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Bladder Cancer

Bladder Cancer - Conditions & Treatments

Bladder Cancer - What is it for

Bladder cancer (sometimes referred to as urothelial cancer), is a disease of the urinary tract. The urinary bladder is a hollow organ in the lower abdomen that stores urine produced by the kidneys before it is discharged from the body. This allows us to control when we want to pass urine, and allows one to pass urine at an appropriate time.

Bladder cancer occurs when there is abnormal, uncontrolled growth of cells within the urinary bladder with the potential to spread to other parts of the body. It is more common in men and in those who are over the age of 60 (the median age at diagnosis is 69 years). Other risk factors include smoking, exposure to certain chemicals at work, chronic bladder problems or repeated urinary tract infections, family history of bladder cancer and genetic conditions (e.g Lynch Syndrome).


Figure 1: Bladder Cancer

The most common type (about 90% of bladder cancer cases) is transitional cell carcinoma, which starts in the urothelial cells in the bladder lining. Other types include squamous cell carcinoma, adenocarcinoma and small cell bladder cancer.

Bladder cancer is commonly categorised into:
  1. Non-muscle Invasive Bladder Cancer (NMIBC) (Stage 0-1): These tumours affect the shallow layers within the bladder and are usually less aggressive. They can often be treated successfully with minimal intervention. The main goal of treatment is organ (bladder) preservation whilst achieving maximal cancer-free rates.
  2. Muscle Invasive Bladder Cancer (MIBC) (Stages 2-3): In these cases, the tumour has spread to involve the muscle layers in the urinary bladder wall. These cancers can invade surrounding tissues, making them more aggressive and potentially leading to metastasis.
  3. Metastatic (Stage 4): At this stage, bladder cancer has spread beyond the bladder to distant organs. This form is highly aggressive and more challenging to treat.


    Figure 2: Classification of Bladder Cancer

Bladder Cancer - Symptoms

The most common symptom of bladder cancer is blood in the urine. Other common symptoms are painful urination and pelvic pain.

Figure 3: Symptoms of bladder cancer

When should you see a doctor for bladder cancer?

Signs and symptoms of bladder cancer are often mistaken for symptoms of a urinary tract infection or kidney stones. However, if you notice blood in your urine, or any of the other symptoms listed, even if they come and go, please go to the doctor so that the cause can be investigated.

Bladder Cancer - How to prevent?

There is no guaranteed way to prevent bladder cancer, however you can reduce your risk by:
  • Not smoking
  • Eating a diet rich in fruits and vegetables
  • Taking regular exercise
  • Following safety instructions to avoid exposure if you work with chemicals

Bladder Cancer - Causes and Risk Factors

Bladder Cancer - Diagnosis

Tests and procedures used to diagnose bladder cancer may include:

  • Blood and urine tests: to help diagnose the bladder cancer or identify other conditions that may be causing the symptoms such as an enlarged prostate, urinary tract infection or kidney stones.
  • Cystoscopy: This is the most common and reliable test for bladder cancer. During a cystoscopy, a thin tube with a camera on the end is inserted through the urethra to allow the doctor to examine the urethra and bladder for signs of disease. At SGH Urology, we may use a high-resolution visual tool called Narrow Band Imaging (NBI) to better identify suspicious growth.
    Cystoscopy is a simple, minimally-invasive procedure (typically performed in the clinic setting), where a small camera (scope) is inserted into the bladder via the urethra (urine passage) to allow your doctor to inspect the surface of the bladder to identify any tumours or suspicious growth.

    Figure 4: Flexible Cystoscopy
  • Biopsy: During the cystoscopy, the doctor may pass a special tool through the scope and into your bladder to collect a cell sample (biopsy) for testing. This procedure is sometimes called transurethral resection. The cells are sent to the pathologist who will examine them under the microscope so that a diagnosis can be made.
  • Urine cytology: A sample of your urine is analyzed under a microscope to check for cancer cells in a procedure called urine cytology.
  • Imaging tests: The most common imaging test for bladder cancer is computerized tomography (CT) urogram. During a CT urogram, a contrast dye is injected into a vein in your hand and eventually flows into your kidneys, ureters and bladder. The contrast dye provides a detailed view to help identify any areas where there might be cancer.
  • Other diagnostic tests that may be done include MRI (magnetic resonance imaging scans), PET (positron emission tomography) scans, bone scans and chest x-rays or chest CT scan. After confirming that you have bladder cancer, additional tests may be recommended to determine if the cancer has spread to your lymph nodes or other parts of the body.

Bladder Cancer - Treatments

The type of treatment recommended for bladder cancer depends on the grade and stage of the cancer.

For Non-muscle Invasive Bladder Cancer (NMIBC): 

  1. Transurethral Resection of Bladder Tumour (TURBT): This is a minimally-invasive surgery where a small camera is introduced into the bladder along with tools to remove superficial bladder tumours and obtain specimens for biopsy and testing. No skin incisions are necessary. 
  2. Intravesical Therapy: This involves introducing medications like Bacillus Calmette Guerin (BCG) and Mitomycin-C into the bladder to reduce the chance of cancer recurrence and maximize the effect of surgery. The medications should be held within the bladder for a period of time before being passed out in the urine. Refer to our leaflet below for more information about BCG.
  3. Combination Chemotherapy for High-Risk Patients: SGH's dedicated High-Risk Bladder Cancer Clinic, established in October 2023, offers a new treatment option for patients with high-risk non-muscle invasive bladder cancer who are unresponsive to standard therapies or unsuitable for invasive surgery. This treatment combines two existing chemotherapy medications – gemcitabine and docetaxel – delivered directly to the bladder via the urethra monthly for up to 24 months. This approach has shown promising results in many academic institutions, with a reported success rate of about 70% according to overseas studies. It aims to effectively manage the disease and avoids removal of the whole bladder thus, maintaining a better quality of life for patients. These combinatory therapy has also been observed to have fewer side effects compared to standard treatments. We also facilitate research by prospectively enrolling patients into clinical trials and tissue studies to aid better understanding of bladder cancer and develop personalised and cost-effective treatments for every individual patient. 

For Muscle Invasive Bladder Cancer (MIBC):

  1. Radical Cystectomy: This major operation involves three main steps
    • Removal of the entire urinary bladder
    • Removal of surrounding lymph nodes
    • Creation of urinary diversion (either an ileal conduit or a neobladder)

      Figure 5: Creation of Ileal Conduit with Urostomy Bag
  2. Robotic-assisted Radical Cystectomy: SGH Urology offers this minimally invasive approach, which achieves lower blood loss and transfusion, better pain control, and shorter hospital stay. We perform approximately 30 radical cystectomies a year, with close to 80 robotic-assisted cases performed till date.
  3. Tri-modal Therapy: For patients not suitable for radical cystectomy, a combination of chemotherapy and radiation therapy may be used.

    SGH Urology works closely with medical oncologists and radiation oncologists under the umbrella of National Cancer Centre Singapore (NCCS) to provide patients with the treatment options most suited to their condition.

    In some cases, a combination of treatments (e.g., surgery + chemotherapy or surgery + radiation therapy) may be recommended. Immunotherapy may also be used to trigger the body's immune system to fight cancer cells.

Bladder Cancer - Preparing for surgery

Bladder Cancer - Post-surgery care

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