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Actos Bladder Cancer : Sometimes an internal bladder connected to the urethra (the tube that carries urine to the outside of the body) isn’t possible and you will instead have a continent urinary diversion system. This means that you’ll have a pouch or reservoir, either external or more commonly internal, that collects your urine, and you’ll have to empty the pouch. This is also known as an ostomy or ileal conduit system.

The more common continent urinary diversion system is an internal reservoir, or pouch, made from a piece of intestine. The pouch is inside your body, but you must manually empty and flush the reservoir by inserting a syringe or catheter into a permanent ”hole” or stoma in your abdomen. Often the stoma is located unobtrusively in your navel, where it is not likely to be detected by a casual glance.

Your doctor, may, however, recommend an external pouch that is situated outside your body and attaches to your abdomen through a “hole” or stoma. You must manually empty the external pouch and cleanse the stoma. Either alternative sounds unpleasant, but having a pouch (particularly an internal reservoir) won’t interfere with your life or self-image as much as you might expect, if at all. You can still snorkel and swim. You can dance in a clingy, swingy dress or bike in Spandex shorts. You can do your job, whether it’s manning a drill press or managing a Fortune 500 company. And you can still look and feel sexy and enjoy a satisfying intimate relationship with your partner.

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One of the difficult issues for you and your medical team is to work out exactly what to do about the treatment of invasive bladder cancer. It is clear that cystectomy can be a life-saving procedure, yet many patients with invasive bladder cancer still eventually die of the disease, especially if it has penetrated the surrounding organs.

Your team will make a recommendation about treatment after carefully evaluating such very important factors as the extent of invasion by tumor cells (the stage), the normal or disorganized/abnormal appearance of die cancer cells under the microscope (grade), whether the cancer cells have invaded lymphatic channels or blood vessels, whether cancer cells are growing within the lymph nodes, and whether a specific cell control gene called P53 is normal.

If your cancer is organ-confined (i.e., if the cancer cells have not spread beyond the boundaries of the bladder and its immediate surrounding tissues), if it has not penetrated beyond the first layers of surrounding muscle, if there is no lymphatic or vascular invasion, and if lymph nodes are negative (i.e., they contain no cancer cells), the chance of permanent cure by cystectomy alone is around 80 percent.

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Since the 1950s it has been known that cancer-killing drugs (chemotherapy) can sometimes shrink bladder cancer that has spread through the body, and sometimes they can completely eliminate the deposits of cancer in different parts of the body. In the past 25 years, several studies have looked at the impact of combining chemotherapy with cystectomy or with radiotherapy in an attempt to improve survival figures. Before that discussion, let’s talk a bit about chemotherapy.

Chemotherapy is a term that refers to the use of drugs to kill cancer cells. Chemotherapy is usually given by intravenous injection (injection by needle directly into the vein), but sometimes it can be administered as a tablet or even through a urinary catheter (intravesical) for a patient with superficial bladder cancer. (See Chapter 4.) There are many different types of chemotherapy, and a detailed discussion is beyond the scope of this book. Your medical team will talk with, you about what type of chemotherapy is best for you and why.

In brief, chemotherapy drugs mostly act to interfere with the ability of cancer cells to divide and multiply, often by inhibiting the function of enzymes within the cells or by blocking cell division and the formation of RNA and DNA, the substances of life. Because these drugs act on cells that are dividing and multiplying, they can also affect some normal tissues and thus can cause a range of side effects.

Our use of the term or terms Actos Bladder Cancer is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Actos Bladder Cancer : Despite prompt and appropriate medical treatment if you have mus­cle-invasive TCC, there is about a 50 percent chance that your cancer will metastasize (spread), either to another organ in the body or with­in the bladder area itself. The most common sites of “distant metastasis” (not in the imme­diate area of the bladder) are the para-aortic lymph nodes and the liver, lungs, and bone. Occasionally, bladder cancer can send deposits through the bloodstream to the brain, but usually this happens only after prolonged and repeated treatment. Most recurrences, both dis­tant and local, occur within the first two years after treatment.

One point worth emphasizing is that cancer cells in a distant metastasis still have the characteristics of the bladder cancer (i.e., they behave in the pattern of those bladder-cancer cells and don’t really constitute ” bone cancer”or “liver cancer”as such).Thus the drugs that may work against bladder-cancer cells also have a chance of working against these metastases located at other sites in the body.

As you might expect, the metastasis of your cancer is a dangerous situation that reduces your chance of a permanent cure. That doesn’t mean that cure is impossible or that you no longer have options. Some established chemotherapy approaches can sometimes achieve cure if the metastases are not too extensive. In addition, new and promising therapies, including novel chemotherapy drugs, are under­going clinical trials as this book goes to print, and many of those may well be available to you.

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When metastasis occurs, the direction of your treatment shifts somewhat from a totally focused attempt to achieve cure. In this situ­ation/ while we attempt to cure the metastatic cancer if possible/ we also tty to palliate (reduce) the symptoms and we place a greater emphasis on comfort and pain control This type of treatment is called palliative care. At this point, not only you but your family and loved ones should be involved with your medical team in understanding the progression of your disease and making decisions about your care.

