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Treatment of bladder cancer

Bladder cancer

Treatment of bladder cancer is separated into two groups:

  • superficial cancer (pT ≤ 1)
  • infiltrating cancer (pT ≥ 2)

For superficial cancer (pT ≤ 1), the patient is offered conservative (organ-sparing) treatment. For cancer infiltrating the muscle (pT ≥ 2), more invasive (radical) surgery is necessary.  

Surgery

  • Transurethral resection (TUR-B)
  • Bladder resection (rarely performed) 
  • Cystectomy

Radiation therapy

Curative radiation therapy is no longer recommended for infiltrating urothelial cancer in the bladder. For a small tumor volume and T ≤ 2, radical TUR-B supplemented with external radiation therapy may cure the disease, and may be used in patients not willing to have a cystectomy. However, these patients must be monitored closely, and if recurrence, a cystectomi must be performed.

Radiotherapy alone is not given to treat bladder cancer, but is used in multimodal treatment of bladder cancer and for palliative treatment. 

Drug therapy

  • Local
    • Intravesical chemotherapy
    • Intravesical immunological treatment (BCG)
  • Systemic chemotherapy

Multimodal treatment

Multimodal treatment involves a combination of drug therapy, radiation, and surgical treatment. Many studies on infiltrating bladder cancer are conducted, but the results are not unambiguously in favor of the patient.

Patients having a poor prognosis should be referred for treatment at institutions having a team including a surgeon, oncologist, pathologist, and radiologist to achieve optimal treatment results.

Renal pelvis and ureters

In most cases of cancer in the renal pelvis or ureters, the treatment is nephroureterectomy. Other treatments are rarely appropriate to consider, other than for single kidney or bilateral disease.

Most cancers in the renal pelvis/ureter must be treated by organ resection. For tumors in the lower third of the ureter, a resection of the distal ureter may be performed, including a bladder resection of the ureteral opening and subsequently reimplantation of the ureter into the bladder. The entire ureter can also be removed and be replaced with a segment of the small intestine, or an autotransplantation of the kidney can be performed where the renal pelvis is anastomosed directly to the urinary bladder. These treatment options are mostly appropriate for single kidney or bilateral disease. Conservative surgery with endoscopic coagulation in the renal pelvis and upper ureters can be attempted if the patient has a low WHO grade. However, the surgery is difficult to carry out and as there will be a lack of confidence in curing the disease. Therefore, it is seldom indicated. If the patient has Tis in the upper urinary tracts, it may be possible to treat by rinsing with BCG via pyelostomy catheter, but these patients must be monitored closely.

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