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Actos Bladder Cancer : The experienced urologist uses several techniques to improve his chances of removing tumors that are difficult to reach. He will often keep the bladder under filled. Although this may reduce visibility, it will allow the tumor to be closer to the resectoscope. Another technique is to place manual pressure on the bladder from above. This is done by an assistant or by the urologist himself. By pushing down from above, tumors at the dome are displaced downwards. An additional technique, for the male patient, is operating through a perineal urethrostomy. The urologist makes a surgical opening into the urethra between the scrotum and rectum, allowing the resectoscope to move further into the bladder, bypassing much of the urethra.

Another option would be to use a laser. Laser fibers are flexible and may be able to reach a difficult tumor. The tumor may be effectively destroyed with laser energy; a disadvantage is no specimen is obtained. Photodynamic therapy may afford additional results. With this novel technique, a chemical is instilled into the bladder, sensitizing the cancer cells to light energy. The entire bladder is then illuminated with laser light via a cystoscope. This treatment is not widely available at the present time and it is most effective for small tumors.

Bleeding is usually present, but rarely severe. Some tumors are more vascular than others and will bleed more. In addition, the resection will involve the bladder wall and vascularity varies here as well. Transfusions are not generally required unless an individual starts with a low blood count from previous bleeding or medical condition. Bleeding can be an on going concern until the bladder completely heals weeks later. Catheterization and irrigation may be required. Just a small amount of blood will change the color of urine red. Urine that is punch colored or the color of rosé wine generally is not serious and will clear on its own. When the urine has large amounts of blood in it, the appearance generally looks like tomato juice, indicating serious bleeding requiring medical attention.

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Bladder perforation may occur, especially with large tumors or those located on the lateral bladder walls. During resection of tumors on the lateral walls, the obturator nerve, which runs alongside the outside of the lateral bladder wall, may cause a strong muscle contraction. This contraction can abruptly move the bladder during a resection, resulting in a perforation. During resection of a large tumor with solid base, the urologist proceeds with deep resection of the tumor to remove the entire tumor and also determine whether or not it is a high stage tumor with muscle invasion. Bladder walls differ in size and integrity, and sometimes a perforation may occur. In addition, bladders which have previously been subject to some form of stress such as radiation or chemotherapy may have extremely poor integrity and are subject to pulling apart during a resection, resulting in a perforation. Bladder perforation is usually detected during the resection when the urologist sees fat (perivesical fat is located on the outside of the bladder). Sometimes, during a particularly bloody resection, the perforation may not be visible intraoperatively, but discovered when the lower abdomen becomes firm and distended (indicating that a large volume of fluid has passed into the abdomen). Small perforations are usually handled by stopping the procedure and maintaining a catheter for a week or more. Large perforations, especially those that communicate with the peritoneal cavity (the cavity that encases the bowels) generally require open surgical repair. Perforations can potentially spread cancer beyond the bladder.

Ureteral injury may occur when a tumor covers the ureter in the bladder. The ureter may be obscured by a bladder tumor, and the urologist may inadvertently resect it along with the tumor. In general, cutting current to remove a bladder tumor does not usually lead to long lasting problems as compared to cauterization, which is more likely to cause permanent blockage or obstruction of the ureter. If the urologist is working in the area of the ureter, he should avoid cauterization as much as possible. He may ask the anesthetist to inject an intravenous coloring agent which will turn the urine blue and allow visualization of the ureter. If he knows a ureter may be in jeopardy, he may insert a stent (a small plastic tube that traverses the ureter) for several weeks to allow the ureter to heal in an open fashion.

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Urethral injury is infrequent and is almost always in males. A stricture or narrowed area of the urethra may result from irritation or injury from the resectoscope pressing on the urethra. Individuals that develop strictures complain of difficulty urinating, experiencing a slow or split stream. Strictures are usually readily handled with a number of urologic procedures.

Bladder tumor “seeding” may occur during the procedure. As the tumors are resected, cancer cells are released into the irrigant which fills the bladder. These cells may implant in other areas of the bladder traumatized during the procedure. It should be understood that the bladder is generally filled with urine, and tumor cells can naturally implant at other locations even without surgery. Implantation can be lessened during surgery by avoiding injury to other bladder areas and by the use of adjuvant intravesical chemotherapy. There have been numerous studies over the past decade showing a number of chemotherapy agents can be effective in decreasing initial tumor recurrence, possibly by preventing seeding. Reduction in recurrence may however be short lived. Previously, it was common practice to obtain multiple random bladder biopsies at the time of initial tumor resection. This was recommended to rule out the possibility of hidden CIS. Understanding these biopsy sites may increase the possibilities of tumor recurrence by tumor seeding, biopsies are now often limited to areas adjacent to the tumors removed and suspicious appearing areas only. CIS can be ruled out by using cytology, or by obtaining biopsies during future cystoscopy after the tumor has already been removed. When dealing with low grade tumors, random biopsies of the bladder will rarely show cancer.

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