This is a very important point and it can be confusing. On the one hand, your medical team is still trying very actively to cure the cancer, if possible, and to prolong your life and improve its quality to the maximum extent. However, as the chance of cure is somewhat small­er, you and your medical team must also give thought to the benefits and drawbacks of treatment, to quality-of-Hfe issues, and to making the decisions that make the most sense. You and they will want to weigh the chance that treatment might be successful against the possible side effects, the time spent in treatment, and the possible limitations on your quality of life.Your doctor may discover the metastasis during a routine check­up, although sometimes a patient will experience symptoms.

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might be bone pain, abdominal discomfort severe headache, or tin­gling in the legs. (The latter may occur if a metastasis is pressing on nerves in the spine.) Perhaps weight has been lost without changing exercise or diet habits. One might develop a cough or abdominal pain, or experience hematuria (blood in the urine) or other symp­toms of bladder irritation. Any of these symptoms should send you to the phone to make an appointment with your doctors to figure out whether something sin­ister is beginning to occur. As you read this you might be thinking that if the cancer is so advanced – if it has spread to the lungs or bones what’s the point of treating symptoms like tingling in your legs or vague abdominal pain?

The point is that even though the cancer has advanced and metas­tasized, you are likely to live for an extensive period of time – months or years – and it makes good sense to make sure that you are able to live that time comfortably and as fully as possible. If you allow symp­toms to go untreated, your ability to participate in everyday life with your family and friends may be greatly diminished, and the time you have left with them may be cut short. On the other hand, occasionally a specialist may decide to watch and wait. For example, when a change is seen on an x-ray but there are no symptoms. Or when a patient is unwell from other medical problems or is just keen to avoid treatment at that time. In such situ­ations, sometimes the decision will be made to observe closely and start treatment when symptoms occur.

What kind of treatment can one expect if the cancer metastasizes? Surgery to remove the bladder is occasionally a possibility if the only site of recurrence is the bladder and surrounding tissues. It usually doesn’t make sense to operate if the cancer has spread to distant sites. Sometimes radiotherapy will be used to reduce the symptoms of recurrence in the bladder if the recurrence is too extensive to permit surgery or if distant metastases have also occurred.

Our use of the term or terms Actos Bladder Cancer is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Actos Bladder Cancer : For those individuals whose bladder tumors are at high risk for recurrence or progression, instillation of agents directly into the bladder can be worthwhile. The forms of therapeutic agents come in two groups: chemotherapy or immunotherapy. It is fortunate the bladder is readily accessible to these agents, allowing for direct action with minimal systemic side effects.

Those individuals at high risk for recurrence and or progression should be considered for this therapy. Individuals with multiple or diffuse superficial tumors, large tumors, high grade tumors, superficially invasive tumors, those with recurrence within one year, or individuals with CIS all should be considered for this treatment. In addition, those with positive cytology after resection or patients with persistent superficial tumors which could not be removed should also be considered.

The agent is passed via a catheter into the bladder. The passage of the catheter generally takes just a few seconds in a woman, and perhaps ten seconds in a man. The urethral meatus (the outermost part of the urethra) is first cleansed with an antiseptic solution and then the catheter, which is made slippery with a sterile lubricant, is inserted up the urethra and into the bladder. On passage of the catheter, there is minor, short lived discomfort which may be reduced by an injection up the urethra with numbing medication. The various therapeutic agents are not painful during the infusion but may cause side effects afterwards. Depending on the agent instilled, the patient is asked not to void for a period of time afterwards to allow the agent to have its maximal effect on the bladder lining.

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BCG is a living but attenuated form of tuberculosis bacteria. Similar to other living vaccines, it is used to create a heightened immunity. There are a number of precautions which must be taken to make sure the BCG is infused safely. BCG should not be infused immediately or shortly after tumor resection. Several weeks should be allowed to pass so the BCG does not gain access into open blood vessels. In addition, BCG should not be infused if the individual has a urinary infection, has active bleeding, or if the catheterization is traumatic and causes bleeding. It should not be used in patients whose immune system is seriously compromised or for those on steroids, which can decrease the immune system.

The exact mechanism(s) of BCG is still not fully understood. It is known BCG actually attaches to and enters cancer cells. BCG is thought to trigger an increased immune reaction in the bladder, thereby killing off cancer cells.

BCG is held in the bladder for two hours. One should not hold it longer as adverse reactions are increased. The individual should then void into a toilet at home, preferably in a seated position to avoid splashing. After voiding, the toilet is disinfected with bleach. Since BCG can be shed from the urethra after treatment for several days, condoms should be used or one should abstain from sexual relations for at least 48 hours after treatment.

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Adverse reactions are side effects of treatment. Approximately 95% of individuals will tolerate treatments well. Adverse reactions may be mild. Common reactions include cystitis (inflammation of the bladder characterized by burning on urination), hematuria, mild fever, malaise, and nausea. These symptoms generally pass without any treatment. For bothersome symptoms, various medications may prove helpful. Your physician can prescribe medication for burning or urinary frequency. For those with persistent cystitis, antibiotics can be utilized. For individuals experiencing severe symptoms lasting more than 48 hours, isoniazid, an anti-tuberculous drug can be prescribed. A short course of 3 days, starting the day before the next dose of BCG can be used to prevent severe side effects. Fortunately severe reactions resulting in sepsis, a life threatening condition characterized by high fever, chills and drop in blood pressure, is exceedingly rare. Sepsis would be treated in a hospital with triple anti-tuberculous drugs, steroids, and broad spectrum antibiotics. There are other serious adverse reactions which may require dose reduction or discontinuation. These are all rare and include: inflammation of the prostate, persistent hematuria, hepatitis, inflammation of the testicles and or epididymis, bladder contraction, ureteral obstruction, joint pain or inflammation of the lungs.

