Our Doctors' Location

Mount Elizabeth Medical Centre
3 Mount Elizabeth
Singapore 228510
Email:
How to get here

Urology Resources

Bladder Cancer

In Singapore, bladder cancer is the 7th most common cancer in males and females. Men are likely to be affected by this disease 3 times more than women. The causes for bladder cancer include ageing, chemical agents and cigarette smoking.

The most common presentation of bladder cancer is painless haematuria (blood in urine). Sometimes, the patient may have irritative symptoms like frequency of urination.

The diagnosis of bladder cancer is usually delayed if the haematuria is intermittent or attributed to ‘other’ causes, such as infection.

Diagnosis

Since haematuria can arise from any part of the urinary tract, the best initial investigation is an xray called Intravenous Urogram (IVU). It involves injection of a contrast material into the vein which is excreted by the kidney to outline the whole urinary tract.

A bladder tumour may show as a filling defect if the tumour is large enough. Sometimes, an ultrasound examination may also show a tumour in the bladder if it is > 1 cm. A negative IVU or ultrasound does not rule out bladder cancer, as small lesions < 1 cm may not be obvious. As such, a cystoscopy is mandatory for haematuria even if the IVU or ultrasound is reported as normal. Cystoscopy can be carried out under local anaesthesia in the clinic with a flexible instrument without much discomfort.

Treatment

Surgery

Once the diagnosis of a bladder lesion is confirmed, endoscopic surgery is needed - not only to surgically remove the tumour but also to accurately stage it. General anesthesia is needed and it may take up to 1 hour to resect the tumour. Biopsies of normal looking bladder are also performed so as not to dismiss early tumours of the bladder lining (carcinoma-in-situ). The pathologist then determines its grade and the depth of invasion.

At the time of diagnosis, approximately 80% of bladder tumours are superficial, i.e. confined to the bladder lining. The other 20% are invasive disease, i.e. deeper into the muscle layer of the bladder. Superficial tumours carry a good prognosis but do tend to recur frequently and have a risk of becoming invasive in the future, especially if carcinoma-in-situ is present. Invasive tumours eventually spread to the lymph nodes and prognosis then becomes poor. Hence, it is important to treat bladder cancer at its early stage, i.e. before it has invaded into the muscle layer.

After endoscopic tumour resection of superficial bladder tumours, periodic surveillance cystoscopies are needed to pick up any recurrences - initially quarterly for the first year, followed by biyearly to yearly, depending on the behaviour of the tumours. Patients with high risk of recurrence, eg. multiple tumours, high-grade and those with carcinoma in situ are additionally given anti-cancer agents,eg. mitomycin C or BCG instilled into the bladder to prevent recurrence. A typical treatment protocol would consist of weekly instillation for 6 weeks.

Treatment of patients with invasive bladder cancer has to be individualised. In muscle invasive disease, complete surgical removal of the bladder (radical cystectomy) gives the best chance of cure. Partial cystectomy is seldom done as most bladder tumours are of the transitional cell type and disease may recur in the remaining bladder. In radical cystectomy, after the bladder has been removed, the urine from the kidneys and ureters are diverted into a short segment of small bowel (ileal conduit), which is fashioned as a stoma on the outside of the abdomen. Urine is then collected in an external collection bag. This type of diversion is relatively easier and quicker to construct with low complication rates. For younger patients and patients who wish to remain continent or avoid a stoma, it is possible to construct a “new bladder” (neobladder) using bowel which is reconnected to the native urethra. Although this avoids an external bag, self intermittent catheterisation 4 times a day may be needed because the neobladder may not empty well or get blocked with mucus. As such types of operations are more difficult and longer to perform, only motivated and fit, young patients are suitable candidates.

Radiotherapy

Although radiotherapy allows bladder conservation, the response rate may not be as good. Hence, radiotherapy is generally reserved for older patients. It is given daily for 6 weeks and tends to cause long-term bladder and bowel irritation.