Bladder cancer can spread to the kidneys

Bladder cancer

Bladder cancer (Urinary bladder carcinoma, bladder tumor, urothelial carcinoma): Malignant growth of the urinary bladder mucosa, which is favored by toxins. Men - especially between the ages of 60 and 70 - are about three times more likely to be affected than women. Currently, every second bladder cancer in both men and women can be traced back to smoking.

If the bladder cancer is discovered early and has not yet broken through the bladder wall, the chances of a cure are good; the 5-year survival rate is then ~ 85%. In advanced stages, surgical removal of the urinary bladder is often necessary, which means a significant break in everyday life and usually leads to disability.

Leading complaints

Early stage: In 80% of the cases visible admixtures of blood in the urine, typically painless and without other symptoms.

In later stages:

  • Sometimes more frequent or increased need to urinate
  • Pain in the kidney area from urinary obstruction in the kidneys
  • Weight loss.

When to the doctor

In the next two days, though

Immediately if

  • urination is no longer possible.

The illness

Disease emergence

Urinary bladder tumors are malignant growths of the bladder lining and are the most common cancer of the urinary tract. The tumors usually grow in the form of small protuberances (polyps) directly from the urinary bladder lining and are malignant in 95% of cases.

to shape

  • About 75% of the diseases are relatively benign papillary (bud-like growing) forms of cancer that only affect the innermost layer of the bladder wall and have not yet grown into the bladder muscles.
  • Carcinoma in situ, bladder CIS, is a special form: it is limited to the superficial layers and is actually a very early stage of cancer, but it is prognostically unfavorable in the bladder due to the rapid spread through the entire bladder wall.
  • If there is extensive infiltrating bladder cancer, it has usually already grown into the muscles of the urinary bladder and is spreading rapidly into the neighboring organs (e.g. prostate or uterus). This means a significantly poorer prognosis.

Causes and Risk Factors

Bladder tumors have been shown to be caused by the harmful influence of cancer-causing toxins, so that smokers have a greatly increased risk of bladder cancer. As a trigger, however, substances from the industry are known that z. B. occur in certain hair dyes or used in the textile and leather industry. Bladder cancer is recognized as an occupational disease if the connection between pollution at work and the disease can be proven.

Other risk factors for the development of bladder tumors are genetic predisposition, chronic cystitis, permanently low drinking quantities and the use of medication such as B. Cyclophosphamide.

Complications

If the urine is very bloody, there is a risk that blood clots will remain in the bladder and eventually block the bladder outlet (bladder tamponade). Urination is then no longer possible and urinary retention occurs. The blood clots are removed through a catheter or endoscopically.

A dreaded complication in the late stage is peritonitis caused by a rupture of the urinary bladder (perforation).

Diagnostic assurance

The doctor uses urine test strips to identify traces of blood in the urine. A urine culture is also created, as there is often an accompanying urinary tract infection. In urine cytology, exfoliated tumor cells can be detected, especially in advanced bladder cancer.

If there is blood in the urine that can already be seen with the naked eye (macrohematuria), clarification is all the more urgent. A rapid urine test (determination of the NMP 22 protein) can provide an initial indication, but it is often positive even if there is no tumor.

The doctor uses ultrasound to detect urinary congestion in the kidneys or causes of the bleeding such as kidney and ureter stones. However, tumors are only visible on ultrasound from a certain size. For this reason, the doctor will carry out a contrast medium examination of the urinary tract (excretory urogram) and a urinary bladder mirror in the event of a single microhematuria. If necessary, he takes urine directly from the bladder (bladder irrigation cytology) in order to detect cancer cells.

With the imaging procedures CT, magnetic resonance and bone scintigraphy, the doctor may discover already existing metastases.

Differential diagnoses: Other diseases with the occurrence of blood in the urine are, besides cystitis, above all other tumors of the urogenital tract such as prostate cancer and kidney cancer, as well as glomerulonephritis, kidney stones and blood clotting disorders.

treatment

The treatment of bladder carcinoma depends largely on the type, location and stage of the tumor. The problem is that the tumors often recur - in ~ 60% of cases even after they have been completely removed. Since the tissue structure in the bladder, ureter and renal pelvis is identical, the tumors can appear in different places at the same time. The therapy of advanced or large tumors proves to be difficult.

Treatment strategies according to tumor stage

Overview of treatment methods for bladder cancer (explanation of each method below).