Recurrence of bladder cancer after the initial induction course, or relapse after complete response, would indicate failure of therapy. When two or more courses result in recurrence or when recurrence develops during the first six to twelve months after induction and maintenance therapy, patients generally are felt to have disease which is at higher risk for progression. A high percentage of patients who are complete responders remain tumor free for up to five years. However, with the passage of more time, additional patients will have late recurrences. For those with late recurrences (two to three years after therapy), most will respond to repeat BCG therapy.

Our use of the term or terms Actos Bladder Cancer is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Actos Bladder Cancer : The actual surgery to form the continent diversion may take several hours more to accomplish compared to an ilea) loop. This additional surgical time is not a problem as long as the individual is in good health, and the surgery has gone well. Not all urologists do continent diversions on a regular basis. If a urologist does not do this operation regularly, you will be better off finding a urologist that does, since complications related to this part of the surgery will be increased by inexperience. Because different techniques exist and the level of expertise and experience of each urologist is different, it is important to ask the urologist about the complications that may occur and the general frequency of occurrence he has seen in his patients. Complications unique to this diversion as compared to the ileal loop may occur, requiring reoperation in up to 20% of patients. If the complication rate is unacceptable, consider an ileal loop. The most common complications are:

Difficulty with catheterization: After the surgery the pouch may become increasingly difficult to empty. Surgical reconstruction is mandatory if a pouch cannot be readily emptied. Incontinence: During surgery, the continence mechanism is checked. However, at some time after surgery, incontinence may occur, necessitating the wearing of a collection device. In addition, the pouch may still need to be catheterized. Surgical reconstruction is required to reformat the continence mechanism. Pouch stones: Stones may form in the pouch. Removal may be accomplished with a scope either through the stoma or directly through the skin above the pouch.

Neobladder means new bladder. In this surgery, the urologist uses a combination of small bowel, large bowel, or a combination of both to create anew bladder pouch which is attached to the remaining urethra. The individual can void by increasing abdominal pressure which is accomplished by holding one’s breath and bearing down. There are many surgical techniques to accomplish the formation of a neobladder.

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There are a number of issues which need to be reviewed. Cancer recurrence in the urethra after the formation of a neobladder would likely require surgery to remove the urethra and a new form of urinary diversion. After cystectomy, urethral recurrence of cancer can be expected in approximately 10% of patients. Those with multi­focal disease and especially with disease near the bladder neck will likely have a higher recurrence rate in the urethra. For those with a neobladder, the urethra must be carefully followed for possible cancer recurrence. Monitoring is accomplished by washings of the urethra for cytology or by visual inspection with a scope. if there is a concern for an increased risk of urethral recurrence given the nature of the individual’s bladder cancer, the formation of a neobladder should be avoided.

Urinary incontinence may occur after the formation of the neobladder because of damage to the continence mechanism of the urethra. The nerves to the urethral sphincter travel deep in the pelvis and generally are not injured during surgery. However, meticulous care must be taken in handling the urethra and the sphincter muscle around it. Complications resulting in scar tissue may also jeopardize the continence mechanism leading to leakage. Marked scarring between the neobladder and the urethra may occur, but is readily handled via an incision or dilation of the blockage accomplished through a cystoscope. Even in those with an intact sphincter, especially in females, leakage often occurs at night, necessitating the wearing of a pad.

For some individuals, the neobladder is not adequately emptied with increased abdominal pressure. The solution is intermittent self catheterization through the native urethra. This can be uncomfortable, especially for male patients. For many individuals continence is preserved and catheterization is not required, making this an excellent form of diversion.

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Creating a neobladder is technically more difficult and will require several more hours of surgery as compared to the simpler ileal loop diversion. Many urologists do not create neobladders on a regular basis. If your urologist does not do this part of the operation frequently, you are better off finding a urologist who does neobladder surgery regularly or you will face the prospect of a higher complication rate. It is important to question your urologist regarding the various complications and the frequency of occurrence he has seen in his patients. Ideally, the individual with a neobladder will empty without the need for catheterization and will remain continent between emptying. It is important to understand what percentage of individuals can expect this ideal outcome. If the probability for incontinence or need to catheterize is too high a risk for you, choose a continent diversion or an ileal loop diversion instead.

Chemotherapy uses drugs to kill cancer. There are many different types of chemotherapy. Some drugs work better than others for specific cancers. Some are given orally as pills. Many are given intravenously. Susceptibility to chemotherapy varies depending on the specific cancer. Some, like testicular cancer, are extremely sensitive to chemotherapy while others, like kidney cancer, are not. Bladder cancer is felt to be moderately sensitive to chemotherapy.

