Superficial bladder cancer, or bladder cancer that has not spread to muscle; Bladder cancer that is confined to the bladder and has not spread to the bladder wall, that is, to the bladder muscle layer, also known as ‘NON-CASSE-INVASED’, refers to cancer that has not grown into the deep layers of the bladder wall. There are three stages of superficial bladder cancer according to the depth of spread. Stage Ta tumors are limited to the inner lining layer of the bladder. T1 tumors have spread to the connective tissue below the inner lining of the bladder, but not to the bladder wall muscle. Tis stage tumors, also known as cancer in situ (CIS), are limited to the inner lining of the bladder but are superficial tumors that carry a potentially high risk of spreading to the deeper layers of the bladder. Stage Ta and T1 tumors are usually grape-like or cauliflower-like (also called papillary) and grow towards the middle of the bladder, not into the deeper layers of the bladder. These tumoral structures can be removed with a method called transurethral resection of bladder tumor (TUR-MT). CIS, on the other hand, are superficial bladder cancer lesions limited to the inner lining of the bladder, showing a smooth, velvety-grass landscape, usually accompanying other stage tumors.
1- Transurethral Resection of Bladder Cancer (TUR-MT): It refers to the endoscopic surgical resection (removal) of superficial bladder cancer. With this method, it is performed for both diagnostic and therapeutic purposes, tumoral tissues are removed completely or partially, if possible, and the tissues are sent for pathological examination. An effective and accurate TUR-MT is important in determining the treatment process of the disease. In some cases, TUR-MT may be re-stretched after a few weeks (ReTUR-MT).
In TUR-MT, the patient is under general anesthesia or spinal anesthesia, the resectoscope is passed through the urethra and advanced into the bladder, and the tumoral tissues are duly resected (removed) with a special operating element. All visible tumors are scraped out, removed together with any additional tissue required for examination (biopsy), scraped areas and bleeding areas are cauterized. The TUR-MT procedure usually does not exceed 1 hour and requires a short hospital stay, and the urinary catheter remains inserted for a few days.
As with all surgeries, post-operative bleeding and infection may occur. Symptomatic infections are treated with antibiotics and you rarely need to stay longer in hospital. Perforation of the bladder during surgery is uncommon, but can happen if the tumor removal goes too deep. Punctures usually heal with a few days of exposure, but in some cases, open surgery and suturing of the bladder may be required. In some cases after the procedure, urethra and bladder damage may occur, which may cause scar tissue and stricture formation.
Although Ta and T1 stage (superficial) bladder tumors can be completely destroyed by this surgical procedure, some tumors frequently recur and may evolve into invasive (spread) cancer over time. -After MT (2-4 weeks), considering the result in pathology, it is decided to flush the bladder with drugs (intrabladder instillation) and is necessary in most of the patients.
Photodynamic Application (FDT): Photodynamic diagnosis (PDT) is an additional diagnostic method available in some centers. It is performed during transurethral resection of a bladder tumor. Photodynamic diagnosis makes cancer cells visible under violet light, enabling better detection and removal of tumors and reducing the risk of recurrence. Shortly before surgery, a catheter is inserted and the bladder is flushed with a solution of 5-aminolaevulinic acid or hexaminolaevulinic acid. The catheter is removed immediately after flushing. Cancer cells in the bladder process the active ingredient in the solution and become fluorescent under violet light. No side effects or complications have been reported for FDT.
Re-TUR-MT (Re-TUR-MT): In some cases, it may be necessary to repeat this surgical procedure 2-4 weeks after the operation.
Among these requirements:
Failure to properly and completely remove the procedure in TUR-MT
Absence of any muscle tissue in the tissue taken with TUR-MT. Incomplete or not enough base tissue is taken
In all T1-stage tumors
In all high-grade tumors (except primary CIS)
2- Bladder Washing-Bladder Instillation: As mentioned before, Ta and T1-stage tumors can be completely destroyed with TUR-MT, but some tumors can frequently recur and become invasive cancers. Intravesical instillation therapy (bladder flushing) should be considered in almost all patients after TUR-MT. Bladder instillation is the procedure of washing the bladder once a week for 4-6 weeks with appropriate immunotherapy or chemotherapy drugs 2-4 weeks after surgery. In intravesical treatment, drugs are administered directly into the bladder with the help of a probe, the patient keeps the drug in the bladder for 2 hours and then empties it into the toilet.
Single Dose Immediate Bladder Washing after TUR-MT-Single dose chemo instillation: If the tumor can be completely and safely removed with TUR-MT and there is no sign of invasive growth, a single dose of intravesical chemotherapy instillation should be performed immediately (within the first few hours) after surgery, and this is the rule. . Single-dose instillation is not performed if you have a tumor in more than one area, if the bladder wall needs to be removed from the deep, if there is a possibility that the bladder was perforated during resection, or if post-operative bleeding is very severe. Single-dose instillation destroys tumor cells floating in the fluid after TUR-MT and It is to destroy the residual tumor cells in the area where the removal process is performed and from small tumors that are overlooked. This reduces the risk of recurrence of the disease. The procedure is given through the catheter inserted after the surgery. The most important side effects of intravesical chemotherapy are; irritation and burning sensation in the bladder and after a few days these disappear on their own.
Chemo-instillation of the additional bladder after TUR-MT: Additional intravesical chemotherapy depends on the progression of the disease after surgery. If you are at low risk for disease recurrence and progression, a single dose instillation will be sufficient to reduce the risk of disease recurrence and this is the standard treatment. If you have an intermediate risk tumor, a single dose instillation may not be sufficient, additional chemotherapy instillations may be required. The optimal number and frequency of chemotherapy instillations has not been defined.
Bladder Flush with BCG After TUR-MT Immuno-Instillation:
Bacillus Calmette-Guérin (BCG) is the attenuated form of the microbe that causes tuberculosis. Therefore, if you have a previous history of tuberculosis, you should tell the doctor, even if it is only suspected. You should also mention different immunotherapies you may have received in the past. BCG instillation activates the immune system by causing an inflammation on the bladder surface, stimulating and attracting immune system cells to kill cancer cells. Treatment is usually started a few weeks after TURBT and given once a week for 6 weeks. In some cases, long-term ‘Maintenance’ BCG instillations may be required, sometimes these washings may need to be continued at regular intervals, the duration can be increased to 12-36 months.
Studies have shown that BCG therapy reduces the risk of progression and recurrence of the disease in non-invasive bladder tumor types that have not spread to the entire muscle. It is an outpatient treatment, the drug is given through a temporary catheter. The patient should ideally keep the medicated liquid in the bladder for 2 hours before urinating. BCG instillation has been tested with many protocols and its efficacy has been proven, but the response of patients to this treatment is variable. As a result, the optimum number of induction instillations and the optimum maintenance instillation time and frequency have not been determined, are not precise, and vary from patient to patient and from center to center.
BCG Side Effect: It is known that BCG therapy has more side effects than intravesical chemotherapy. BCG can cause flu-like symptoms such as a burning sensation in the bladder and fever, chills, and fatigue. Rarely, BCG is absorbed by the circulatory system and enters the rest of the body, causing a serious infection (sepsis). In this case, you may feel a high fever that cannot be relieved with painkillers. Anti-tuberculosis drug treatment may be needed, it may be recommended to be taken for a few weeks. In some cases, temporary discontinuation of therapy, a change in dose, or discontinuation of therapy may be considered.
Routine check-ups after primary treatment in bladder cancer are performed by cystoscopy and are performed quarterly for the first year, every 6 months for the second year if there is no problem, and annually thereafter.