Bladder disease 1

Tumors of the urinary bladder are the most common neoplasms of the urinary tract. In western industrialized countries, the incidence of the disease is about 3 times higher in men than in women. The higher tumor rate in men is u. a. Exposure to carcinogenic substances. Attributed to heavier cigarette consumption. With an increase of the disease during the last two decades in the highly developed industrialized countries, a relative increase of bladder tumors in women has also been observed.

At the time of initial diagnosis, 70% to 80% of cases are early findings. Red blood cells in the urine or even visibly bloody urine are one of the first early signs of this type of tumor. Also other symptoms, such as z.B. Discomfort during urination or uncharacteristic pain may be indicative, but occur less frequently.

Diagnostics

When this so-called hematuria occurs, a cystoscopy is essential to detect or exclude bladder tumor growth. It is undertaken under local anesthesia or, in individual cases, can be performed under a so-called short anesthesia. It is possible to use rigid and flexible, d. h. mobile instruments. The burden for the man and the woman is low.

In addition, urine analysis and an ultrasound examination of the urinary bladder and kidneys as well as an X-ray examination of the urinary tract with contrast medium are carried out.

Classification of bladder tumors

The urinary bladder consists of four different layers (from the inside to the outside: urothelium (mucous membrane) – inner musculature – outer musculature – outer urinary bladder boundary). According to the involvement of the individual layers, the urinary bladder tumors are classified into categories 1 to 4 (T1 to T4).

Fortunately, 80% of urinary bladder tumors are confined to and originate in the inner layer of the urinary bladder (so-called "non-invasive urothelial carcinomas" or superficial carcinomas, Ta). These tumors can be cured by endoscopic surgery (via the urethra) in a way that preserves the bladder. Advanced bladder tumors that extend beyond the innermost layer are considered invasive bladder tumors: this type of tumor, which fortunately affects only 20% of all bladder tumors, must be treated by removal of the bladder (cystectomy). This results in the necessity of a new urinary diversion.

Stage-specific therapy

If you are suspected of having a bladder tumor, the first step is transurethral removal by means of an endoscopic procedure, followed by fine tie or microscopic examination (histology). At this point, the so-called photodynamic diagnosis (PDD) with Hexvix® has a supporting effect. By instillation of this drug into the urinary bladder, conspicuous findings are "stained" under blue light during the operation. This makes the smallest findings and tumor precursors more visible and thus provides greater safety for the patient.

The subsequent microscopic findings determine the tumor stage, which results in various forms of therapy: Superficial tumors have in principle a good prognosis and can be cured by transurethral resection. However, recurrence occurs in 80% of cases, which is why regular follow-up is very important. In the case of very frequent recurrences and progressive tumors, a single or regular bladder filling therapy with various chemotherapeutic agents may be useful.

An exception are superficial findings of very aggressive tumors or high degree of degeneration. This tumor is a special type of superficial bladder tumor. In addition to the risk of recurrence described above, it has a high tendency to progress and metastasize. Therefore, the treatment of this tumor must be consistent and aggressive. In individual cases, it is necessary to decide between a radical bladder removal. A local chemotherapy (local bladder filling) resp. immunotherapy can be decided. The same applies to an additional special form of superficial bladder carcinoma, the so-called carcinoma in situ.

Advanced tumors of the urinary bladder, which reach the bladder muscle layer, can no longer be treated in an organ-preserving manner. Here, radical removal of the bladder should be performed with the need for some form of urinary diversion. The different types are divided into continent (orthotopic neobladder, Pouch) and non-continent (Ileum Conduit) Drains subdivided.

In the case of cystectomy in men, the prostate gland and seminal vesicles usually also have to be removed. Under certain conditions and after appropriate diagnostics it is also possible, nerve-sparing procedures apply. In women, the uterus, ovaries and a small part of the vagina must also be removed for reasons of radicality. Then it must be decided whether the creation of a replacement bladder from intestinal parts is possible for the man or the woman. In this form of surgery, the patient can subsequently urinate in the normal way and a bag supply is not necessary. Sometimes it is necessary to remove the urethra at the same time. Then a so-called orthotopic neobladder is not possible. Depending on the patient, other urine reservoirs can be created, either the formation of a pouch with the need for relief via intermittent catheterization or stoma care by means of a bag. In any case, after such an operation, you will be instructed in the care/handling of the various urinary diversion systems, also in cooperation with a trained Stoma nurse, introduced.

Depending on the histological findings, z.B. if the tumor exceeds the organ boundaries or if the lymph nodes are positively affected, subsequent chemotherapy may be advisable. Such chemotherapy should only be given in centers that have experience in an aggressive form of chemotherapy. Patient education is of great importance, especially in the case of bladder cancer, since the therapist and the patient must work together to shape the often difficult course of treatment. The patient's understanding of certain measures is of crucial importance here.

Aftercare

Bladder tumor patients must be followed up regularly by a urologist. A distinction must be made between whether the previous operation was able to preserve the bladder or whether a bladder removal with subsequent bladder replacement became necessary. In most patients, the urinary bladder can be left in place, so that here, in addition to regular cystoscopy, in order to detect a recurrence of the tumor at an early stage and to treat it again, urine examination, regular physical examination and ultrasound examination of the kidneys and urinary bladder and, if necessary, even X-ray examination of the kidneys and ureters should be performed. Patients who have had their bladder removed should also undergo ultrasound examinations of the kidneys, blood tests, chest X-rays and, in some cases, computer tomography as part of the routine program in order to detect the recurrence of the tumor at an early stage. Furthermore, it is important to ensure the function of the various forms of urinary diversion.

The entire spectrum of bladder tumor diagnostics (outpatient cystoscopy, urine cytology), therapy (surgical therapy, chemotherapy) and follow-up care (special consultation hours for tumor follow-up care) is offered in our clinic. Complicated cases can be discussed in our regular interdisciplinary tumor board.

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