Usually, it is the progressive stage of the tumour that is the main factor in the choice of initial treatment for bladder cancer. It takes into account the depth of bladder tumour implantation in the bladder wall and the possible remote swarming of the bladder.
Also considered are the size of the tumour, the malignancy cell grade and the patient’s personal history, comorbidities and age.
It is important to consider the treatment of localized bladder cancers, those that have not metastasized to the lymph nodes or organs at a distance from the bladder as opposed to metastatic and advanced tumours.
In the non-metastatic localized tumour group, patients with superficial bladder tumours and those with tumours that infiltrate the bladder muscle will be considered.
Superficial bladder tumours
These are tumours that do not infiltrate the bladder muscle.
In this group, patients with a low-grade superficial tumour will be further distinguished from those with an aggressive superficial tumour.
Low-grade superficial tumours
These are usually patients whose tumour is infected with the Ta factor, i. e. a tumour implanted at the level of urothelium but which has not yet passed through the basal membrane to infiltrate the chorion.
Low-grade superficial tumours are low-grade malignancies.
This type of tumour, whether single or multiple sites, is usually healed by trans-urethral resection of a bladder tumour.
However, there is a risk of recurrence or even further progression of the disease to more aggressive aspects.
After the transurethral resection of the bladder tumour, rigorous monitoring is therefore instituted to allow for the earliest possible detection of any recurrence.
This monitoring protocol is based on urinary cytology and endoscopy, which is usually a flexible bladder fibroscopy performed in an outpatient setting.
The rhythm of this monitoring is to carry out the first control by cytology and flexible fibroscopy 3 months after the initial resection of the bladder tumor.
If there is no recidivism, the 2nd control takes place 6 months after the first one and then again if there is no recidivism, the controls take place at intervals of one year every 5 years.
It is also recommended that a uroscanner be performed every 2 years to verify the absence of urothelial tumour transplantation in the upper urinary tract, since it has been seen that the bladder tumour is in fact a urothelial tumour and that the location can reach the entire urothelium, i. e. the renal cavities, ureters and also the ureters.
In the event of recurrence, after transurethral resection of the recurrent bladder tumour, and provided that the anatomopathological examination confirms that it is still a low-grade superficial tumour, treatment with endovesical instillation is indicated to avoid and limit the risks of subsequent recurrence. For low-grade superficial tumours, the choice is usually to perform intravenous chemotherapy with instillations of Mitomycin (Amestycine).
Some urologists routinely instigate amethycin at the time of initial endoscopic resection, at the end of the procedure.
This early postoperative instillation (IPOP) can only be carried out in the case of endoscopic resection involving a small volume localization, less than 3 cm in diameter, provided that the resection has remained superficial and has not penetrated the bladder wall too deeply.
Usually these low-grade superficial bladder tumours are of good prognosis and this disease can be controlled by natural interventions. It is exceptional for this indication to have to resort to complete bladder removal, i. e. to perform a total cystectomy.
This may, however, be necessary if the tumour cannot be controlled by natural pathways because the localisations are too numerous and bulky, and it may also be necessary in the case of multiple and iterative resections of bladder tumours, since bladder scarring was carried out in a pathological manner and resulted in a small sclerose bladder that has lost all reservoir capacity and caused major discomfort in the patient.
Aggressive surface tumours
Aggressive superficial tumours are those patients with a high-grade malignancy tumour and/or whose tumor has crossed the basal membrane to invade the chorion.
These patients are therefore patients with a Ta, N0, M0 high grade cell tumour or T1, NO, M0 whatever the cell grade. The risk of recurrence after initial transurethral resection of such an initial tumour is greater.
For these aggressive superficial tumours, it is recommended that one month after the first intervention a new transurethral staging resection be performed by resecting more deeply at the foot of the initial tumour and also by taking biopsies at the bladder level at a distance to look for carcinoma in situ.
If on iterative staging resection, there is infiltration of the bladder muscle, then it is returned to the treatment of infiltrating bladder tumours which will be examined later.
If the superficial nature of the tumour is confirmed, given its aggressive nature, it should be considered immediately without waiting for recurrence of treatment with intravenous instillations, and it is usually BCG intravenical instillations that are indicated.
For specific cases of carcinoma plan in situ (CIS), it is advisable to follow a BCG intravenical instillation protocol after transurethral resection of the bladder tumour.
It is usually a single protocol of 6 instillations to be performed every week. The duration of this treatment is therefore 6 weeks.
It should be noted that the BCG treatment protocol has more side effects than the MITOMYCINE intravenous instillation protocol. This carcinoma in situ is easily exposed to the risk of recurrence and, above all, to the risk of developing an infiltrating tumour with metastatic potential.
In case of recurrence of these aggressive bladder tumours, after BCG intravesical instillation protocol, and precisely because of their aggressive nature, radical cystectomy type surgery may be indicated.
Treatment of localized and infiltrating tumours of the bladder
These tumours are T2 and T3, N0, M0.
These are tumours that have invaded the muscle layer of the bladder wall.
Trans-urethral resection of these bladder tumours is usually their first treatment, but it is especially useful in determining the extent of cancer.
It is illusory to expect to have cured infiltrating cancer by a simple endoscopic resection, even if this may be the case in too few of these patients.
The treatment of infiltrating bladder tumours is indeed the radical cystectomy, i. e. removal of the entire bladder. The regional lymph nodes of the bladder drainage lymph nodes are also removed during the procedure and subjected to anatomopathological examination. Very few patients have a bladder tumor which is a reasonable indication for partial cystectomy.
Although the preoperative extension assessment of this cancer did not show any lymph node spread or to surrounding organs outside the bladder, the aggressiveness of infiltrating tumours of the bladder is such that small metastases that cannot be detected by current imaging methods may have spread throughout the body.
For this reason, a number of practitioners prefer chemotherapy prior to surgery (neo-adjuvant chemotherapy) or after surgery (adjuvanted chemotherapy) to reduce the risk of recurrence of this bladder cancer.
The current preference is for neo-adjuvant chemotherapy, given before surgery because scientific studies have shown that the survival of patients who were treated with chemotherapy and then surgery was greater than that of patients who were treated by surgery alone.
When neo-adjuvant chemotherapy is decided, the date of surgery is delayed.
This is usually not an oncologic problem since chemotherapy reduces the volume of bladder cancer, but ongoing chemotherapy monitoring is necessary if the tumour continues to progress significantly during chemotherapy.
Radical removal surgery, radical cystectomy is the reference treatment for infiltrating bladder cancer.
However, for patients who refuse this mutilating surgery, the alternative is to perform a new transurethral resection of the bladder tumour, as complete as possible, followed by a concomitant radiochemotherapy protocol. The healing results are lower than those of surgery. Usually, patients who recur in bladder cancer after concomitant radiochemotherapy can theoretically be caught up with total cystectomy-type removal surgery, but in practice the surgery performed at that time can only in a very small number of cases control the carcinologic evolution.
In patients with an infiltrating bladder tumour in which heavy surgical intervention cannot be considered because of their age and/or medical history and comorbidities, local procedures such as trans-urethral resection, irradiation, chemotherapy alone or in combination remain the only possible options.