Dr James Thompson is an experienced robotic, laparoscopic, endoscopic and open urological surgeon. He has sub-specialty training in (and passion for) the treatment of prostate, bladder and kidney cancer using the latest robotic surgery techniques and for high-impact cancer research that has the ability to immediately improve quality of life and cancer cure rates for the community.
Bladder Cancer
WHAT IS BLADDER CANCER?
Bladder cancer is a condition where cells that line the inner surface of the bladder over-grow, in an un-regulated way. It is one of the most commonly diagnosed cancers, affecting both men and women.
WHY DOES BLADDER CANCER DEVELOP?
The cells that line the inner surface of the bladder and urinary tract are constantly being replaced by new ones, like how cells are constantly shedding and being replaced on the skin and the inner lining of our gut.
This occurs in a carefully regulated “cell cycle” where new cells are constantly born from stem cells, then age and undergo ‘wear and tear’ DNA damage from toxins in the bladder and then self destruct in a carefully controlled way, only to be replaced by healthy new bladder cells. Bladder cancer develops as a result of bladder cells experiencing DNA damage to the genes that regulate cell the normal cell cycle. This means that damaged cells lose their normal ‘self-destruct’ mechanism and start to grow excessively in an uncontrolled way, forming a ‘lump’.
In some cases, this is purely ‘bad luck’ as there is no explanation for why the DNA damage occurred. There are, however, many known factors that increase the risk of developing bladder cancer:
smoking: cancer-causing toxins in smoke pass from the lungs into the bloodstream and are then filtered into the urine, where they sit in the bladder for many hours before passing out in the urine; smoking is the most common cause of bladder cancer: the risk increases with the number of cigarettes smoked per week and number of years smoking;
older age: like most cancers, ageing leads to cumulative lifelong exposure of the bladder to common everyday environmental toxins e.g. air pollution, pesticides in food, etc;
strong family history: some families carry silent gene DNA mutations that predispose them to this type of cancer;
work-related chemical exposure: painters, textile factory workers, printing-press workers, hairdressers, truck drivers, vehicle maintenance workers etc are all exposed to high levels of chemicals that cause bladder cancer, e.g. benzene and other colour dyes, paints, solvents, diesel and petrol fumes;
radiation or cyclophosphamide treatment: these medical treatments damage the DNA of bladder cells and increase the risk of secondary cancers.
HOW DOES BLADDER CANCER PRESENT?
Bladder cancer most commonly presents itself suddenly with painless blood in the urine. It may also present gradually as needing to pass urine more frequently or urgently, or as persistent urine infections despite treatment.
HOW IS BLADDER CANCER DIAGNOSED?
Diagnosis is confirmed via a combination of:
Urine samples examined under the microscope looking for cancer in bladder cells shed in the urine; and
CT or MRI scan with dye to provide a 3D picture of the bladder; and
Cystoscopy, where a small fibre-optic camera is inserted into the bladder to remove the ‘lump’.
Once the lump is removed, we send it to an expert pathologist to examine under the microscope. This enables us to find out which of the five categories below that you fit into:
Slow growing (the medical term for this is ‘low grade’) and has NOT spread below the bladder surface.
Fast growing (the medical term for this is ‘high grade’) but contained within bladder surface or collagen layer: in some cases, cancer cells are growing rapidly, and may be contained within the surface or growing down below the thin inner surface of the bladder to reach a thin layer layer of collagen (called the ‘lamina propria’). Further treatment is required in these cases, after the lump is removed.
Growing through the bladder wall to reach the muscle layer (the medical term for this is muscle-invasive or T2): the bladder wall is very thin (just a few millimetres thick) and thus once cancer cells grow down below the inner surface of the bladder they reach a thin layer layer of collagen followed by a layer of muscle fibres. If your cancer reaches the muscle layer, it is serious and major surgery or radiotherapy is required.
