Bladder Cancer is a form of urological tumor among many. When at an early stage, it is very treatable. Should you or a family member be told that blood in the urine warrants a further investigation, or that a concerning lesion has formed in the bladder, you have come to the right site for the transparent, honest answer.
Here is a very important fact. Most bladder tumors are formed at an early, non-invasive stage. Non-invasive tumors are located on the top layer of bladder lining. When this lining is removed endoscopically, with a quick follow up, the lesion is, for all intensive purposes, gone. Working with the right early stage bladder tumor specialists, it is possible to maintain the bladder throughout the entire treatment.
The bladder is a pelvic muscular organ that acts as a urine reservoir until excretion. Its inner wall is made of flexible tissues and can stretch and contract. The bladder’s cells around this inner wall are primarily where this cancer starts.
The start of bladder cancer metamorphoses its cells from normal functioning cells to proliferative tumorous cells. Tumorous cells can cause a breach in the bladder wall to deepen and invade other structures. Cancer cells treat the wall and organs like swift water. The severity of this condition is the only determining factor for correct prediction and prognosis.
Bladder cancer is the 4th in occurrence of cancer among Indian men. The occurrence of bladder cancer among both men and women is on the rise. The cause of this is tobacco use which surprisingly accounts for 50% of cases in men and 30% of cases in women. The amines in darts and skin cell rubber are known to be a cause of bladder cancer. Since urinary tract infections are predisposing factors to the squamous type of cells in bladder cancer, the location and type of infection is of much importance.
A defining feature of bladder cancer is how often it recurs, even after treatment. In 50% to 80% of patients, early-stage bladder cancer can transform after a successful tumor removal, and patients can develop new degenerative tumors which often appear in the bladder lining in 5 years. This makes cystoscopy and bladder cancer management vital to keep a check on the new tumors and catch any early growth to a make sure they don’t grow in an invasive manner.
Transitional Cell Carcinoma (TCC), called Urothelial Carcinoma (UC) in some contexts, is a subtype of bladder cancer and encompasses 90 to 95 % of all urinary bladder malignancies. These types of cells, are derived from the lining of the bladder. Field carcinogenesis is a phenomenon resulting from the development of TCC also in the renal pelvis, ureters, and urethra. Because of shared urothelial linings in all of the stated structures, TCC is known to cancer multiple urinary tract sites.
TCC can be further subclassified based on the degree of histological differentiation or grade, and the extent of infiltration into surrounding tissues, or depth of invasion, Among the bladder cancer grading system, the great versus the less grading is the most pathophysiologically and clinically relevant separation.
In India, Squamous Cell Carcinoma (SCC) accounts for 3 to 5% of bladder cancers, which are caused by chronic irritation of the bladder lining (due to chronic urinary infections, like North African and Middle Eastern schistosomiasis, long-term catheterization, bladder stones, and chronic inflammation). Unlike Transitional Cell Carcinoma, which is the most common type of bladder cancer, bladder SCC is usually diagnosed with advanced stage cancer and has a poor prognosis. Treatment is usually radical cystectomy with adjuvant treatment like chemotherapy and/or radiation.
Adenocarcinoma of the bladder is unusual as it comprises around 1-2% of bladder tumor cases. They originate from the glandular elements of the bladder wall and are related to chronic inflammation of the bladder or a bladder exstrophy. Different diagnosis is needed in order to determine primary bladder adenocarcinoma as opposed to metastatic adenocarcinoma which refers to adenocarcinoma that has involved the bladder from external sites such as the bowel and prostate. Management is largely surgical, and in some instances, bladder cancer chemotherapy regimens that are used for colon cancer are warranted.
Non-Muscle Invasive Bladder Cancer (NMIBC) pertains to bladder malignancies that have not invaded the bladder’s muscle wall. NMIBC includes Stage Ta (superficial papillary tumours), Stage T1 (tumours that penetrate the lamina propria), and carcinoma in situ (CIS), which are flat, high-grade tumours confined to the surface lining. It is estimated that 75 to 80% of patients diagnosed with bladder cancer have NMIBC making it the most common type of bladder cancer diagnosed.
