It is the second most common tumor in the urogenital system tumors. It is seen in men four times more than women. It usually occurs over the age of 50. The aniline group aromatic amines used in the paint and adhesive industry have been shown to bladder, digestive and skin through the urinary system, especially by irritating the bladder mucosa for many years and causing bladder cancer. These aromatic amines, 2-Naphthylamine, Benzidine and 4-Aminodiphenyl do not have direct bladder cancer-causing effects. Their metabolites are carcinogenic. After these substances enter the body, they are conjugated with sulfate and glucuronic acid in the liver and converted to neutral carcinogenic orthoaminophenols. While they are filtered through the kidneys and excreted in the urine, they are activated by the beta-glucuronidase enzyme and converted into active carcinogenic orthophenols. These active carcinogenic orthophenols affects (stimulates) the urinary mucosa for many years, producing the most bladder less and leading to multi-layer change epithelial cancer (transitional cell cancer) in the kidney collection systems and pool mucosa. The reason why it is more common in the bladder is that the urine is stored in the bladder and exposed to the effects of carcinogens for a longer period of time. In other parts of the urinary tract, urine flows into the bladder without waiting.
Bladder cancer is also observed in cows eating ferns in the eastern Black Sea region. People who drink the milk of these cows may also have bladder cancer. It is perhaps this reason that bladder cancer is more common in the eastern Black Sea than other regions. In a study conducted by Prof. Pamukçu, a veterinarian, he found that shikimic acid in ferns caused bladder cancer in cows.
The metabolites of tryptophan amino acid, which are normally found in the human body, are metabolized into the neutral carcinogen orthoaminophenols with the effect of sulfate and glucuronic acid by the metabolism of quinurine, quinurenic acid, 3 hydroxy quinurine and acetyl quinurine. They interact with the enzyme beta glucuronidase in the urine and are converted into active carcinogenic orthophenols. Also in these, it causes bladder cancer by irritating the urinary system mucosa for many years.
Bladder cancer is seen 3 times more than non-smokers. Smoking disrupts normal endogenous tryptophan metabolism, leading to bladder cancer.
Excessive phenacetin group and similar analgesics (painkillers) can cause bladder cancer due to the metabolites of the benzene ring in the structure of artificial sweeteners.
In diseases such as prostate enlargement, urinary tract stenosis (urethral stricture) that causes bladder failure to empty completely, residual urine in the urine can cause bladder cancer even if it does not harm the bladder without waiting. As urine will not be discarded in bladder pockets (bladder diverticulum), it may cause cancer again.
Irritations of bladder and kidney stones for many years can cause the urinary mucosa to turn into multi-layer flat epithelium and then cause multi-layer flat epithelial cancer (squamous epithelium).
One cm and smaller maggots that live in human bladder veins called chiistomia hematobium bilharzi pierce the bladder wall and lay their eggs under the mucosa, causing them to bleed in the urine and to multiply epithelial metaplasia (change) in the mucosa, causing squamous cell bladder cancer. This disease, which is seen especially in Egypt and some Arabic countries today, has been found in Mardin and its surroundings, while it has been rooted for 70-80 years.
Radiotherapy to the abdominal region, cyclophosphamide drug used for chemotherapy in general cancer treatment may affect the DNA of the cells of the bladder and lead to the development of cancer due to hyperchromia.
This indicates the probability of the causes of bladder cancer we have counted. There is not a certain rule that every pain killer or who uses artificial sugar, smoke, eat dyed food etc. will have bladder cancer.
94% of bladder cancers are transitional cell cancer (multi-layer change epithelial cancer), 5% are squamous cell cancer (multi-layer squamous cell cancer-epidermoid cancer), 1% are adenocancer (such as gastrointestinal cancer cells).
The bladder tumor is most often located on the side and back walls of the bladder floor where the urinary holes (ureter orifices) are opened. If it grows too large, it causes the patient’s kidneys to become obstructed by enlarging the urine holes (hydroureteronephrosis), the patient’s urea to rise, and if it keeps the bladder outlet, it can not urinate like a prostate.
Bladder tumors usually grow like a polyp towards the bladder lumen. If they are not operated, these small polyps grow and deepen towards the bladder wall as they look like cauliflower. If they are late, they spread to the surrounding tissues, intestines, prostate, glands, uterus and vagina. Meanwhile, it is spread in the intra-abdominal lymph nodes. While it is easy to treat with closed surgery at the beginning, in this case, all bladder should be removed even in the surrounding organs with open surgery. In addition, radiotherapy and chemotherapy are added to the treatment when appropriate. Of course, this spread is also related to the cell grade of the tumor. Bladder tumors with grade I cells are tumors that are more superficial and do not show recurrence tendency. II. In degrees, cells are a little more distorted atypical. These are low-grade papillary cancers. The tumor is larger, the papillae has become shorter in length, has progressed slightly deeper into the bladder wall, bladder wall. III. In degree tumors, the cells are degraded, papillae are shortened and spread deeply into the bladder wall. These are high-grade invasive bladder cancers. Spread to surrounding organs and lymph nodes usually occurred. The tumor that does not protrude in the bladder called carcinoma in situ (CIS) is quite malignant. It has the form of red areas like velvet in the bladder.
