Further information may derive from instrumental tests such as urography , pelvic ultrasound , scintigraphy ( to highlight any bone metastases ) and abdominopelvic CT .

Among all diagnostic techniques, however, cystoscopy remains the cornerstone examination in the diagnosis of bladder tumors; during this procedure, a thin tube equipped with a camera and a light source at the end (cystoscope) is inserted into the urethra and brought up to the bladder . At this level the microcamera transmits detailed images of the organ, allowing the urologistto identify any suspicious lesions. During the examination, small samples of an abnormal mass (biopsy) can also be taken and examined under the microscope to look for neoplastic cells. In many cases, as we will see better in the next chapter, cystoscopy has both diagnostic and therapeutic value, since it allows the entire tumor lesion to be removed.

Staging

Based on diagnostic results, bladder cancer is classified into stages of increasing severity. In general, the stage of the tumor is more advanced the greater the penetration of the tumor into the bladder muscles. The bladder wall is in fact made up of three layers of different tissues. The innermost one, the tunica mucosa, is made up of a transitional lining epithelium (tissue in which the number of layers and the shape of the cells vary depending on whether the bladder is full or empty) and a tunica proper of connective tissue. More externally we find the tunica muscularis , which with its bundles of smooth muscle continues deep into a connective covering called the tunica serosa. Although different severity scales are found in the literature, a general indication can be the following:

• Stage 0: the cancer is confined to the most superficial layer (mucosal layer) of the organ and has not invaded the underlying muscular layer;
• Stage I: the tumor cells have invaded the underlying layer (lamina propria), but without involving the muscularis layer;
• Stage II: unlike the previous case, the carcinoma has invaded the bladder wall deeply (muscle layer);
  Stage III: Cancer cells have invaded surrounding tissues and may have reached the prostate in men and the vagina or uterus in women;
• Stage IV: Cancer cells have invaded local lymph nodes and may have involved other organs, such as lungs , bones and liver , via the lymphatic circulation .

Treatment

For further information: Drugs for the treatment of bladder cancer

Treatment of bladder cancer depends on the type of tumor and its stage of development, as well as the patient’s general health condition. If the carcinoma has not invaded the deep layers of the bladder wall, surgery is usually performed to remove the tumor mass, which in less serious stages can be performed transurethrally. In this case, the malignant formation is destroyed by inserting into the urethra, after local regional anesthesia, a flexible cytoscope capable of conveying a destructive electric current or high-energy laser to the anomalous formation. It is therefore a minimally invasive procedure, normally free from significant complications. To support these treatments, the doctor can opt for local chemotherapy interventions,

Another type of therapy commonly used in association with endoscopic treatments is immunotherapy . With this relatively recently developed technique, we try to improve the body’s immune response against tumor cells; for this purpose, attenuated bacterial strains, such as the one responsible for tuberculosis , are administered directly into the bladder (appropriately inactivated).

In the most serious cases, i.e. when the carcinoma has invaded the deep layers, the optimal therapeutic choice presents important difficulties, is very invasive and often causes a significant worsening of the patient’s quality of life (use of the bladder catheter ) . Often a multiple treatment is necessary, combining different therapeutic techniques. Among these, a prevalent role is played by major surgery operations performed under general anesthesia, through which it is possible to remove only the portion of the bladder containing the neoplasm (partial or segmental cystectomy) or the entire sac (total cystectomy) together with the surrounding lymph nodes (radical cystectomy). In man,seminal vesicles , while in women it is associated with the removal of the uterus, ovaries and the anterior part of the vagina. At the same time, it is necessary to reconstruct the structural continuity of the urinary tract, in order to allow the elimination of urine externally. In this regard, the surgeon can use a small section of intestine to reconstruct a urinary duct or a small bag, which can be drained via a catheter brought out from a hole created in the abdomen and connected to a collecting bag. In selected cases, this artificial bladder can be connected to the urethra, allowing the patient to urinatesimilar to that of normal subjects without the slavery of the urine collection bag.

If necessary, as happens in forms that have already metastasized , the treatment of bladder cancer can be combined with general chemotherapy and radiotherapy .