The treatment of NMIBC is TURBT (Transurethral Resection of Bladder Tumour) which is done to the patient using an endoscope to see the patient’s bladder and remove the tumour. After the TURBT is performed, the chance for the patient’s bladder cancer to reoccur is lessened, and the chance for the cancer to spread is lessened if the instillation of the medication takes place. Although NMIBC is the most common type of bladder cancer and is the least invasive, if the tumours are of high-grade, it is imperative that these tumours be treated as aggressively as possible.
Muscle Invasive Bladder Cancer, Stage T2 and beyond, is when cancer has metastasized to the muscle wall of the bladder (the detrusor muscle). Thanks to the elevated muscle layer involvement, MIBC can be an order of magnitude more aggressive than Non Muscular Invasive Bladder Cancer (NMIBC). In addition to the radical cystectomy (and removal of the bladder) that is performed, the chemotherapy for MIBC undergoes neoadjuvant (given before the start of the cystectomy) and is, more often than not, of the aggresive cisplatin framework. In fact, MIBC occurs in 25 % of individuals at the start of their bladder cancer. To add to the accursed impacts of MIBC, in particular, there is a large cohort of NMIBC patients that can, and often do, progress to MIBC while undergoing treatment, particularly those individuals that are suffering from high grade T1 tumours or Carcinoma In Situ (CIS).
The management of MIBC Patients is an arduous, multifaceted process that requires input from various specialties like urology, medical as well as radiation oncology. Taking Dr. Vikas Singh’s expertise in laparoscopic and open radical cystectomy along with his training as a uro-oncologist, he is hands down the best in MIBC management in Central India.
Bladder cancer is staged using the TNM system where T is the depth of tumor invasion, N is regional node involvement, and M is distant organ metastasis. Of these, the T stage is the most important. The T stage is assessed using the TURBT specimen that pathologists evaluate intra-operatively.
Stage | T Category | Description | Treatment | 5-Year Survival |
Stage 0 (CIS) | Tis / Ta | Flat CIS or papillary tumour on bladder lining only | TURBT + BCG intravesical therapy | ~95% |
Stage 1 | T1 | Into lamina propria but not muscle | TURBT + re-TURBT + BCG or chemotherapy | ~70–80% |
Stage 2 | T2 | Invades into or through bladder muscle (detrusor) | Neoadjuvant chemo + radical cystectomy (or bladder-preserving TMT) | ~45–65% |
Stage 3 | T3–T4a | Perivesical fat, prostate, uterus, vagina involved | Neoadjuvant chemo + radical cystectomy + adjuvant if needed | ~35–50% |
Stage 4 | T4b, N+, M+ | Pelvic wall, regional nodes, or distant metastasis | Platinum-based chemo + immunotherapy; palliative surgery if needed | ~5–15%v |
Stage 0 includes two different tumor types. Ta tumors have papillary projections that extend into the bladder cavity without deeper invasion. Ta tumors are mostly low grade and low risk for muscle invasion, but they are highly recurrent. CIS tumors are flat and from the first layer of the bladder. CIS tumors, although superficial, are also high-risk tumors due to their propensity to advance to muscle invasion if aggressive treatment is not initiated. For Ta tumors and CIS, TURBT is used, but CIS also requires immunotherapy to the bladder, also known as BCG instill, due to high tumor progression risks if not treated.
Stage 1 (T1) bladder cancer starts to penetrate beyond the urothelium and breaching the lamina propria, the thin connective tissue lining, and have yet to breach the muscular sub-wall. T1 tumours are thus classified as Non-Muscle Invasive tumours, albeit with a far greater risk than Ta tumours; especially high-grade tumours with concomitant CIS, or those demonstrating T1b lamina propria deep invasion. T1 tumours are classified as high-risk NMIBC and are thus managed more aggressively. In high-grade T1 tumours, a second TURBT (re-TURBT 2 to 6 weeks following the first) is performed to ensure complete tumour excision and to facilitate more accurate tumour categorisation. Maintenance therapy with BCG for beyond one year and up to three years is prescribed in such cases. In cases of very high-risk T1 tumours, and especially those that are unresponsive to BCG, radical cystectomy is done early.
