Some surgeons in all honesty are not phone friendly. But when it remains silent for a reasonable period, they become very bored. And when the call eventually comes from some category of persons, it could give one a jolt. That was my stress 0n the 30th of December last year. A former staff of mine had informed me through a phone call that she was sending her sister’s husband for medical examination. The history was straight forward; low abdominal pains with vague urinary symptoms. Funny enough they thought it had to do with an inflamed appendix. And that was why they came.
After a physical examination; I had my doubts. Instinctively I decided to scan the pelvic organs for whatever it was worth. To my pleasant surprise there was a mass dangling from the anterior aspect of the bladder. This obviously was not the prostate gland. It could only be one thing; a tumor with its origin being the inner lining of the bladder or the so called Uroepithelium. Our clinical impression then, with a very high index of suspicion was Cancer of the bladder. When I broke the news and informed them about the measures to be taken immediately and on the long run to see what can be salvaged; the room was enveloped by depression and melancholy.
For a recap, bladder cancer is a lesion in which abnormal cells proliferate without control in the bladder. The commonest type of this cancer reflects the transitional epithelial inner lining of the bladder. The term transitional is so described because of the expansible function of the bladder. In its typical presentation cancer of the bladder causes blood to be present in urine. It could be frank and visible to the naked eye or can only be detected through microscopy. Blood in urine clinically is referred to as haematuria irrespective o0f the amount and t s the commonest symptom in bladder cancer.
Other symptoms include dysuria or pains during urination, increased frequency in urination and a sense of urgency to urinate without voiding much. It must be stated that these symptoms are not specific to bladder cancer alone. They could be present in the inflammation of the prostate gland known as prostatitis, cystitis or infection of the bladder and over active bladder. Haematuria is also a feature of bladder and ureteric stones, infections and renal cell carcinoma.
In terms of causative factors, tobacco smoking has been identified as a main contributor to bladder cancer. This is also true of those by the nature of their jobs are exposed to 2-Naphthylamine like bus drivers, motor mechanics, shoemakers, rubber factory workers and so on. In our environment no specific carcinogen has been identified besides rubber tapping and processing in the delta region of clime has practically been abandoned now for a while for obvious reason. Perchance with the increasing numbers of commercial drivers we may be in for an upsurge in the near future. This is not a prayer.
The gold standard for the diagnosis of bladder cancer is obtaining a sliced tissue of the tumor and confirming the cell type under a light microscope. This procedure is known as biopsy and facilitated by a cystoscope, which is a device used in viewing the bladder. This makes the obtaining of tissue and control of bleeding easy. When the lesion is relatively obvious as often the case in this environment, urine obtained from the patient can be examined for cancer cells; a process known as cytology. This procedure is usually not very sensitive and reliable. In our environment late presentation is the rule such that symptoms are already florid by the time they come like our index case that was seen during ultrasonography.
Medical imaging has gotten a lot of boost with CT Scanning, Magnetic Resonance, and X-ray with contrast studies and so on; but this should not take away the importance of the usefulness of ultrasonography for its portability and easy use by a surgeon in private practice. As a matter convenience, bladder cancer s staged based on the traditional TNM system. Basically this means tumor, nodes (lymph) and metastasis (spread). Space would not allow a detailed description here. Suffice it to say this gives a guide on treatment options and how far the caregiver can go.
With regards to treatment options for cancer of the bladder; tumors that have not invaded the muscles can be ‘burnt’ off using an electric device that is passed through the urethra into the bladder. This is attached to a cystoscope for clear vision. This procedure is known as transurethral resection of bladder tumor. It is also used in prostatectomy. It is not useful when the cancer has spread. That would need extensive surgery leading to sometimes removal of the whole bladder known as cystectomy and replacing it with an intestinal loop. A procedure that is better left for an experienced Urologist.
Interestingly the use of BCG has been of great help in terms of immunotherapy. Bacillus Calmette-Guerin is a vaccine against tuberculosis given to babies at birth. No one is certain how it works; but it s believed that on being injected intravesicularly it initiates an immune reaction that clears the cancer cells. Conventional treatment options like radiation and chemotherapy are also applicable. Routine screening for bladder cancer as we have in prostatic lesions has not evolved because of the prevalence of the lesion.
Coming back to our index case, I had instructed that he should come back the next day for further evaluation in terms of investigation and possible treatment options. The next day, I waited and did not hear from them. My guess was that perchance they were running around for money which they knew would be needed for the various tests. I was shocked when a very simple text message came into my phone. It was from my ex-staff, who had referred him to me, it simply stated: “that man is dead.” I couldn’t believe it. When I probed further she said that on leaving my place, they went to another hospital, and by the time she got to them, he was bleeding from the anus and passing blood in urine.
The truth was that they had gone for a massage somewhere and when the bleeding started they rushed him to the hospital. He passed on before they could get blood to transfuse him. I felt really bad and was forced to ask:” was I in the wrong to have told the patient my honest clinical impression?” The truth is that in this environment we are still very constrained about telling patients certain diagnosis. Well that was my end of year blues.