Bladder Tumours Urology Patient Information Leaflet Page 1
Bladder Tumours You have just been informed that you have a bladder tumour (cancer). Bladder growths vary in severity and can range from a minor inconvenience to a serious condition. This leaflet is designed to give you the facts about your condition. We believe that time spent understanding the disease will reduce your fears and help you to know what to expect. What is the bladder? The bladder is a hollow muscular organ which acts like a balloon, in that it expands to collect and store urine. Urine is made up of water and waste products that your body does not need. In normal health, the kidneys produce urine which then passes into the bladder via 2 tubes called the ureters. At regular intervals we feel the need to pass urine as the bladder fills. The urine leaves the bladder via another tube called the urethra. The male and female anatomy vary, in that the female exit tube for urine (urethra) is very short, while in the male it is much longer and passes through the prostate gland and penis before expelling the urine. The bladder is made up of 4 layers: The outer coat of peritoneum, which only covers the upper part of the bladder The muscle layer The submucous layer which contains the blood vessels, lymphatics and nerves The mucous membrane layer (inner lining) composed of cells which form a waterproof lining. What is a tumour? Our bodies are made up of structures called cells. In health, cells are constantly being replaced as they age. A tumour forms when the rate of replacement is too rapid or erratic. What causes bladder cancer? Usually the cause of bladder cancer is not known. Studies have shown that cigarette smoking is a potential cause and others note a higher incidence in people who work in the chemical, printing and rubber industries. There is some evidence to suggest that bladder cancer is up to 3 times more common in men than in women, and that it is rare before the age of 50. Other hereditary, environmental and genetic factors have also been linked to bladder cancer occurrence; however no conclusive information is available. Research into the causes of bladder cancer is ongoing and more will be known as new results are published. Page 2
What happens when a tumour is present? 70-80% of tumours simply grow on the surface of the bladder and do not invade into the deeper layers; such tumours are not a threat to life but can be troublesome because they may recur over the years. These are called superficial tumours. These tumours can be quite easily removed by an operation called a transurethral resection (see explanation later in leaflet). However 20-30% of tumours invade into the deeper layers of the bladder and these are more serious. These are called invasive tumours. Sometimes superficial tumours can change and become invasive tumours. After an initial transurethral resection, patients may have to undergo further resection or treatment. Before treatment can be planned, you may need some more tests. We realise that this is a very trying time for you and your family. However, it is important that we have a clear picture of what is happening so that we can decide the best treatment for you. What investigations will I have? Flexible Cystoscopy: - you may already have had this investigation by the time you read this leaflet. It involves passing a fine telescope into your bladder and inspecting the bladder lining. This is usually done under local anaesthetic as an outpatient procedure. Blood Tests: - some blood tests are done routinely to assess your general fitness. Others are concerned with the function of the kidneys and the nature of your current illness. Ultrasound Scan: - this is performed to look for any abnormalities within the urinary system such as the kidneys or ureters, to assess whether they have been affected by the presence of bladder cancer. CT or MRI scans: - these are performed in the more serious invasive tumours to assess the extent of the growth, and sometimes for surveillance of noninvasive tumours as they can form anywhere in the lining of the urinary system. What treatment may I have? Your treatment is planned to meet your individual needs. Listed below are possible treatments explained in very broad terms. You may need one or more of these treatments. Surgical removal of the tumour Transurethral Resection of Bladder Tumour (TURBT) We can remove most tumours completely with an instrument called a resectoscope. You will be given a general anaesthetic. Page 3
You will be admitted on the day of your surgery. You will be informed of this date in your admission letter, which will also contain details of any instructions you should follow prior to your admission. If you are taking Warfarin, Aspirin or Clopidogrel (Plavix ) on a regular basis, you must discuss this with your urologist because these drugs can cause increased bleeding after surgery. There may be a balance of risk where stopping them will reduce the chances of bleeding, but this can result in increased clotting which may also carry a risk to your health. This will, therefore, need careful discussion with regard to risks and benefits. You will be told before your discharge when these medications can be re-started safely. If you smoke, try to cut down or preferably stop, as this reduces the risks of heart and lung complications during and after the operation. Prior to your admission date, you will receive an appointment for preassessment to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations. Once admitted, you will be seen by members of the surgical team which may include the Consultant, Specialist Registrar, House Officer or your Named Nurse. Your admission letter will contain guidance about when you can eat and drink before your operation. Please ensure that you inform your surgeon in advance of your surgery if you have any of the following: An artificial heart valve A coronary artery stent A heart pacemaker or defibrillator An artificial joint An artificial blood vessel graft A neurosurgical shunt Any other implanted foreign body A regular prescription for Warfarin, Aspirin or Clopidogrel (Plavix ) A previous or current MRSA infection A high risk of variant-cjd (if you have received a corneal transplant, a neurosurgical dural transplant or previous injections of human-derived growth hormone) At some stage during the admission process, you will be asked to sign a consent form giving permission for your operation to take place, showing that you understand what is to be done and confirming that you wish to proceed. Please ensure that you have discussed any concerns and asked any questions you may have before signing the form. Either a full general anaesthetic (where you will be asleep throughout the procedure) or a spinal anaesthetic (where you are awake but unable to feel anything from the waist down) will be used. All methods of anaesthesia minimise pain; your anaesthetist will explain the pros and cons of each type of anaesthetic to you before your surgery. Page 4