Stage 2 (T2) signifies the onset of muscle-invasive bladder cancer. The inner half of the bladder muscle is known as superifical. The outer half of the muscle is known as deep. The approach for managing muscle-invasive bladder cancer (MIBC) is significantly dissimilar to managing non-muscle invasive bladder cancer (NMIBC) cases. For MIBC, the common practice is the administration of 3 to 4 cycles of gemcitabine + cisplatin (GC) or the methotrexate, vinblastine, adriamycin, and cisplatin (MVAC) and radical cystectomy. In the case of NACT, it is observed that the long survival is improved to 5 to 8% by eradication of NCMD which cannot be visualized by imaging. For patients preferring to avoid radical surgery, trimodality therapy (TMT) TURBT followed by chemotherapy and radiation, is a recommended bladder cancer treatment with evidence emonstrating its long-term effectiveness.
Stage 3 bladder cancer makes its way into the bladder’s wall and into perivesical fat and beyond. Men will experience cancer expanding into adjacent pelvic organs which notably include the prostate and seminal vesicles, while women will experience cancer expansion to the bladder as well as the uterus and vagina. The extension of cancer to these organs includes (T3 and T4a). There are, however, curative potential even at this stage with treatment options of radical cystectomy and neoadjuvant chemotherapy with the posterior pelvic exenteration and removal of all of the reproductive organs (including the uterus and ovaries) for women and for men, radical cystoprostatectomy. The surgical removal of the bladder and prostate will result in the need of urinary diversion, while construction of a urinary conduit (ileal) will also be necessary.
Stage 4 bladder cancer includes regional lymph node metastasis and distant metastasis. The most common sites of distant metastasis are the lungs, liver, and bones. Stage 4 bladder cancer is most often}< not curable and systemic therapies more effective than what we had 10 years ago. First line treatment remains cisplatin based combination chemotherapy. Patients who are cisplatin ineligible can have carboplatin combination chemotherapy, or monotherapy with gemcitabine. For the patients on the chemotherapy and have demonstrated no disease progression, second line treatment can have maintenance avelumab and chemotherapy. For all of these second line therapies, maintained second line therapies, and addition of enfortumab vedotin, patients can receive second line of the antibody therapies or newly approved monoclonal antibody therapies. New injuries of the monoclonal antibodies toward a new antibody space are monoclonal avelumab.
Painless hematuria is the strongest indicator of bladder cancer and is the most common first symptom of bladder cancer. Hematuria occurs in 80 to 85% of bladder cancer cases at the time of diagnosis. Hematuria can be a first and even the only symptom of early-stage bladder cancer. The blood can cause the urine to be red, pink, and brown or be present without a visible color change and only be detected during a microscopic urine examination. The bleeding is often intermittent, which can mislead a patient to conclude the problem has spontaneously resolved, yet the issue can last for months or even years.
The presence of blood in urine has to be taken extremely seriously. An adult patient has hematuria caused by bladder cancer until proven otherwise. In India, the most common cause of preventable bladder cancer deaths is the delay of an investigation. Hematuria has to be investigated with a cystoscopy and an imaging of the entire urinary tract. If you see blood in your urine, contact Dr. Vikas Singh immediately.
Bladder cancer, primarily carcinoma in situ (CIS), can lead to irritative bladder symptoms: urinary frequency (an increase in how often a person needs to urinate), urgency (a strong, sudden, or difficult-to-defer need to urinate), and dysuria (pain correlated to urination). These symptoms are often conflated with symptoms of urinary tract infections (UTIs). Due to this, many patients are incorrectly subject to repeated treatment cycles involving antibiotics. Due to the imposing nature of irritative urinary symptoms, if they persist or recur in the absence of a positive urine culture after antibiotics, bladder cancer or CIS need to be considered, and this can only be done with cystoscopy.