Localized tumors (Carcinoma in situ and tumors that have not yet broken through the muscles of the urinary bladder:

  • The Transurethral resection of the bladder (TUR-B, TUR-bladder, generalizing also electroresection) is carried out by the doctor as part of a urinary bladder endoscopy. To do this, he leads a rigid tube over the urethra in the direction of the urinary bladder under general anesthesia. B. bring a wire loop leading high frequency current. With their help, a superficial tumor is then completely removed.
  • Local chemotherapy: After the operation, Mitomycin C or BCG is given directly into the bladder (once or weekly).

Locally advanced tumors (Tumors that have broken through the muscles of the bladder wall but have not yet spread distant metastases):

  • Urinary bladder removal (radical cystectomy) and urinary diversion through an artificial bladder (see below).
  • Possibly systemic chemotherapy before or after the urinary bladder removal in order to shrink the tumor before the operation or to combat any residual tumor after the operation.

Tumors with distant metastases

  • Systemic chemotherapy / immunotherapy
  • Possibly palliative urinary bladder removal and urinary diversion (e.g. if the urinary tract is blocked by the tumor or metastases).

Transurethral Resection of Bladders (TUR-B)

Through the transurethral resection of the bladder (TUR-B), the urologist removes a bladder tumor: To do this, he uses a wire loop carrying high-frequency electricity, with which he removes the tumor (shown in the top left corner). The lower partial images show how he removes the tumor layer by layer.
Georg Thieme Verlag, Stuttgart

They have been around for a few years Photodynamic diagnostics (PDD), with which even the smallest tumors can be detected. Before the operation, the doctor fills the bladder with a fluorescent substance that accumulates in the tumor cells. If the tumor is then irradiated with light of a certain wavelength, the fluorescent molecules glow so that the tumor cells can be clearly differentiated from the healthy tissue cells in the cystoscopy and can be removed in a more targeted manner.

The subsequent fine-tissue examination of the removed tissue in the laboratory shows how far the tumor has grown into the deeper layers of the mucous membrane. If the tumor has already been completely removed by the biopsy, any further therapy is often unnecessary.

Follow-up check. In the first few years, it is important to have regular urinary reflections as a check-up, because in up to two thirds of cases it comes back. Depending on the stage and degree of differentiation of the tumor cells, the doctor usually removes them again using the TUR-B.

Removal of the urinary bladder (cystectomy)

In the radical cystectomy the doctor removes the urinary bladder completely. He also removes the pelvic lymph nodes as a precautionary measure, as well as the prostate (radical prostatectomy) in men and the uterus, fallopian tubes and ovaries and part of the vaginal wall in women.

Urinary diversion. Without a urinary bladder, the urine must be diverted: the surgeon creates a urinary bladder replacement (neobladder) from parts of the intestine, into which the ureters are implanted. These interventions are complex and temporarily very stressful for the patient. They are now carried out in all major urological clinics.

Consequences of urinary bladder removal and urinary diversion. Despite modern surgical techniques, a complete removal of the urinary bladder and subsequent replacement lead to undesirable side effects in the replacement bladder and neighboring organs.

  • Urinary incontinence usually occurs at least at the beginning, because holding and controlled emptying of urine must first be learned again. Pelvic floor training is very helpful here. Sometimes, however, the patients are no longer able to completely empty the replacement bladder, in which case the bladder may have to be emptied several times a day via a catheter.
  • Men lose their erectile function as a result of the procedure, because the prostate and seminal vesicles must also be completely removed together with the urinary bladder. The nerve cords responsible for the erection can often not be spared - but the libido is preserved.
  • In women, the ovaries are often removed, which leads to premature menopausal symptoms in the under 50s.

Pretreatment and other treatment options

Local chemotherapy. With an immunomodulator (active ingredient that influences the immune system) such as Mitomycin C or BCG® from weakened tuberculosis pathogens, tumor growth can often be stopped in the early tumor stage. So that this chemotherapy only works inside the bladder, the substances are poured directly into the bladder via a catheter according to a specific therapy scheme (initially usually once a week, then monthly) and left there for about 2 hours - then the patient discards them "naturally "(Instillation therapy). Possible side effects are inflammation of the bladder and severe irritation of the bladder and, when given BCG, occasionally triggering or activation of tuberculosis.

