Having had the CT scan I was called by the local hospital to come and visit the urologist. Meeting him he said “Yes, yes, you really have to do something about this”, without telling me what really the problem was. I thought something related to my prostate. I think he never used the word cancer, I had to suggest the word cancer to him and he still only confirmed this with an unclear move of his head. He told me I would need to have an operation as soon as possible. He then told me my problem concerned bladder cancer. The urologist informed me that the tumor was located at the top right section of the bladder with a diameter of about 5-6cm. I would have to undergo a Cystoscopy (see below for a detailed description) followed by a TURBT operation(see below for a detailed description) to remove the initial main part of the tumor probably followed by a second TURBT to remove remaining tumor, and possibly invasive, parts. This because the tumor was located so high at the top of the bladder and may have become invasive in areas surrounding and above the bladder.

I could not hear anything anymore of the remaining part of our discussion but  just wanted to run home to tell my wife in tears that I had “it”, the “big C”.

In my meetings with the urologist it never became clear to me that this was serious business what the urologist and I were talking about. I thought the only thing that I had to was a Cystoscopy and that was it. I was scared enough for the Cystoscopy (later this fear became justified) to refuse it. Only then it became clear how serious my condition was when the urologist said that I would then have only a couple of months to live. I then asked for evidence, photos etc. which the urologist finally showed to us. The pictures were so clear that a Cystoscopy was not necessary. The first operation, a TURBT, whereby the operating urologist inserts a cystoscope, a small, lit camera, through the urethra and into the bladder had to take place in the next few days. A small tool with a wire loop at the end is inserted through the cystoscope. A high-frequency electric current passes through the wire tool removing and burning cancer cells. This method is called fulguration. In some situations, fulguration will not be enough to eradicate the tumor.

Cystoscopy

Overview of Cystoscopy

Cystoscopy, or cystourethroscopy, is a procedure usually performed by a urologist that allows the physician to see the inside of the lower urinary tract (urethra, prostate, bladder neck, and bladder). Cystoscopy can be used to detect abnormalities of the lower urinary tract or to assist in transurethral surgery (e.g., prostate surgery).

In this procedure, a cystoscope (thin, telescope-like tube with a light and tiny camera attached) is inserted into the bladder through the urethra (tube that carries urine from the bladder out of the body).

Cystoscopy may be used to evaluate and diagnose the following conditions:

• Bladder cancer
• Blood in the urine (hematuria)
• Chronic pelvic pain
• Frequent urinary tract infections (UTIs)
• Interstitial cystitis
• Painful urination
• Urinary blockage (e.g., enlarged prostate [BPH], narrowing of the urinary tract [stricture], polyps, tumors)
• Urinary incontinence or overactive bladder
• Urinary stones

The physician uses the cystoscope to visualize changes in the lining of the urinary tract. Abnormalities that can be detected include the following:

• Diverticula (sacs caused by abnormal holes in the urethra)
• Ectopic (displaced) ureter
• Fistula (abnormal passage)
• Trabeculation (strands of connective tissue)
• Tumors
• Ureterocele (ballooning of the lower end of the ureter)

Cystoscopy Procedure

Cystoscopy may be performed in a physician’s office, under local anesthesia, or as an outpatient procedure, under sedation and regional or general anesthesia. Before undergoing the cystoscopy, patients should inform their physician if they are taking any medications, especially blood thinners (e.g., aspirin, ibuprofen, warfarin [Coumadin®]).

If regional or general anesthesia is being used, patients are instructed to fast for at least 4 hours before the procedure. If local anesthesia is being used, a topical anesthetic (e.g., lidocaine) is introduced prior to the procedure to numb and lubricate the urethra.

During the procedure, the cystoscope, which can be flexible or rigid and is about half the diameter of the urethra, is slowly inserted into the urethra to the bladder. A camera may be attached to the cystoscope to allow images to be viewed on a monitor. The physician examines the urethra and introduces a sterile liquid (e.g., water, saline) into the bladder to improve the view of the bladder wall. As the bladder fills, the patient may experience an uncomfortable urge to urinate.

Additional instruments can be passed through the cystoscope to allow the urologist to perform procedures, such as stone removal, bladder biopsy, resection of a bladder or prostate tumor, and cauterization (application of a small electrical charge to minimize bleeding).