If a burning or stinging feeling occurs during urination that cannot be explained by a bacterial UTI or that persists after an antibiotic course, this would necessitate an investigation of the cause. While inflammation during infection would cause dysuria, high grad bladder cancers can irritate the bladder lining as well and cause this and not be caused by an infection. If the burning urination continues despite various antibiotic treatments, and the urine cultures that are taken are negative for bacteria, a referral to a urologist should be made.
In a patient with risk factors for bladder cancer (older age, smoking history, previous episodes of hematuria), persistent lower back, pelvis, or flank pain should not be classified as musculoskeletal pain. Cause of these pain symptoms may be due to locally advanced bladder cancer that has caused the pelvic side walls to become involved as well as upper urinary tract obstruction caused by the tumor blocking the ureteral openings. In this context, the two primary techniques of investigation are a CT scan and cystoscopy.
If you lose more than 5% of your body weight over a few months and feel tired all the time, you may have advanced bladder cancer. The metabolic effects of a growing cancer and the inflammatory cytokines cause symptoms similar to the advanced disease and explain the fatigue. Symptoms of bladder cancer and weight loss with fatigue symptoms should be investigated thoroughly and quickly.
The Transurethral Resection of Bladder Tumour (TURBT) is both a diagnostic and a therapeutic method used to treat bladder cancer. Non-invasive bladder cancer surgery is performed to achieve a pathologic diagnosis that triggers the management of subsequent treatment pathways. At the Kokilaben Hospital in Indore, Dr. Vikas Singh combines the use of modern resectoscopes and high-definition resectoscopy, achieving complete resection of bladder tumors, yet of the pathologic specimen, with minimal artifacts, thus providing the pathologic tissue.
TURBT is indicated for:
Step 1 – Anaesthesia: TURBT is done under spinal or general anesthesia, meaning you are either numb from the waist down or completely asleep. There is no cutting of the skin and the entire procedure is done via the urethra which is the natural passage for urine.
Step 2 – Cystoscopy and Assessment: A Rigid telescope with a working channel, called a resectoscope, is used. Against the bladder walls, The resectoscope is inserted trans-urethrally and Dr. Vikas Singh examines the whole bladder including all the walls and performs the same with the bladder neck and the ureter. Dr. Singh records tumours as to their measurements, their locations, and their appearances and performs a constant topographic survey of the bladder.
Step 3 – Tumour Resection: The resectoscope’s electrosurgical loop cuts the tumor in layers – surface tumor, then the tumor base, then the base tumor’s surrounding muscle. Each slice is collected for pathology. The muscle temrs the pathologist if the tumor is indeed non muscle invasive. Therefore, in order for true non-muscle invasiveness to be pathologically confirmed, at least one layer of the detrusor muscle must be included in the specimen.
Step 4 – Haemostasis: After the tumor removal, the surgery site is examined visually. Bleeding points are bound using the electrosurgical loop so that a dry, controlled surface is maintained.
Step 5 – Immediate Intravesical Chemotherapy: For patients with low or intermediate-risk NMIBC, a single dose of the intravesical antineoplastic MMC can be performed shortly after the TURBT (within the first hour of the procedure). As a post-surgery supplement, MMC intravesical instillation can help with the destruction of cells released by resection during TURBT. The implantation of MMC has proven to be an improvement over the TURBT procedure alone and has been shown to reduce recurrence by 15 to 20%.
Step 6 – Catheter Placement: We place a urinary catheter to drain the bladder post procedure. The bladder is left catheterized and is flushed with saline for the first 12 to 24 hours. The urinary catheter is removed the following day.
Stage 0 and Stage 1 bladder cancer is treated using a combination of TURBT and intravesical therapies to remove the tumor, dissuade reoccurrence, and reduce the likelihood of the cancer advancing to a more aggressive, muscle-invasive state.
