Superficial cancers may be single or there may be more than one. They are usually removed surgically, using a cystoscope.
If your surgery shows that the cancer is beginning to affect the deeper levels of the bladder lining, you may be advised to have further treatment. Anti-cancer drugs – chemotherapy or immunotherapy – may be put into the bladder to try to reduce the chance of the cancer coming back (recurring). This may be given immediately after the surgery or up to a few weeks later.
Surgery
Before surgery you will have a blood test to check your general health. You will also have a chance to discuss the surgery with a specialist nurse or a doctor. You will have a medical examination to make sure that you are fit enough to have an anaesthetic. You may be admitted to the surgical ward on the day of surgery, or the day before. The anaesthetist will talk to you about your operation and ask you to sign a consent form. You may also be asked by the research nurse for permission for blood samples and some of the tissue taken at the time of surgery to be kept and used for research. If you agree to this, you will be asked to sign a second consent form.
The operation
Many tumours in the bladder are the small papillary type. These can usually be removed very easily using a cystoscope. You will be given a general anaesthetic and a cystoscope will be inserted into the bladder. The tumour is snipped off at the stem and the area is burned (cauterised), using a mild electrical current to limit bleeding. This procedure is known as a transurethral resection of a bladder tumour (TURBT) and in this way several tumours can be treated at the same time, if necessary.
The operation usually takes from 20 minutes to an hour. Chemotherapy may be given into the bladder immediately after surgery.
After the operation
When you go back to the ward you will have a thin, flexible tube (a catheter) in your bladder, which drains your urine into a bag. It may make you feel as though you want to pass urine. Your urine will be bloodstained at first. Large bags of fluid may also be used to flush out the bladder continuously. This is to make sure that clots of blood do not form and block the urethra.
Once you are drinking normally and your urine looks clear, the catheter will be taken out. This is not painful but may feel a little uncomfortable. Once your catheter has been removed and your urine is no longer bloodstained, you will be allowed to go home. This is usually about 2–3 days after the operation.
Possible risks of surgery
Removing superficial bladder cancers is a safe procedure. However, it can have some risks. These are outlined below.
Urine infection 5–10 out of every 100 patients (5–10%) may get a urine infection. This may be while they are still in hospital or after they go home. Signs of an infection include: feeling cold, shivery, hot or sweaty; feeling generally ill; or your urine becoming smelly or cloudy. If you think you may have an infection, you can take a urine sample to your doctor for testing.
Bleeding for more than a few days occurs in up to 5 out of 100 patients (5%) and a blood transfusion may be needed. If the bleeding does not stop on its own, another operation to cauterize the bleeding area may need to be done under anaesthetic.
Damage to the bladder A hole may be made in the bladder during surgery. This happens in up to 5 out of 100 patients (5%). If this happens, you may need to have a catheter in the bladder for up to 10 days to allow the hole to heal. If the hole does not heal in that time, you may need to have an operation to seal it. This is done in an operation that involves making a cut in the abdomen. Your doctor or nurse will explain this procedure if it is needed.
After cystoscopy – follow-up
After this type of treatment, you will need to have regular follow-up cystoscopies. This is because the tumours will come back in between 5–7 out of every 10 people (50 – 70%). The cystoscopies are usually done every three to four months at first. Most follow-up cystoscopies are done in the outpatients department under local anaesthetic.
If the cancer comes back, the tumours can usually be surgically removed while they are still in the early stages. However, some people may also have chemotherapy or BCG given directly into the bladder.
Intravesical chemotherapy
Intravesical chemotherapy is given directly into the bladder. The most commonly used drugs in this situation are mitomycin-C and epirubicin. The drugs are given into the bladder through a flexible tube (catheter). Giving chemotherapy in this way puts the drugs into direct contact with the cancer cells in the lining of the bladder. It also causes very few side effects, as very little gets into the bloodstream to affect the rest of the body. The drugs may be given once, immediately after the transurethral removal of the bladder tumour, or as a course of weekly treatments, for about six weeks.
Side effects of intravesical chemotherapy
Chemotherapy given directly into the bladder may cause inflammation of the bladder lining (cystitis). This can lead to soreness or pain and you may need to pass urine more often than normal. Your doctor can prescribe medicines to reduce this effect. Some drugs can also make the skin of the hand or perineum (the area between the openings to the bowel and bladder) sore if they come into contact with them. In about 1 in 100 (1%) people, a skin rash occurs and the treatment may need to be stopped.
Contraception
It is not advisable to become pregnant or father a child while having any of the chemotherapy drugs used to treat bladder cancer, as they may harm the developing foetus. It is important to use effective contraception during your treatment and for a year afterwards. You can discuss this with your doctor or specialist nurse.
Condoms should be used during sex within the first 48 hours after chemotherapy to protect your partner from any of the drug that may be present in semen or vaginal fluid.
Intravesical BCG
A vaccine called BCG can be put into the bladder. BCG is the vaccine used to prevent tuberculosis (TB). It is also an effective treatment for some superficial bladder cancers. BCG is a type of immunotherapy. Immunotherapy stimulates the body's immune system to destroy cancer cells.
The exact way this treatment works is not fully known, but it seems the vaccine can make the bladder react in a way that triggers the body's immune system to reduce or get rid of cancers.
BCG treatment is given in the urology outpatient department. It is usually given once a week, for six weeks.
The vaccine is a liquid that is given directly into the bladder through a tube (catheter). You should not pass urine for two hours afterwards, as the treatment is working during this time. For the next six hours, men should sit rather than stand when they pass urine. This is to avoid splashing, which might lead to infection.
It is important to avoid getting any urine on your hands. You will be asked to put bleach into the toilet bowl to destroy any live vaccine. Your nurses and doctor will give you instructions about this.
Side effects of BCG
During treatment you may have side effects, such as: blood in your urine; fever and chills; needing to pass urine often; pain in your joints; nausea and vomiting; pain when you pass urine; a cough; a skin rash and feeling very tired. These are common effects that almost always settle down on their own. However, if you have any of these, tell your doctor or nurse when you next see them.
It is very important to tell your doctor as soon as possible if you have joint pains, as this means treatment must be stopped immediately. About 1 in 100 patients (1%) may have continuing high temperatures (fever) due to infection with BCG. This is treated with specific antibiotics in the same way as TB itself.
It is important to let your doctor know about any other medicines you are taking, because drugs that suppress your immune system may interfere with how effective BCG is for your bladder cancer.
Contraception
It is not advisable to become pregnant or father a child while having BCG, as it may harm the developing foetus. It is important to use effective contraception during your treatment and for six weeks afterwards. You can discuss this with your doctor or specialist nurse.
Condoms should be used during sex within the first 48 hours after treatment to protect your partner from any of the drug that may be present in semen or vaginal fluid.
Repeated treatment with BCG
This treatment may need to be repeated at times over the next two or three years. If so, your doctor will arrange this with you.
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