Spread beyond the bladder wall (the medical term for this is ‘locally or regionally advanced’): this group includes people where the cancer has grown into the fatty tissue layer that surrounds the bladder or into surrounding organs near the bladder such as the pelvic bones or muscles, the prostate in men or the vagina and womb (cervix/ uterus) in women.
This group also includes people where the cancer has spread to involve lymph nodes near the bladder. Lymph nodes are made up of white blood cells; these are the first line of the body’s immune system that detect and destroy cancer cells.
Spread to other areas of the body (the medical term for this is ‘metastatic’): this group includes people in which scans (for example PET scans or CT scans) show that the cancer has spread to involve other sites such as the lungs, liver, bones or lymph nodes outside the pelvis.
Prognosis & Treatment options
Prognosis and treatment varies widely, depending on which of the 5 groups (outlined above) that you fit into:
Slow growing: if you are in this group, it is great news because these ‘lumps’ can be cured simply by removing the lump via a camera. No further treatment is required, but it is important you are monitored carefully with regular cystoscopy (a check inside the bladder with a camera) for any sign of recurrence.
Fast growing but contained to the surface/ collagen layer: If the tumour is high grade or extends down to the collagen layer beneath the surface, you will require further treatment medicine placed inside the bladder via a catheter tube, once weekly for 6 weeks and then 3 monthly. The types of medicine we use include BCG, chemotherapy or immunotherapy. We will recommend the best option for you, tailored to your situation.
Growing through the bladder wall to reach the muscle layer: If your tumour reaches the muscle layer, it is an aggressive tumour but the good news is that it is still curable in most cases with urgent treatment. The preferred treatment is chemotherapy followed by surgery to remove the bladder. In men we also usually remove the prostate, and in women we sometimes need to remove the uterus and a small part of the vagina.
Once the cancer has been removed, a new bladder substitute is needed. This is created using a short tube segment of small intestine, which can either be brought up to the skin to the side of the belly button as a small stoma (urine drains into a bag on the skin) or can sometimes be re-joined to the urethra (water pipe) below thus creating a new bladder, so you can continue to pass urine the ‘natural’ way and can avoid a stoma.
In the past, this operation (called ‘cystectomy’) was performed via a large open cut in the abdomen, however the invention of the Da Vinci robotic system has revolutionised bladder surgery. It allows us to safely perform keyhole surgery that was previously not possible.
Robotic surgery results in less blood loss, less blood transfusions, less pain, shorter hospital stay, faster recovery time and less complications.
Some people are not suitable for (or unwilling to accept) surgery, in which case we treat with radiotherapy, ideally combined with chemotherapy; some cases are not suitable for radiotherapy, so we will discuss all your options and tailor the ideal treatment according to your cancer factors, past medical history, life circumstances and personal preferences.
Spread beyond the bladder wall to reach surrounding fat, organs or lymph nodes: In these cases, the treatment is usually the same as for category 3 above, however in some cases surgery may not be possible (for example if the cancer has spread to involve the bone/ muscles that cannot be removed). In this group, there is a higher chance of recurrence after treatment, however cure is often still a real possibility and prompt treatment by an expert team can give you the best chance of cure or at least the longest life expectancy with the best quality of life too.
Spread to other areas of the body: in this situation, our aims are to use the camera to remove as much of the bladder tumour as possible, then commence a combination of chemotherapy, immunotherapy and/ or radiotherapy to shrink the tumour into remission, hopefully for many years. Whilst it is difficult to achieve cure, we have a wide variety of treatments and an expert team of specialists and nurses from all specialities including urology, oncology, palliative care and community nursing to ensure you have access to the latest cutting edge treatments, live as long as possible and often for many years, have good quality of life and a strong team to support and care for you as well as your family, throughout your cancer journey.
Whichever type and stage of bladder cancer you have, you can rest assured that I am a specialist in bladder cancer and will take the time to perform a detailed assessment of your cancer, your medical history, your life situation and your personal goals and priorities. In this way, we can work together to tailor the optimal treatment plan for you to ensure the best outcome.