Chemotherapy drugs work systemically, throughout the body. These drugs work via various mechanisms to damage and hopefully kill rapidly dividing cells. Since cancer cells are for the most part rapidly dividing, they are generally sensitive to chemotherapy. Other rapidly dividing cells in the body may also suffer injury during chemotherapy, which is why people often experience hair loss, anemia, and diarrhea as a result of therapy. Chemotherapy also can lower the blood cells that fight infection, leading to a diminished immune system and an increased susceptibility for acquiring a potentially serious infection.

Our use of the term or terms Actos Bladder Cancer is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Actos Bladder Cancer : A catheter is a plastic or rubber tube which is placed through the urethra into the bladder. It is kept in place by a fluid filled balloon, at the end of the catheter, which is inflated in the bladder. The tube allows for drainage of urine which may be mixed with blood after a TURBT. When small tumors are removed, a catheter is not usually required unless there is a concern that you may have difficulty urinating after the procedure because of an enlarged prostate, weak bladder or swelling of the urethra after instrumentation. After large tumors are resected, a catheter is often required. It serves the following purposes:

It allows one to monitor the amount of bleeding after surgery (although the urologist attempts to stop all bleeding, this is not always possible and bleeding may persist). It provides for bladder irrigation if required. If much bleeding is present after surgery, it is important to avoid the possibility of blood clots forming and blocking the flow of urine. Irrigation can be done intermittently with a syringe or continuously via a 3 way catheter, which has a port for inflow and outflow of irrigant. It keeps the bladder decompressed, which may be important if the resection was deep and bladder integrity is in question. The bladder may have been thinned markedly in the area of resection or biopsies. Decompression provides for reduced risk of leakage through the wall of the thinned bladder.

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.

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There are potential risks and complications of any surgical technique. Bladder tumor removal via resectoscope is usually safe and complication free. However, potential problems may arise:

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.

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.

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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.

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.

Our use of the term or terms Actos Bladder Cancer is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Actos Bladder Cancer : Magnetic resonance imaging, or MRI, is one of the new­est imaging modalities in use. Hie images that it provides are very detailed, and MRI has the added advantage of ob­taining these images without the use of radiation. How­ever, it does take a lot longer than the imaging modalities previously mentioned and is quite expensive. MRIs are performed when you lay on a small table and are passed through a small tube, which is actually a collection of very strong magnets. Because of this, it is very important to remove all metal objects and jewelry before this exam. If you have a fear of small spaces and become anxious at the thought of them, you may be given a small dose of an anti­anxiety medication before the exam. There are two types of MRI machines currently in use: open ones, which are more comfortable, and closed ones.

Although MRIs are wonderful tests that provide a great view of the urinary system, there are a few risks. If you have an aneurysm clip from a prior brain procedure, you must let your doctor know because this clip could become dislodged during the exam. No one with a cardiac pace­maker should have an MRI performed. If you have any type of implanted device such as an electrical stimulator or pump, you should not have an MRI performed. Pregnant women during the first trimester should not have an MRI; neither should metal or machine workers who may have a small fragment of metal in their eye. Contrast is sometimes given during MRI exams and patients rarely experience al­lergic reactions to it. MRI pros include detailed imaging and a lack of radiation. Its cons are its expense and patient discomfort due to claustrophobia.

Any of the previously mentioned exams may be ordered during your workup. As mentioned before, it is extremely important that you bring copies of the actual images with their accompanying reports to your first appointment with, members of your bladder cancer team.

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Cancer grade and stage are two terms you will most likely hear abotit during the course of treatment. Bladder cancer grade and stage are not the same and should not be used interchangeably to describe your cancer. Grade, expressed as a number, is used to describe the appearance of cells under the microscope and increases from i to 4 depending on how they look compared with normal cells. Grade of cancer refers to the aggressiveness of the disease. Grade 4 cancers are typically more aggressive than grade 1 cancers, and they recur more often. Cancer staging describes the extent or spread of the disease at the time of diagnosis. It is essential in determining the choice of therapy and in as­sessing prognosis. Cancer stage is based on the size and location of the primary tumor and whether it has spread to other areas of the body.

Surgery plays an important role in both the staging and subsequent treatment of bladder cancer. Transurethral resection of a bladder tumor (TURBT) is the initial treat­ment step in the vast majority of patients with bladder cancer. TURBT provides valuable staging information, and pathological results from these procedures are used to make further decisions regarding what, if any, addi­tional therapy is needed. The gold standard treatment for muscle-invasive bladder cancer is radical cystectomy (removal of the bladder). Advances in surgical technique and anesthesia have reduced the complications associated with this procedure in the last two decades. The develop­ment of continent urinary diversion, which allows one to empty the bladder through the urethra, is an option for certain patients. Minimally invasive procedures such as laparoscopic or robotic-assisted radical cystectomy may also be treatment options.

In addition, bladder-sparing procedures (either with partial removal of the bladder or aggressive TURBT frequently in combination with che­motherapy and/or radiation therapy) have allowed some patients to treat their cancer while leaving their blad­ders intact. Advances in surgical techniques continue to this day with the development of minimally invasive approaches to cystectomy. Both robotic-assisted and lapa­roscopic radical cystectomy have been performed safely in highly specialized centers and have the potential for decreased morbidity and a shorter period of recovery, but longer term follow-up is needed to determine if these pro­cedures are equivalent to open surgical techniques.

