Diagnosis and Treatment
To diagnose bladder cancer, we start by taking a detailed medical history and performing a physical examination. We may also look at a urine sample under a microscope to see if you have abnormal bladder cells and to rule out the possibility of an infection. We can examine the lining of the bladder with a cystoscope, a flexible viewing instrument that we insert through the urethra.
If we see abnormal bladder cells, we may perform a biopsy or remove the tumor (called resectioning). We use a resectoscope, a flexible viewing instrument with a wire loop on the end, to remove a sample or the whole tumor. We may also perform imaging scans such as magnetic resonance imaging, computed tomography, intravenous pyelogram, bone scans, and chest X-rays.
Part of diagnosing bladder cancer is determining the stage of the tumor. Staging affects your treatment and prognosis. There are five stages of bladder cancer:
- Stage 0 (also called noninvasive or in situ): Cancer cells are only on the surface of the inner lining of the bladder.
- Stage I (superficial, non-muscle-invasive): Cancer cells are only in the inner lining of the bladder.
- Stage II (muscle-invasive): Cancer cells have spread into the muscle wall of the bladder.
- Stage III (muscle-invasive): Cancer cells have spread into the muscle wall of the bladder as with Stage II and also into the fatty layer surrounding the bladder and the reproductive organs (e.g., prostate, uterus, or vagina).
- Stage IV (metastatic): Cancer cells have spread beyond the bladder to lymph nodes and/or other parts of the body.
At Mount Sinai, we work closely with you to develop a customized treatment plan that takes into account your age, medical history, and overall health. We also consider the type, location, grade and stage of your cancer; your expectations; and your preferences and tolerance for certain procedures and therapies.
Stages 0 and I bladder cancers are generally manageable. We remove these tumors with a narrow, lighted tube with a cutting instrument (called a resectoscope). However, these tumors can recur frequently. For this reason, we monitor you closely by conducting periodic cystoscopies and urinalyses. If the rate of reoccurrence becomes excessively high, we may deliver medicine directly into the bladder using a catheter (intravesical chemotherapy) to destroy any existing tumors or prevent new ones from developing. For cancers stages 0 and I, we typically use a chemotherapeutic agent such as mitomycin. For high grade tumors, we are more likely to use bacillus calmette-guerin, an immunotherapeutic vaccine.
For Stages II and III, the standard treatment is removing the bladder (radical cystectomy). In men, we may remove the prostate as well; in women, we may remove the urethra, uterus, fallopian tubes, ovaries, and anterior vaginal wall. We can also take out the tumor while preserving healthy tissue and bladder function using nerve-sparing surgery and a combined-modality approach. This combined modality includes separating the bladder tumors from the bladder wall (transurethral resection of bladder tumors), partial bladder removal (cystectomy), chemotherapy, and/or radiation. We often perform radical cystectomies and partial cystectomies with robot-assisted procedures. This approach allows us to observe much more clearly than with traditional open surgery. We can see around corners and can view the smallest nerves and vessels. Robot-assisted cystectomies involve smaller incisions and less scarring, decreased pain and blood loss, shorter hospital stays, and quicker recovery. After a radical cystectomy, we can perform advanced reconstructive procedures such as continent diversions to create new bladders (neobladders) from sections of the small intestine.
About a quarter of all bladder cancer patients have metastatic bladder cancer (Stage IV cancer that has spread to one or more other organs) when they are initially diagnosed. It can be very difficult to remove all of the cancer, so our goal is often to slow tumor growth and help you feel better. We typically start with chemotherapy to shrink the tumors, followed by surgical removal of the tumors. For some patients, we may administer chemotherapy directly to the bladder during surgery. Our physicians have the advanced training and experience to ensure the precise timing and dosing of these medications.
We can also use radiation therapy after surgery to destroy any remaining cancer cells. The Division of Interventional Radiology at the Mount Sinai Health System—one of the first in the country to provide image-guided therapy—offers the most advanced interventional radiology techniques and technology.