BCG (Bacillus Calmette-Guerin) Intravesical Immunotherapy: For bladder cancer, the most significant and beneficial intravesical agent is BCG. BCG is the live attenuated form of Mycobacterium bovis, which is the bacterium used in the BCG vaccinations for tuberculosis. After mutating into a genital BCG and being introduced into the bladder, the BCG forms a local immune response to the entire lining of the bladder that causes cell death to the remaining cancerous cells. It also “educates” the immune system to detect and destroy any newly formed cancerous cells in the bladder in the future. BCG therapy involves weekly instillations for six weeks, followed by a maintenance schedule of three weeks at 3, 6, 12, 18, 24, 30, and 36 months. The entire 3 year schedule of BCG instillations is recommended by both the American and the European urological societies.
Intravesical Chemotherapy (Mitomycin-C, Epirubicin, Gemcitabine): Intermediate-risk NMIBC requires instillation of chemotherapy agents in the bladder through a catheter either on a single occasion shortly after the TURBT procedure, or on a weekly basis at an outpatient setting. The agents go to work to kill the cancerous cells of the bladder lining. This method is also employed on the lower-risk tumours instead of BCG, or when BCG is either unavailable or poorly tolerated.
Re-TURBT for High-Grade T1: For T1 high-grade tumors, guidelines worldwide, considering that studies show that the high grade T1 tumors are found to be understaged in up to 45% of the cases, recommend a second TURBT (re-TURBT) 2 to 6 weeks after the first resection. (Residual tumors or muscle invasion are commonly found in repeated audits of re-TURBT). Re-TURBT is used to complete the original resection, restate the stage, and subsequently improve the BCG outcome.
Early Radical Cystectomy for BCG-Unresponsive High-Risk NMIBC: Patients with high-risk NMIBC (particularly T1G3/Grade Group 3 with CIS, or BCG-unresponsive CIS after adequate BCG) who have not responded to intravesical therapy face a significant risk of muscle invasion and death from bladder cancer if the bladder is not removed. Early radical cystectomy – though a major operation – offers the best chance of cure for these patients. Dr. Vikas Singh presents this option transparently and discusses the timing and type of urinary diversion appropriate for each patient.
The definitive treatment for muscle-invasive bladder cancer requires a major surgical and/or oncological intervention. The two primary approaches are:
Radical Cystectomy (Surgical Removal of Bladder): Radical cystectomy is the gold standard surgical treatment for MIBC. In men, this involves removal of the bladder, prostate, seminal vesicles, and regional pelvic lymph nodes (radical cystoprostatectomy). In women, the bladder, urethra, uterus, ovaries, and anterior vaginal wall are removed (anterior pelvic exenteration). Radical cystectomy is performed laparoscopically at Kokilaben Hospital by Dr. Vikas Singh – using minimally invasive keyhole techniques that significantly reduce blood loss, recovery time, and post-operative complications compared to open surgery.
Urinary Diversion After Cystectomy: After the bladder is removed, a new mechanism for storing and passing urine must be created. The two main options are: Ileal conduit (urostomy) – a segment of small bowel (ileum) is fashioned into a short conduit that connects the ureters to a stoma (opening) on the abdominal wall, through which urine continuously drains into an external bag. Orthotopic neobladder – a pouch is constructed from a larger segment of bowel, shaped to replace the bladder, and connected to the urethra – allowing the patient to urinate (with some effort) through the natural urethra without a bag. The choice depends on patient fitness, tumour anatomy (particularly whether the urethra is cancer-free), patient preference, and lifestyle considerations. Dr. Vikas Singh discusses both options in detail at the pre-operative consultation.
Neoadjuvant Chemotherapy: Cisplatin-based chemotherapy (gemcitabine + cisplatin or MVAC) given before radical cystectomy has been shown in multiple randomised trials to improve overall survival by approximately 5 to 8% – making it the standard of care for cisplatin-eligible patients with Stage 2 and Stage 3 bladder cancer. Dr. Vikas Singh coordinates with the medical oncology team to arrange neoadjuvant chemotherapy before planned cystectomy.
Trimodality Therapy (TMT – Bladder Preservation): For selected patients with MIBC who prefer bladder preservation or are not fit for radical cystectomy, trimodality therapy (maximal TURBT + concurrent chemotherapy + radiation therapy) is an evidence-based alternative. TMT has been shown in prospective studies to achieve survival rates comparable to radical cystectomy in carefully selected patients. However, patients who choose TMT require very close surveillance for recurrence in the preserved bladder – and must accept the possibility of urgent cystectomy if the cancer recurs invasively.