The operation The tumour is shaved off the inside of your bladder. The fragments of tumour are washed out of the bladder and sent to the laboratory for analysis (results can take 10-14 days). Depending on the size and position of the tumour, it may be necessary to leave a catheter inside your bladder after the operation. Sometimes this catheter is irrigated with saline to wash away any blood from the area where the tumour has been removed, which will now be quite raw. When the bleeding has settled, a nurse will remove the catheter; this is usually on the day of, or the day after your surgery. Before the catheter is removed, it is normal practice in most patients to instil a special purple chemical (Mitomycin C) (see Chemotherapy later in this leaflet for more details); this reduces the risk of subsequent tumour recurrence in the bladder. This is left in place for one hour, usually on the day of surgery. Occasionally it may be necessary to leave the catheter in place for longer; if this is the case, your doctor will explain why it is necessary. You will normally be able to go home on the day of your surgery. If you need to go home with your catheter still in place, we will inform you of the arrangements for its removal. Please make arrangements to have a lift home available. What are the risks? Common (greater than 1 in 10): Mild burning or bleeding when passing urine, for a short period after the operation Temporary insertion of catheter for bladder irrigation Need for additional treatment into the bladder (including installation of drugs into the bladder), in an attempt to prevent recurrence of tumours Occasional (between 1 in 10 and 1 in 50): Infection of bladder requiring antibiotics No guarantee of cancer cure by this operation alone Recurrence of bladder tumour and/or incomplete removal Rare (less than 1 in 50): Delayed bleeding requiring removal of clots or further surgery Damage to ureters requiring additional therapy Injury to urethra causing delayed scar formation Perforation of the bladder requiring a temporary urinary catheter or surgical repair Hospital-acquired infection: Colonisation with MRSA (0.9% - 1 in 110) Clostridium difficile bowel infection (0.2% - 1 in 500) MRSA bloodstream infection (0.08% - 1 in 1250) Page 5
The rates for hospital-acquired infection may be greater in high risk patients, e.g. those with long term drainage tubes, after previous infections, after prolonged hospitalisation or after multiple admissions. What should I expect when I get home? When you leave hospital, you will be given a draft discharge summary of your admission. This holds important information about your inpatient stay and your operation. If you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge. When you get home, you should drink twice as much fluid as you would normally for the next 24-48 hours; this helps to flush your urinary system through and to minimise any bleeding. You may notice some burning, frequency or pain in your lower abdomen initially but this usually settles after a few days. Please avoid any strenuous exercise or heavy lifting for at least 2 weeks or until after the bleeding has settled. If you develop a fever, severe pain on passing urine, inability to pass urine or worsening bleeding, you should contact your GP immediately. It is your responsibility to ensure that you are fit to drive following your surgery. You do not normally need to notify the DVLA unless you have a medical condition that will last for longer than 3 months after your surgery and may affect your ability to drive. You should, however, check with your insurance company before returning to driving. Your doctors will be happy to provide you with advice on request. You will be contacted at home with the histology (laboratory testing) results and follow-up plan, which may be one of the following options: Intravesical Chemotherapy Sometimes tumours are so numerous or recur so rapidly that resection becomes difficult. To reduce the rate of formation, we sometimes put chemicals into the bladder (Intravesical). This is a type of chemotherapy. However, because it is instilled directly into the bladder, you should not experience the side effects usually associated with other types of chemotherapy. You will be asked to attend the ward on a weekly basis for 6 weeks; the nurse will then pass a small catheter into your bladder and instil the chemical. If you are to receive this treatment, you will be given more detailed information. Page 6
Intravesical Immunotherapy Immunotherapy is a treatment which uses the body s immune system to fight cancer cell growth; the drug most commonly used is Bacillus Calmette-Guerin (BCG). As with intravesical chemotherapy, immunotherapy is given initially once a week for 6 weeks, directly into the bladder via a catheter. It has its own side effects, and pre- and post-care requirements, all of which will be discussed with you before the treatment course starts. If you are to receive this treatment, you will be given more detailed information. Although most tumours grow on the surface of the bladder lining (superficial tumours), some are invasive and grow into the muscle layer. In these cases patients are seen by an oncologist (cancer specialist), and may need to have further treatment such as radiotherapy, chemotherapy and further surgery. Chemotherapy Unlike the intravesical chemotherapy given for superficial bladder tumours, this treatment is given directly into a vein via an injection or an infusion (drip). The chemotherapy passes around the whole body in the bloodstream. A course of treatment will be given over several weeks in a chemotherapy outpatient clinic. If you are to receive this treatment, you will be given more detailed information. Medication Please make sure before you come into hospital you have enough of your regular medication to take when you get home as it s unlikely that the medication prescribed by your GP or another hospital Consultant will be changed. Also please make sure you have a supply of painkillers to take when you get home. We recommend Paracetamol which can be purchased in pharmacies or supermarkets, alternatively whatever painkillers you normally take. Getting medication from the hospital pharmacy can sometimes take a long time as they are very busy and this will delay your discharge. Further Information If you have any questions, are unsure about any of the information provided in this booklet, or require any further information regarding your treatment or our services, please contact a member of our Urology team on one of the numbers listed below. Urology Nurse Specialists:- Monday Friday 08:00 16:00 Tel: 01384 456111 Extension 2873 or Mobile 07787512834 Out of Hours (16:00 08:00 Monday Friday) and at weekends Ward B6 Tel: 01384 244125 Ask to speak to the nurse in charge. If the nursing staff are unable to address your questions, they will suggest alternative contacts. Page 7
Other Resources www.cancerresearch.co.uk www.rcseng.ac.uk/patient _information www.patient.co.uk www.patientinformation.org.uk www.rcoa.ac.uk (for information about anaesthetics) www.prodigy.nhs.uk.pils www.nhsdirect.nhs.uk www.besttreatments.co.uk Page 8
www.nhs.uk This Information can be made available in large print, audio version and in other languages, please call 0800 0730510. Originator: Caroline Salt Date: November 2012 Version: 1 Date for Review: November 2015 DGOH Ref: DGOH/PIL/00617 Page 9