In some cases, the physician uses another instrument called a ureteroscope to allow visualization of the ureter (tube that carries urine from the kidney to the bladder). This procedure, which is called ureteroscopy, may be used to diagnose and treat urinary stones higher in the urinary tract. Ureteroscopy usually is performed under regional or general anesthesia.

Cystoscopy usually takes from a few minutes to about 20 minutes to perform. If the physician removes a stone, or sample of tissue (biopsy), the procedure may take longer. After the procedure, fluid is drained from the bladder and a catheter (thin, flexible tube) may be left in the bladder.

Side effects, which are usually mild and resolve within a couple of hours to days, include burning during urination and blood in the urine (hematuria). When local anesthesia is used, patients usually can go home immediately following the procedure; when regional or general anesthesia is used, patients require a recovery period (usually 1 to 4 hours).

Complications are rarely serious and may include the following:

• Adverse reaction to anesthesia
• Excessive bleeding
• Formation of scar tissue, which can result in narrowing of the urethra (stricture)
• Infection (fever, chills, severe pain, vomiting)
• Tear or perforation of the urethra, bladder, or ureter
• Testicular pain and swelling (may indicate infection)
• Urinary retention (inability to urinate), usually as a result of swelling, bladder distention, or anesthesia

Rarely, complications such as acute urinary retention occur following cystoscopy. This condition is a medical emergency and requires prompt medical attention.

TURBT (Transurethral Resection Of The Bladder Tumor)

Transurethral resection (TUR) for bladder cancer

Transurethral resection (TUR) of the bladder is a surgical procedure that is used both to diagnose bladder cancer and to remove cancerous tissue from the bladder. This procedure is also called a TURBT (transurethral resection for bladder tumor). General anesthesia or spinal anesthesia is usually used. During TUR surgery, a cystoscope is passed into the bladder through the urethra. A tool called a resectoscope is used to remove the cancer for biopsy and to burn away any remaining cancer cells. Bladder cancer can come back after this surgery, so repeat TURs are sometimes needed.

What To Expect After Surgery

Following surgery, a catheter may be placed in the urethra to help stop bleeding and to prevent blockage of the urethra. When the bleeding has stopped, the catheter is removed. You may need to stay in the hospital 1 to 4 days.

You may feel the need to urinate frequently for a while after the surgery, but this should improve over time. You may have blood in your urine for up to 2 to 3 weeks following surgery. You may be instructed to avoid strenuous activity for about 3 weeks following TUR.

Why It Is Done

TUR can be used to diagnose, stage, and treat bladder cancer.

• Diagnosis. TUR is used to examine the inside of the bladder to see whether there are cancer cells are in the bladder.
• Staging. TUR can determine whether cancers are growing into the bladder wall.
• Treatment. One or more small tumors can be removed from inside the bladder during TUR.

How Well It Works

TUR is the most common and effective treatment for early-stage superficial bladder cancer. It may also be effective for more advanced cancer if all the cancer is removed and biopsies show that no cancer cells remain.

Follow-up to TURBT

Transurethral resection is often a successful treatment for patients with low-risk cancers. These cancers are described as noninvasive, papillary cancers. The noninvasive characteristic keeps them from penetrating into deeper layers of tissue but does not prevent their recurrence. Up to seventy percent of patients with superficial bladder cancer have some recurrence within five years of treatment. Therefore, follow-up therapy is an important part of post transurethral resection therapy.

Follow-up therapy includes a cystoscopic evaluation three months after the initial TURBT treatment and then every six months for an additional year. If cancer reappears, follow-up cystoscopy and urinalysis is typically performed every three months for the first year and every six months for an additional three to five years.

Partnering Chemotherapy with TURBT

Patients with high-risk tumors – those that are likely to become invasive – may benefit from the TURBT procedure but may need other “adjuvant” treatment. Because of the relatively high chance of progressing (thirty percent), high risk bladder cancers are often treated with transurethral resection combined with intravesical therapy. Intravesical therapy is a type of chemotherapy or immunotherapy instilled directly into the bladder.

Risks

The risks of TUR include : -

• Bleeding.
• Bladder infection (cystitis).
• Perforation of the wall of the bladder.
• Blood in the urine (hematuria).
• Blockage of the urethra by blood clots in the bladder.