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The first person you will meet with a new diagnosis of blad­der cancer is your urologic oncologist. When you call to make the appointment, you will be asked whether or not a surgeon (usually a urologist) has already performed a biopsy to confirm that you indeed have bladder cancer. If they have, you will be asked to bring with you (or have sent to the urologic oncologist’s office) the glass slides of the actual pathological material taken at the time of the biopsy for review by another pathologist. You will also be asked for the written report of the original pathologist’s interpreta­tion of your biopsy material, all images taken in evaluation of your bladder cancer (either on CD or printed film) along with the written report of then interpretation, and any sur­gical operative notes from procedures performed by sur­geons seen in the initial evaluation and diagnosis of your bladder cancer.

Be sure to obtain the address and clear directions, if neces­sary, of specifically where you are to go and what time you are to be at your initial appointment. If you haven’t been to the facility before, allow yourself extra drive time to find it, find parking, and get to the location where the doctor will be. Being late only frustrates and distracts you from your ultimate goal of determining the treatment to help you arrive at your desired outcome. Bring the information requested above to ensure that your visit is as productive and efficient as possible for you and the doctor who will be seeing you. Often, the urologic oncologist or his or her of­fice may have requested that the pathology slides be sent in advance with the goal that his or her urological pathologist can look at them before your arrival and render an opinion about the accuracy of the information provided in the typed report that you will bring from the outside evaluation. It is also helpful to know in advance if your insurance company requires you to get preauthorization for having additional tests done, such as a CT or MRI.

There are situations in which the urologic oncologist, once he or she has reviewed the films, may find them inadequate. If this occurs, he or she may want to get additional imaging done while you are there for this visit. It is also likely the urologic oncolo­gist will want you to leave your imaging studies with them to be reviewed by a radiologist. The imaging studies per­formed on your behalf are your property, but your urologic oncologist may need to retain them for use during your surgical care. Once the surgery and associated care for your bladder cancer is completed, the imaging studies can be returned.

Our use of the term or terms Actos Bladder Cancer is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Actos Bladder Cancer : Radical cystectomy is one of the biggest and most complex procedures performed by urologists. In addition to its complexity from a technical standpoint, you will likely have many questions not only related to cancer control but also to quality of life after surgery. Cystectomy can affect your quality of life from both an emotional and physical standpoint. After surgery, you may face specific physical adjustments to die urinary diversion, possible changes in sexual function, and changes in bowel habits and function. Specific side effects and complications related to cystectomy and urinary diversion are discussed in Chapter 4. An essential aspect to enhanced quality of life after surgery is to be proactive in the decision-making process before surgery. Ask your surgeon many questions before surgery, because knowing what to expect after surgery will ease this transition. A cancer diagnosis is a difficult time for anyone, and thoughts and questions will race through your head faster than you can remember them. Write them down as you think of them, so you can have a complete discussion at the time of consultation with your physician.

As stated previously this is a big surgery, and your surgeon may have you see other specialists before your procedure to ensure you are in the best medical condition to undergo surgery. You may be admitted to the hospital the day before your scheduled surgery for any remaining tests and to prepare your bowel for surgery. In the last decade, however, medicine has become increasingly more outpatient based, and many surgeons have eliminated the preoperative admission and have you report to the hospital the morning of surgery. Your surgeon will most likely have you only consume clear liquid on the day before surgery to clear out your GI tract, which allows for a technically easier urinary diversion and may also decrease your risk of complications. Along this same line, most surgeons will have you do some form of bowel preparation the day or two leading up to surgery. This is also used to cleanse your GI tract before surgery.

Immediately after surgery you will generally stay in the hospital 5-10 days. Postoperative practice varies from surgeon to surgeon, but most leave a small drain in the abdomen to monitor for leakage of urine from the newly created diversion and intestinal contents from the reconnected bowel. If there is no evidence of an internal leak, the drain routinely is removed at the bedside (with minimal discomfort) before discharge from the hospital. Your surgeon may also leave a nasogastric tube in for the first day or so after surgery. This is a tube that goes from your nose to your stomach and keeps your stomach decompressed, which prevents abdominal bloating and vomiting.

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Generally, starting on the day after surgery you will be out of bed and with assistance from the hospital staff will start walking. It is very important to begin walking as soon as possible because it will make you feel better, will help with early return ofbowel function, and will decreasethe chances of developing blood clots in your legs and pelvic veins. You will also be instructed on breathing exercises while in bed and sitting to help expand your lungs after surgery and to prevent pneumonia. One of the major obstacles before discharge is return ofbowel function and resumption of a regular diet. Your GI tract can be slow to return to normal function, largely related to the bowel work required for the urinary diversion. This will take time, and it is important to not force your diet too soon after surgery because this will increase your chances of nausea and vomiting. In general, your body will tell you when you are ready to eat.

Use your time in the hospital to learn as much as you can about your urinary diversion. Most centers in which cystectomies are performed have an enterostomal therapist with expertise in taking care of patients with urinary diversions. If you have a new ileal conduit, they will go over the general maintenance of the abdominal stoma and urinary appliance bags. This will make you more comfortable and confident in dealing with your diversion at the time of discharge from the hospital. Upon discharge from the hospital, your surgeon will give you precise instructions regarding physical activity, exercise, and resumption of sexual intercourse. It is important to follow these instructions carefully to ensure a smooth postoperative recovery.