Metastatic bladder cancer requires systemic therapy – treatment that reaches cancer cells anywhere in the body. The treatment landscape has been transformed in recent years by the addition of immunotherapy and targeted agents:
Yes – particularly when diagnosed at an early, non-muscle-invasive stage. Stage 0 and Stage 1 bladder cancer have five-year survival rates of 70 to 95% with appropriate treatment and surveillance. Even Stage 2 and 3 MIBC can be cured with aggressive multimodal treatment including chemotherapy and radical cystectomy in many patients. Stage 4 metastatic bladder cancer is generally not curable but increasingly manageable with modern immunotherapy and targeted agents.
TURBT is a minimally invasive endoscopic procedure performed entirely through the urethra – no external incision is made. It is performed under spinal or general anaesthesia and takes approximately 20 to 60 minutes. Most patients go home within 1 to 2 days. It is not “major surgery” in the conventional sense – there are no cuts, no stitches on the skin, and recovery is significantly faster than for conventional surgery.
BCG (Bacillus Calmette-Guerin) is a live, weakened bacterium instilled directly into the bladder through a catheter as an immunotherapy treatment after TURBT. It triggers a local immune response in the bladder that destroys remaining cancer cells and reduces recurrence. BCG is the most effective treatment for preventing recurrence and progression in high-risk NMIBC. It is given as weekly instillations for 6 weeks (induction), followed by maintenance instillations over 1 to 3 years.
Yes – people live active, fulfilling lives after radical cystectomy with urinary diversion. The two main diversion options are: an ileal conduit (urostomy bag), where urine drains continuously into a small external pouch on the abdomen; and an orthotopic neobladder, where a new bladder is fashioned from bowel and connected to the urethra, allowing urination through the natural passage. Most patients adapt well to their chosen diversion. Dr. Vikas Singh provides detailed counselling about both options, including meeting with a specialist stoma care nurse, before surgery.
This depends on the risk category of your tumour. Low-risk patients need cystoscopy at 3 months, then annually for 5 years. Intermediate-risk patients need cystoscopy at 3 months, 9 months, then annually. High-risk patients need cystoscopy every 3 months for the first 2 years, then every 6 months for years 3 to 5, then annually. Every follow-up cystoscopy is important – do not skip or delay them. A cystoscopy takes approximately 10 to 15 minutes and is typically well-tolerated with local anaesthetic gel.
Yes – cigarette smoking is the single largest risk factor for bladder cancer, responsible for approximately 50% of cases in men and 30% in women. The carcinogens in cigarette smoke are absorbed into the bloodstream, filtered by the kidneys, and concentrated in the urine – which means they are in constant contact with the bladder lining, causing DNA damage over years of exposure. If you currently smoke and have received a bladder cancer diagnosis, stopping smoking is the single most important thing you can do to reduce your risk of recurrence. Dr. Vikas Singh can provide smoking cessation counselling and referral to support programmes.
Non-muscle invasive bladder cancer (NMIBC) is confined to the inner lining of the bladder and has not grown into the muscular wall. It is treated with TURBT and intravesical therapy, and the bladder is preserved. Muscle-invasive bladder cancer (MIBC) has penetrated into or through the bladder’s muscular wall – requiring a fundamentally different approach involving chemotherapy and radical cystectomy (or trimodality therapy). The distinction between NMIBC and MIBC is made by the pathologist examining the TURBT specimen under the microscope.
For non-muscle invasive bladder cancer, yes – the bladder is always preserved. TURBT removes the tumour endoscopically, without any external incision or removal of the bladder. For muscle-invasive bladder cancer, bladder preservation is possible through trimodality therapy (TMT) – maximal TURBT, followed by concurrent chemotherapy and radiation – in carefully selected patients. However, for most patients with MIBC, radical cystectomy provides better cancer control and remains the gold standard. Dr. Vikas Singh discusses both options honestly and helps patients make informed decisions based on their clinical situation.
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