your body (urethra). As a result, you're able to eliminate urine without having an external opening, although you may need to use a catheter inserted through your urethra. Neobladder reconstruction isn't an option if some or all of your urethra has been removed, and it may lead to a number of complications, including scarring, internal urine leakage and incontinence.

Prevention

Although bladder cancer can't always be prevented, these steps may help reduce your risk:

  • Don't smoke. Not smoking means that cancer-causing chemicals in smoke can't collect in your bladder.

  • Be careful with chemicals. If you work with chemicals, follow all safety instructions to avoid exposure.

  • Drink plenty of fluids. Drinking liquids, especially water, dilutes toxic substances that may be concentrated in your urine and flushes them out of your bladder more quickly. Because water sometimes can have high levels of chlorine or arsenic, be sure you drink the purest possible water.

  • Learn to love broccoli. A 10-year study conducted by researchers at the Harvard School of Public Health indicates that a high intake of cruciferous vegetables such as broccoli and cabbage may cut the risk of bladder cancer in men. Although eating plenty of fresh vegetables and fruits is important for overall health, only broccoli and cabbage seem to affect bladder cancer risk. The Harvard doctors studied only men, and it's not known if the results apply to women.

  • Seek medical attention early. If you notice blood in your urine, see your doctor.

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