If you underwent a continent urinary diversion, you will likely be discharged from the hospital with a catheter in the newly created reservoir to temporarily drain the urine until the reservoir is completely healed. If you have a cutaneous catheterizable diversion, a catheter is left in the catheteriz- able channel and a separate catheter is often brought out through a separate incision in the abdominal wall. These are temporary and generally removed 2 to 3 weeks after surgery. If you have an orthotopic diversion, a Foley catheter is generally placed in the diversion through your urethra. It is extremely important that you are careful with these tubes at home because dislodgement requires replacement and occasionally can lead to damage of your newly constructed leservoir. Mucus is often secreted from the bowel used to create your new urinary reservoir, and the nurses in the hospital will teach you how to flush your tubes with sterile saline before discharge to avoid mucous obstruction, which can lead to inadequate drainage.

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Occasionally, a portion of the bladder involved with tumor can be removed while sparing the remainder of the bladder. In selected patients this allows for preservation of normal bladder function and continence and decreased complications because no urinary diversion is required. Unfortunately, only a small percentage of individuals will be candidates for such an approach—generally, patients with smaller, solitary tumors on the dome of the bladder. Individuals with multifocal tumors, large tumor, or carcinoma in situ are not candidates for this procedure. Recovery time for a partial cystectomy is generally quicker tiian that of a radical cystectomy, and hospital times tend to be shorter. A Foley catheter is left in place for 7-10 days to allow the bladder time to heal.

The basic function of the bladder is to store urine. By directly instilling medications into the bladder, physicians have capitalized on this property of the bladder. By placing these agents into the bladder, these agents come into direct contact with the cancer cells. Intravesical (within the bladder) therapy is often used for patients with non-muscle-invasive bladder cancer. It can be used immediately after TURBT, as a single dose, to prevent recurrence of noninvasive tumors and is also used in the form of weekly outpatient administrations (usually 6 weeks at a time) to prevent both the recurrence and progression of bladder cancer.

The two basic agents that are used as intravesical therapies are chemotherapy drugs and immunotherapy agents. The most commonly used therapy in the United States is bacillus Calmette-Guerin (B CG), which is a form of immunotherapy. BCG is actually a vaccine that was originally developed for protection from tuberculosis. In the 1970s and early 1980s, it was noted to have intravesical effectiveness for the treatment of non-muscle-invasive bladder cancer. Although the exact mechanism of BCG activity is unknown, it works through local stimulation of the immune system. A Foley catheter is placed in the bladder, and then BCG is administered through the catheter into the bladder for 1 to 2 hours. Traditionally, BCG has been given once a week for 6 weeks to patients with high-grade non-muscle- invasive bladder cancer or to those patients with carcinoma in situ. Some studies have shown that routine maintenance instillations in addition to die traditional 6-week course may be more effective in preventing disease recurrence. BCG has proven not only to prevent recurrence of bladder cancer, but also to prevent progression to muscle-invasive disease and therefore is the first-line intravesical agent used in the United States.

Our use of the term or terms Actos Bladder Cancer is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Actos Bladder Cancer : The patient will be encouraged to do deep breathing exercises to prevent lung collapse. This process is generally assisted with a small device called a spirometer. If the individual has a history of lung disease or is congested post-operatively, respiratory treatments with inhaled medication may be instituted and provided by a respiratory therapist.

Pain post-op is initially treated often via the epidural catheter. Intravenous medication may be given as an alternative and switched to oral pain meds once the individual is tolerating liquids. Many physicians order a PCA (patient controlled anesthesia) in which the patient pushes a button that releases pain medication via an intravenous line into the blood stream. Maximal amounts of drug administered are carefully controlled by settings on the PCA to allow safe, effective analgesia.

During the post-op period, you will meet regularly with an enterostomy nurse who will teach you the mechanics of caring for an ostomy and handling the ostomy appliance. Gradually, your pain will diminish, strength will increase, and diet will be advanced. Drains placed intraoperatively to siphon off any excess fluids from the abdomen will be removed when no longer needed. Depending on the individual’s age, general health, the surgery itself, and whether any complications have occurred, discharge to home can be expected after approximately seven to ten days.

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For most patients in reasonably good health, few if any complications are the rule. A host of complications can occur with any major surgical procedure and hospital stay. The major complications associated with Radical Cystectomy include

Bowel injury: During difficult dissection, small intestines may be inadvertently opened. These injuries are usually immediately recognized and repaired without difficulty. During removal of the bladder, the rectum may be entered. Assuming the patient has had a complete bowel prep prior to surgery, the rectum is usually readily repaired.

Vascular injury: During removal of the pelvic lymph nodes, entry into a major vein or artery may result in significant blood loss. Smaller, inconsequential veins or branches into larger veins are usually ligated with a suture or cauterized shut. Larger veins and arteries require repair with a fine vascular suture and needle. Troublesome bleeding can also occur during removal of the bladder and from deep in the pelvis after the bladder and prostate are removed. Bleeding is stopped through suture ligation, vascular clips, or cautery.

