Urology Clinic RBH

The Urology clinic in RBH is the centre of excellence in Bahrain for the following treatments -

Laser surgery for prostate diseases.
Laser surgery for kidney stones.
Urodynamic study and incontinence treatment.
Laparoscopic urology.
Microscopic varicocele surgery.
Peyronie's disease,Erectile dysfunction and Penile Prosthesis implantation.
Infertility Treatment.
Female urology and Sexual health.
No Needle No scalpel Vasectomy.
Cancer Screening and treatment.
Plastibell Circumcision
.

BLADDER CANCER

BLADDER CANCER
A bladder cancer is the cancer from cells lining the urinary bladder. Due to exposure of some toxic substances or irritating factors damage happens to certain genes in the cell. This makes the cell abnormal and multiplies out of proportion to cell death and results in a cancer.
The commonest type of bladder cancer is known as transitional cell cancer.

These most common risk factors include:
Increasing age- Most bladder cancers occur in people over the age of 50
Smoking- Bladder cancer is four times more common in smokers than non-smokers.
Occupational exposure- Certain occupational and environmental chemicals have been linked to bladder cancer like substances used in the rubber and dye industries.
Gender- Bladder cancer is about three times more common in men than women.
Race- Bladder cancer is more common in white people than in black people.
Radiotherapy or chemotherapy- increases the risk.
Schistosomiasis- This bladder infection caused by a parasite in certain Asian, African and south American countries, increases the risk of a particular type of bladder cancer called squamous cell cancer.

How do bladder cancer patient present to us?
Blood in urine
The most common and the first symptoms are to pass blood in the urine without any pain known as painless haematuria. The blood in urine can be visible with our naked eyes (macroscopic hematuria) or it can be seen only under a microscope (microscopic hematuria)
Some superficial cancers in certain areas of bladder may cause irritation of the bladder and cause symptoms similar to a urine infection. In conditions were the cancer has spread out of the bladder the patient may present with weight loss, pain abdomen, renal colic, fever, infection etc.

How do we diagnose bladder cancer?
Urine test - a sample of urine can be sent to the laboratory to look for blood.

Cytology or NMP 22- a sample of urine can be sent to the laboratory to identify cancerous cells or proteins from cancer cells. under the microscope or special tests. However, if no cancer cells are seen it does not rule out bladder cancer.
Cystoscopy -A cystoscopy is a procedure by which a thin telescope called a cystoscope is introduced into the bladder via the urethra to view the complete bladder. In suspicious cases a biopsy can be taken for histopathology study. This can be done under local anaesthetic or a general anaesthetic.
PDD ( Photo Dynamic Diagnosis)- The same cystosopy done using special fluid medium and special light source colour up the flat and small lesions impossible to idetify by normal cystoscopy.

Ultrasound scan - This may be used to diagnose a bladder cancer especially in big cancers protruding into the bladder lumen..

CT scan or MRI – CT scan or MRI with contrast may give a better information about the size and shape of bladder cancer. This can also help in staging of the cancer. The staging will help to identify the growth of bladder cancer and whether the cancer has invaded nearby organs or has spread to local lymph nodes. This can also show whether the cancer has spread to other areas of the body

How do we treat superficial bladder tumors?
Endoscopic surgery
Most superficial bladder tumours are removed by a procedure called Transurethral Resection of Bladder Tumor (TURBT).The resected tissues are sent for a histopathology study under microscope.
Post TURBT chemotherapy
Following a TURBT we use to give one dose of intravesical chemotherapy (chemotherapy instilled into the bladder) within 24 hours of having a TURBT. We commonly use an anticancer drug called Mitomycin C for intra vesical application.
Chemotherapy / immunotherapy
The tumor removed during a TURBT and if the histolo-pathology study shows a high grade tumor we make an induction treatment by intravesical application of a drug called BCG every week for 6 weeks. The maintenance scheme for BCG therapy we follow is BCG vaccine 3 weekly instillations at 3 months, 6 months and every 6 months for 3 years. BCG is the same vaccine used to prevent TB.

Follow Up Cystoscopies

After a superficial tumor is removed, you will need routine check cystoscopies. The risk of recurrence is calculated using special table and if one recurs it needs to be resected again. The time interval between check cystoscopies is every 3 months at first but may become longer if the bladder remains free of tumor at each check. This may need to continue for several years to label the person as cancer free.