Systemic chemotherapy. If the tumor has progressed so far that the tumor has grown into the muscles of the bladder wall, the doctor may consider systemic chemotherapy (e.g. with gemcitabine or cisplatin) to reduce the size of the tumor in individual cases before surgical removal of the bladder. The medication is administered via an infusion. If the tumor can be reduced in size in this way, it simplifies the operation or sometimes makes it possible in the first place.

In some cases, doctors recommend systemic chemotherapy even after radical bladder removal, e.g. B. when tumor growth was advanced. This chemotherapy usually starts within the first 12 weeks after surgery.

Systemic chemotherapy is only used as the sole therapy if distant metastases are already present. B. be in bones, liver or lungs, so the tumor has already spread to other tissues. Sometimes it is the only way to increase survival time. However, the effectiveness is limited: A form of chemotherapy has proven to be best in which four different active ingredients are used according to a certain scheme (e.g. according to the MVAC scheme with the substances methotrexate, vinblastine, adriamycin and cisplatin). The tumor only regresses completely in ~ 20% of cases, and in even fewer patients the success lasts in the long term. Therefore, new schemes are being tested, some of which are also more compatible.

Immunotherapy. Various substances (e.g. antibodies) are used to induce the patient's own immune system to fight the tumor itself. In the meantime, several studies have proven the effectiveness of immunotherapy with so-called PD1 or PDL1 inhibitors in bladder cancer. They are mainly used when previous chemotherapy has failed. Approved for the therapy of bladder cancer are z. B. Atezolizumab (Tecentriq®), nivolumab (Opdivo®) and pembrolizumab (Keytruda®).

Irradiation. Radiation alone is unfortunately not very effective and is therefore not an alternative to radical surgical bladder removal. Radiation is only carried out if the patient cannot be operated on or if it is expressly requested. The 5-year survival rate is then only a maximum of 40%.

Chemoradiotherapy. The combination of radiation and chemotherapy, chemoradiotherapy, is somewhat more successful than using either method alone. The bladder tumor should have been completely removed beforehand using a TURB, if possible.

forecast

The 5-year survival rate depends on whether it is a locally limited tumor (5-year survival rate ~ 85%) or a locally advanced tumor (5-year survival rate maximum 60%). If there are lymph node metastases, the 5-year survival time is about 33%. In distant metastases, the mean survival time is 6–9 months. With chemotherapy or immunotherapy, it can be extended to around 14 months.

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What you can do yourself

As with all types of cancer, the diagnosis of "bladder cancer" is accompanied by the feeling of "falling into a deep hole". In addition, the patient often has to put up with a bladder removal and endure the side effects and consequences of the treatment. These include urination problems, erectile dysfunction and (temporary) urinary incontinence after the operation. Therefore, after overcoming bladder cancer, rehabilitation in a special clinic or outpatient follow-up care, tailored to the individual needs of the patient, is very important.

Be sure to talk to your doctor about your fears and symptoms. To what extent the following advice is useful in your very personal situation, ultimately only you can decide for yourself:

  • Physical activity releases new energy: Regularly do endurance training that is appropriate to your physical condition, such as hiking, walking or swimming.
  • Eat a balanced diet - this will make you feel better and strengthen your immune system.
  • Mobilize your inner strength: relaxation processes, creative activities with music and literature or a hobby will help you cope with the disease.
  • Exchange ideas with other people affected: Self-help groups offer opportunities to speak openly about worries and problems.

Prevention

In the case of bladder cancer, it is particularly important to adhere to the recommended follow-up examinations - even after successful therapy.

Further information

www.krebshilfe.de

Website of the German Cancer Aid, Bonn: Under the heading of information there is a detailed overview of bladder cancer.

www.blasenkrebs-shb.de

Website of the Self-Help Association for Bladder Cancer e. V., Mülheim / Ruhr: Offers a wide range of information for those affected and their relatives as well as patient reports.

Authors

Dr. med. Martina Sticker, Dr. med. Arne Schäffler in: Gesundheit heute, edited by Dr. med. Arne Schäffler. Trias, Stuttgart, 3rd edition (2014). Revision and update: Dr. med. Sonja Kempinski | last changed on at 10:14


Important note: This article has been written according to scientific standards and has been checked by medical professionals. The information communicated in this article can in no way replace professional advice in your pharmacy. The content cannot and must not be used to make independent diagnoses or to start therapy.