Abscess: An abscess is a pocket of pus located deep within the body. It may form from a bowel or urine leak, and generally will require drainage since antibiotics alone may not resolve it. If percutaneous drainage (drainage through the skin) is possible, the radiologist will drain the abscess. If this is not possible, the urologist will need to open the incision or make a new incision to allow the pus to be drained. A sizable abscess will generally not be cured without proper drainage. Left untreated, an abscess can result in sepsis, a life threatening bacterial infection.

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Bowel leak: When the bowel is reconnected after removing the section for the urinary diversion, healing may not be adequate and bowel contents may leak into the abdomen. A bowel leak often will present as a failure of the bowel to return to normal function, resulting in a distended abdomen with poor bowel sounds. Distention, ileus (poor bowel function) may occur after the bowels are working well and feeding has been going on for some time. Evaluation is usually accomplished with CT Scan and oral contrast. Immediate surgical correction may be necessary. Left untreated, a bowel leak will generally lead to an abscess or possibly a fistula (a drainage tract from the bowel which may extend out through the incision or drain). The incidence of bowel leak is increased if bowel has been exposed to prior radiation, most often from radiation used to treat prostate cancer in men and uterine cancer in women.

Bowel obstruction: When a piece of bowel is separated from the intestine to create the new urinary drainage system, the remaining bowel must be reanastomosed (brought back together). This may be accomplished via sewing the bowel together or through the use of staples. Sometimes the opening of the bowel connection may be obstructed secondary to swelling. If an obstruction does not clear after a reasonable time, reoperation may be required.

Erectile dysfunction: During a standard radical cystectomy in the male, the fine nerves which run along the base of the prostate to the penis are severed, resulting in loss of erections (impotence). If the individual having surgery still has good erections and is sexually active, these nerves can be attempted to be saved by modifying the surgery. Saving the nerves is more difficult to do, it takes more time, and is not always successful.

Female sexual dysfunction: In the female patient at the minimum, the section of the vagina contiguous to the bladder is removed. In the presence of extensive bladder cancer, more of the vagina may need to be removed. Narrowing and shortening of the vagina may result, making sexual intercourse difficult, painful, or impossible. The vagina is reconstructed intraoperatively so that sexual relations can continue. For those requiring major removal of the vagina, future reconstruction of the vagina by additional surgery can be accomplished once the individual has fully recovered and is free of cancer.

Our use of the term or terms Actos Bladder Cancer is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Actos Bladder Cancer :  While still awake, you will be transferred onto the operating room table and secured on it. If an epidural has not already been placed, one may be inserted. You may have an additional intravenous line placed. Next, your anesthesiologist will have you breathe through a mask placed over your nose and mouth. You will be given a mixture of agents which will allow you to become relaxed. Further anesthetics will result in an unconscious state. At this time, an endotracheal tube will be passed down your windpipe to provide oxygen, which is delivered automatically by a respirator, controlled by the anesthesiologist. The anesthesiologist will continuously monitor your heart rate, blood pressure, electrocardiogram, and tissue oxygenation throughout your operation.

Fluid balance may also be measured via an intravenous line passed close to your heart. Urine output will be followed. Antibiotics will be infused intravenously. Usually, compression stockings will be secured around your legs. These stockings periodically squeeze the legs to prevent blood from becoming stagnant, lowering the risk of blood clots forming in your legs, which can occur when you lie completely motionless for extended periods of time. A nasogastric tube will be passed through your nostril down your esophagus into the stomach, draining the stomach secretions during and after the surgery. A grounding pad will be placed on your side to allow for the safe use of electric current which is used to sometimes cut tissue and often in the cauterization of small bleeding vessels to stop bleeding.

Your abdomen will be prepared for surgery by shaving any hair and prepping the skin with an antiseptic solution. Female patients will have the vagina prepped with antiseptics as well. The surgical field will then be draped with sterile towels and sheets to prevent contamination from surrounding non-sterilized areas. Your upper body may be kept warm with a warming blanket. Your surgical nurse, surgeon, and assistant will all have thoroughly cleaned their hands and arms (scrubbed) and will then don a sterile gown and gloves. Their hair will be covered with a surgical cap, and they will be wearing masks over their mouths to prevent any contamination of the sterilized surgical field.

The standard operation is called Radical Cystectomy. This operation is accomplished through an incision which extends down the middle of the abdomen beginning at the level of the umbilicus and extending down to the pubic bone. The peritoneum (the sac around your intestines) is opened. The surgeon will examine the abdomen to make sure there is no evidence of cancer spread. Removal of the lymph nodes from the pelvis around the bladder is accomplished. The bladder is removed in its entirety along with the prostate and seminal vesicles in the male. In the female, the uterus and vagina are adjacent to the bladder and may be involved with local spread of cancer beyond the bladder. Consequently, the uterus and part of the vagina are removed. Since most females having a cystectomy are well past menopause, the ovaries are also removed, thus avoiding the possibility of future diseases including ovarian cancer.

