Cancer of the bladder lining range all the way from almost innocuous benign warty growths through lesions of increasing malignancy to solid ulcerating deeply invasive tumors. During an illness with bladder cancer, which may extend over very many years, there is a relentless progression from the benign to the more malignant end of the scale.
The disease is multi focal in origin, meaning that the whole mucosa from kidney to bladder is unstable and in pre malignant condition. This means that even if one tumor at point A in the bladder is successfully treated, similar lesions are very likely to appear at points B and C, and that continued surveillance is essential.
The association between exposure to certain industrial chemicals and the development of bladder cancer in heavy tobacco smokers and heavy coffee drinkers as well as in certain persons with some inborn error of tryptophan metabolism. All these circumstances, occupational, social, and metabolic, result in the excretion of chemical carcinogens in the urine. There are also other urinary carcinogens that have still to be identified.
Bladder cancer usually makes its presence known by hematuria. Other symptoms are increased frequency and urgency micturition, resulting from diminished bladder capacity, and finally local pain. The condition is diagnosed, assesses, and in early cases treated by cystoscopy the passage of a fiberoptic telescope along the uthera into the bladder under anesthesia.
Small Lesions and lesions that are still clearly towards the bening end of the spectrum can be treated satisfactorily by cystoscopic electrocoagulation. Larger lesions may require that this procedure be carried out through the open bladder, or, if the tumor is invisible but still comparatively localized, that the whole tumor bearing segment of the bladder be removed.
For still larger and more deeply invasive tumors, the first choice of treatment is usually megavoltage radiotherapy, which, although individually rather unpredictable in response, can often methods fail to control the disease, the final choice is total removal of the urinary bladder.
Such a procedure clearly requires some form of urinary diversion, either by implanting the ureters to drain into the sigmoid colon or by implanting them into an artificial bladder formed from an isolated loop of small intestine opening through the abdominal wall.
The former procedure subjects the patient to the risk of renal infections and biochemical disturbances, while the latter necessitates the constant wearing of an ileostomy bag. Bladder cancer is relatively slow growing and tends, to cause symptoms more by infiltration of adjacent organs than by distant metastases.
Total cystectomy is by any standard major surgery, with an appreciable operative risk and considerable port operative morbidity. However, the alternative, to leave such a patient untreated, condemns him to a particularly cruel and miserable death.