Grading
Grading refers to the degree of change in appearance of the cancer cells under the microscope. The grade gives an idea of aggressiveness of a cancer
• grade 1 (well differentiated)
• grade 2 (moderately differentiated)
• grade 3 (poorly differentiated)


Grade 1 means that the cancer cells look very much like normal bladder cells. They are usually slowly growing and less likely to spread. In grade 3 tumours the cells look very abnormal. They are likely to grow more quickly and are more likely to spread. There is one group called carcinoma in situ (CIS) which is always considered high grade.
Staging
The stage of a cancer describes its size and extend. This may help in deciding on the most appropriate treatment for you.
The most commonly used staging system for bladder cancer is called the TNM system:
• T is the size of the cancer
• N –Lymph Nodes , whether it has spread to the nearby lymph nodes.
• M-Metastases , whether the cancer has spread to other parts of the body.












Tumour size (T)
Early or superficial bladder cancer
• CIS CIS (carcinoma in situ) is sometimes described as a flat tumour only in lining cells of the bladder lumen.
• Tx primary tumour cannot be assessed..
• Ta There is a small area of cancer within the bladder lining.
• T1 The cancer has started to grow into the layer of connective tissue beneath the bladder lining.
• T2 The cancer has started to grow into the muscle of the bladder wall under the connective tissue layer.
T2a The cancer has grown through the superficial muscle.
T2b The cancer has grown deeply into the muscle.
• T3 The cancer has grown through the whole layer of muscle.
T3a The cancer has grown into the fat layer microscopically .
T3b The cancer has grown visibly into fat layer
• T4 The cancer has spread outside the bladder to any of the following: the prostate,uterus and vagina, pelvic or abdominal wall.
T4a The cancer has spread to the prostate, uterus or vagina.
T4b The cancer has spread to the pelvic or abdominal wall.
Lymph nodes (N)
• Nx lymph nodes status cannot be assessed.
• N0 There are no cancer cells in any lymph nodes.
• N1 There are cancer cells in one lymph node smaller than 2cm across.
• N2 There are cancer cells in one lymph node larger than 2cm, but smaller than 5cm, or more than one node affected, but all of them smaller than 5cm in diamteter.
• N3 There are cancer cells in at least one lymph node larger than 5cm in diameter.
Metastases (M)
• Mx-the cancer spread cannot be assessed.
• M0-the cancer cells have not spread to other parts of the body.
• M1 -the cancer cells have spread to other parts of the body. Most common metastases happen to the bones, the lungs or the liver.

How to calculate the risk of cancer recurrence and progression

How do we treat in case of recurrence or progression?
We assess the risk or progression from the above table and use the below table for opting the treatment plan.
See attached video of a TURBT.


How do we treat muscle invasive bladder cancers?
Muscle invasive and other high grade cancers need complete removal of the urinary bladder and nearby organs to which the cancer spreads and also removal of suspicious lymph nodes.In some cases radiotherapy and chemotherapy maybe needed.

What happens when the urinary bladder is removed?
When the urinary bladder is removed the urine maybe collected in a bag attached to the body or the intestine is used to make an artificial bladder.

he U.S. Food and Drug Administration (FDA) is informing the public that use of the diabetes medication Actos (pioglitazone) for more than one year may be associated with an increased risk of bladder cancer.


Actos (pioglitazone) and increased risk of bladder cancer


Facts about pioglitazone
·         Sold as a single-ingredient product under the brand-name Actos. Also sold in combination with metformin (Actoplus Met, Actoplus Met XR) and glimepiride (Duetact).
·         Used along with diet and exercise to improve control of blood sugar in adults with type 2 diabetes mellitus.

·         There may be an increased chance of having bladder cancer when you take pioglitazone.
·         You should not  take pioglitazone if you are receiving treatment for bladder cancer.
·         Tell your doctor right away if you have any of the following symptoms of bladder cancer: blood or red color in urine; urgent need to urinate or pain while urinating; pain in back or lower abdomen.
·         Read the Medication Guide you get along with your pioglitazone medicine. It explains the risks associated with the use of pioglitazone.
·         Talk to your healthcare professional if you have questions or concerns about pioglitazone medicines.
·         Report side effects from the use of pioglitazone medicines to the FDA Med Watch program, using the information in the "Contact Us" box at the bottom of the page.
·         Do not use pioglitazone in patients with active bladder cancer.
·         Use pioglitazone with caution in patients with a prior history of bladder cancer. The benefits of glycemic control versus unknown risks for cancer recurrence with pioglitazone should be considered in patients with a prior history of bladder cancer.
·         Counsel patients to report any signs or symptoms of blood in the urine, urinary urgency, pain on urination, or back or abdominal pain, as these may be due to bladder cancer.
·         Encourage patients to read the Medication Guide they get with their pioglitazone medicine.
·         Report adverse events involving pioglitazone medicines to the FDA Med Watch program using the information in the "Contact Us" box at the bottom of this page.