In bladder cancer, the patient complains of painless, clotted and visible (macroscopic) hematuria (blood from the urine). The blood in urine is intermittent. It is seen for a few days and not for a week. The patient should not think that he has recovered. Even if urine is visually clean, there are always blood cells microscopically. Clots are shapeless and red. The clot is always found. When blood is seen in the urine, the patient should not be in a hurry. Many urological diseases cause blood in the urine. However, it is appropriate to see the patient immediately to a urologist for diagnosis.
Complaints of dysuria (burning during urination), pollakiuria (frequent urination during the day), nocturia (waking for urine at night) are observed if the tumor holds the bladder outlet or ulcerates. There can be an urgent urination need. If the tumor obstructs the ureter holes in the bladder floor, no urine called anuria and urea height occur.
According to metastases (spreads), complaints about that organ can be seen.
Patient examination is usually normal. Nothing is found in the abdominal and finger-examination. But there is always blood in the urine test. If the infection is added, it appears in the urine leukocyte. The patient has anemia as there is a gradual loss of blood gradually. Sometimes the patient’s urea may be high.
For diagnosis, the drug kidney film (IVP) used to be diagnosed by filling the bladder with a catheter (cystography) is diagnosed with abdominal ultrasound today. Computed tomography and MR of the whole abdomen also make a diagnosis while showing the prevalence of the disease.
However, definitive diagnosis is made by cystoscopy (observation of the bladder with an optical device) and biopsy and pathological analysis.
Academic tests such as cytological examination of urine and NMP22 test in urine are unnecessary tests to be used in routine.
LDH (lactic dehydrogenase), CEA (carcinoembrionic antigen), Ig G and Ig A may increase in urine and blood. However, they do not have much importance since they do not have specific tumor markers.
Treatment of bladder tumors is surgery. In the early stage and in low grade tumors, the closed method is resected with a special optical device that shows the inside of the bladder with an electrical system (Transurethral bladder tumor resection-TUR Tm). This treatment is sufficient in 60-70% of patients who apply early. It should be noted, however, that bladder cancers tend to recur. These patients who undergo surgery should stop smoking, stay away from painted foods and beverages, do not use artificial sweeteners and pain medications, do not smear or smell adhesives. They should also drink plenty of water to extract 2 liters of urine per day to reduce the density of carcinogens that can be found in the urine. These patients undergo control ultrasound and cystoscopy once a year for 3 years, for a second year, every 6 months for a third year. If there is no relapse at the end of 5 years, the patient is considered to be completely cured. If relapse is seen in 30-40% of patients, TUR Tm is performed again. Control starts over again. These patients and their tumors in several foci have been given TUR Tm 10-15 days after surgery (when blood is not seen in the urine), a weakened tuberculosis vaccine (imminocyst) or chemotherapeutic agents (thiotepa, mitomycin) is given once a week for 6 weeks. The patient lies on his back. He changes his position every half hour, lies on his right side, left side and face, and urinates two hours later. Since the patient, who was given a tuberculosis vaccine only, carried live microbes, they were advised to make two or three urine in the hole of the toilet, immediately flush the toilet and soap their genitals after urine. Rarely, tuberculosis cystitis and egg inflammation may develop. These patients are treated with double tuberculosis medicine for 3 months. Those who receive intracavitary chemotherapy should have their blood counts checked weekly and their leukocytes checked. It may fall.
Laser treatment can also be applied to patients with the same group of superficial tumors. But TUR-Tm is more suitable.
Partial cystectoma surgery (removal of the tumor with the entire bladder wall) can be applied to the bladder anterior, lateral walls and larger tumors located on the hill.
For tumors that are not larger or larger than many bladders, the entire bladder is removed (total radical cystectomy surgery). To ensure the continuity of urine, ureters can be attached to the skin of the abdomen (ureterocutanostomy surgery), the ureters can be connected to a bowel segment in the abdomen and the other end of the intestine can be opened to the skin of the abdomen (ileal loop surgery), the ureters can be connected directly to the sigmoid, the last part of the large intestine (ureterosigmoidostomy surgery).
Radiotherapy and chemotherapy can be applied in advanced diseases.
Permanent nephrostomy (putting a permanent tube from the skin in the kidney) can be applied to patients who cannot be operated, who have progressed, urine holes are not able to urinate (anuria).
We wish you healthy days.
Prof. Ibrahim Bozkirli, M.D.