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Once the bladder and surrounding organs are removed, the urinary tract must be reconstructed. This is most often accomplished by sewing the ends of the ureters into a piece of ileum (a section of small intestine) which is brought out through the skin as an ostomy. This form of reconstruction is called an ileal loop diversion. Since this reconstruction involves the urinary tract, the ostomy is referred to as a urostomy. Prior to sewing the ureters into the ileum, a biopsy of the ends of both ureters is examined by a pathologist to make sure there is no carcinoma in situ present. If cancer is found at the end of the ureter, this section is removed and the next higher level is examined by the pathologist to assure the ureter is free of cancer at the implantation site. If a neobladder is being planned, the prostatic urethra is examined by the pathologist to assure no cancer is present prior to proceeding further.

Transitional cell cancer extending into the urethra of a female patient or the prostatic urethra of a male patient would generally require urethrectomy at the time of cystectomy. Urethrectomy requires more dissection, potential for bleeding and infection, and possibly increased post operative drainage. It should therefore be performed only when necessary. Cancer located close to the bladder neck may raise the odds of cancer developing in a urethra which is left behind. The status of the urethra can be followed post cystectomy with washings sent for cytology. If cancer subsequently develops, a urethrectomy can be accomplished as a separate operation long after cystectomy has been done.

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At the conclusion of surgery, generally while still in the operating room, the endotracheal tube is removed when the patient is awake enough to breathe on his own. The patient will then be brought to the recovery room where he will be carefully observed by trained nurses in conjunction with the anesthesiologist and urologist. The individual is kept in the recovery room until conscious, breathing on his own and stable. Recovery room stays may be short, on the order of 30 minutes, or may extend to several hours, depending on how the individual is doing. If doing well, the patient will then be transferred to a floor in the hospital. If the individual’s surgery was particularly complicated, extended, or if the individual is unstable (irregular heart beat, low blood pressure, inability to be taken off the respirator), or if the individual has significant medical problems or has experienced a complication from surgery, transfer to an ICU (intensive care unit) may be warranted. In the ICU, there exists a much higher ratio of nurses to patients than on a standard postoperative floor, allowing for constant surveillance and care for critical patients. Also, if a respirator is required postoperatively, initial treatment in an ICU is usually necessary.

After transfer to the floor from the recovery room, the patient is often kept on bed rest for the rest of the day. The nasogastric tube is left in and placed to gentle suction to remove excess stomach fluids. Initially, nothing is allowed by mouth other than ice chips or sips of water. Adequate fluids and some nutrition are given via an intravenous catheter. By the following day, patients are often out of bed and sometimes walking with assistance. Sequential stockings on the lower legs are removed while ambulating, and discontinued once the individual is able to move about well. Traditionally, nasogastric tubes have been left in until the bowel activity returns (generally 3-4 days). This is generally heralded by the passing of flatus (gas) or the presence of active bowel sounds, which will be checked by your urologist with a stethoscope. Recent studies have indicated nasogastric drainage for this length of time may not be necessary and may impede normal breathing, leading to other problems. Some urologists are therefore removing the tubes earlier. Feeding is gradually introduced however, once bowel activity has returned.

Our use of the term or terms Actos Bladder Cancer is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Actos Bladder Cancer :

Some tumors, including carcinoma in situ (CIS) tumors, are considered a high-grade bladder cancer because they characteristically have a high rate of progression to muscle- invasive tumors and also because they don’t have any differentiated features. The paradox is that they are only one cell thick, which usually correlates with lack of invasion. About 50 percent of the people diagnosed with CIS who have no other types of tumor present in the bladder will eventually have the CIS invade the muscle.

Recently, an extensive body of research work has suggested that abnormalities (known as “mutations”) of the genes that control the growth of bladder cancer may be important in helping to determine the prognosis of bladder cancer. While this is not yet routinely applied to clinical practice, preliminary studies have suggested that mutation of such genes as the P53 gene may be associated with more aggressive behavior of the tumor, with a greater tendency to spread. The P53 gene, which is part of the genetic makeup of the tumor, normally acts to suppress tumor growth; in some cancers, when an abnormality or mutation occurs, that tumor suppressive role is lost.

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Other genes may also be involved in this process, including those known as the Rb gene, Pi6 gene, and a gene that controls the epidermal growth factor receptor (EGFR). As this book is being written, a major clinical trial is studying whether these preliminary observations are true, and the final results are not known. We mention this to encourage you to discuss with your own physician the current state of the art of measuring genes and comparing the results with the outcomes of treatment of bladder cancer.

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Physicians and researchers can draw some general conclusions about bladder cancer and its diagnosis and treatment, but it is not always easy to predict how it will behave in a given individual.

Your physician and oncologist work with the pathologist to get an idea of your likely prognosis that is a5 accurate as possible, but the reality is that tumors of the same type don t always develop or progress in the same way. Nor do vthey always respond to treatment in the same way, and they don’t always follow a predictable pattern of recurrence.

Generally, one can say that the more deeply into the bladder layers cancer has spread, the more likely it is to recur. But some superficial cancers become invasive. And some don’t. Doctors and researchers don’t yet have all the key indicators to predict which superficial cancers will become invasive and recur and which ones wont.

In general, if you have been diagnosed with superficial urothelial cancer, you can expect a 40 percent chance that the cancer won’t recur, especially if you have a low-grade tumor where the cancer cells closely resemble normal bladder cells.

Our use of the term or terms Actos Bladder Cancer is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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