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Actos Bladder Cancer : Not resting on their laurels, the clinical research community has moved forward and is now testing a new combination that adds paclitaxel, another active drug mentioned above, to the gemcitabine- cisplatin regimen. A three-drug combination (gemcitabine-cisplatin- paclitaxel) has been compared to the two-drug standard, to see whether this produces better cancer shrinkage and improved survival. In June 2007, the first report of this trial was made public. It indicated that the three-drug combination offered no significant benefit compared to gemcitabine-cisplatin and was associated with more side effects.

Another new agent, pemetrexed, also targets the division and reproduction of cancer cells, and has a relatively gentle profile with regard to side effects. It is being tested in patients who have already been treated with gemcitabine and cisplatin to see whether it will cause tumor shrinkage. Early reports are promising, but its true use­fulness is not yet known, and it has not yet been assessed by the Food and Drug Administra tion, which must give formal approval for its use in the treatment of bladder cancer.

In addition to the use of chemotherapy, another class of anti-can- cer agents, the so-called growth inhibitors or targeted agents, is being tested in patients with advanced bladder cancer. It is known that pro­teins located on the surface of cancer cells can control the rate of DNA production and division and stimulate cancer-cell growth. An example is the epidermal growth factor receptor (EGFR), which sits on the surface of some bladder-cancer cells and helps to control the rate at which they grow and divide. Inhibitors of the function of EGFR (and of the genes that control its production) have been developed and are known to slow or stop the growth of some cancer cells.

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You may be alarmed if your doctor suggests the possibility of par­ticipating in a clinical trial Does it mean that you have no hope? What should you do? How should you respond? It’s important not to dismiss the idea out of hand. The words experimental, research, and human volunteer can be upsetting, particularly at a time when you are dealing with the emotional issues surrounding a diagnosis of advanced cancer. But treatments in clinical trials can often be highly beneficial to those who volunteer. You and your loved ones should talk with your medical team members about the kind of clinical trial they are recommending and why it may benefit you. In fact, several studies have shown that patients participating in clinical trials have better outcomes than those found in the community at large. However, this also may be due to the types of patients who agree to participate in trials.

Does referral to a clinical trial mean that there is no hope of your surviving this illness? Not at all! There is always hope of survival, and any doctor can tell you about people who have responded positively to treatment and not only survived, but thrived. Being in a clinical trial doesn’t mean that you won’t continue to receive medical treatment; you wall, and since it’s a voluntary process, you have the right to stop participating in the trial at any time.

As with any aspect of your treatment plan, you make the decision about whether to proceed. Don’t feel pressured to participate in a trial if it doesn’t feel right for you, but do give it objective thought and consideration. How do you begin thinking through the decision on whether to participate in a trial?

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Probably the first question that comes to your mind is whether clinical trials are safe. Scientists and medical investigators work hard to ensure that they are as safe as possible. The medical community and the U.S. Department of Health and Human Sendees have put rules in place ensuring that every clinical trial is highly regulated and reviewed by health-care professionals, who determine that the trial is designed and conducted in compliance with federal regulations gov­erning research on human volunteers. Everything about the trial, from the doctors involved to the people who volunteer and the treat­ment being tested, is subject to strict review and monitoring. However, it is important to understand that some clinical trials do carry increased risks.

As with any treatment, you’ll want to ask about possible risks, ben­efits, side effects, how the treatment works, and what results doctors expect from the study.You’ll want to know who is conducting the clin­ical trial and what kind of oversight is in place. Also ask what is expected of you. Where will you go for the treatments? How often will you go? Are there more tests or office visits than you might have with standard treatment? Who administers the treatments and how are the results measured? Do you have to report regularly to those running the trial? Who pays for it all? Will there be extra costs to you as a result of your participation? Will the team conducting the trial (or the doctors involved) stand to benefit personally from the results of the trial or its conduct?

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 word “invasive”refers to whether cells from your bladder cancer have “invaded” the muscle wall of the bladder, and if so, how far into the layers of muscle tissue it has penetrated.This can usually be deter­mined from biopsy results, or occasionally when an operation has been performed to remove the bladder and some of the surrounding tissues. In some cases, organs near the bladder (such as the vagina in women, or the prostate in men) may have been invaded as well.

Invasive cancer extends further into the body than superficial TCC does and is therefore a more serious stage of the disease. It requires more complicated treatment, such as surgical removal of the bladder. This may, in turn, change how you manage basic physical functions in your everyday life, such as your bathroom habits and even your sex life. Also of importance is the significant rate of recurrence connected with invasive cancer. Often other organs, such as the lymph nodes, lung or liver, are involved.

Despite such a gloomy introduction to this chapter, there is every reason for you to be hopeful if youVe been diagnosed with invasive cancer. Current treatment, which includes surgery (cystectomy), chemotherapy, radiation therapy, or two of these approaches com­bined, offers you an excellent chance for long-term survival and, in many cases, for a cure. This applies particularly to those invasive tumors that have not penetrated outside the bladder, the so-called ” organ- confined” tumors.

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There is no question that the after effects of surgical removal of the bladder (cystectomy) can be unsettling to think about. You won’t have a bladder or maybe even a urethra any longer. How will you be able to pass urine? Will you have to have some type of urine-collect­ing bag? Will there be an odor? Will it show when you wear certain clothing? We’ll talk about all those things in more detail, but in brief, your team will need to surgically create an artificial urine-collection system for you. This is known as a urinary diversion system. In years past, the only option was a urine-collection bag worn outside the body which many people found to be unpleasant or even embarrassing.

The good news is that now, in many cases, an artificial bladder (sometimes called a neobladder) can be fashioned from a piece taken from the intestine (bowel), enabling you to void urine in a normal or near-normal fashion. You’ll have to learn to use a different set of mus­cles when urinating, and there may be some leakage now and then, particularly at night. Leakage can be controlled by wearing under­wear designed with a disposable pad or, for men, a sort of condom. Overall, it’s a more attractive option that makes it easier to face a complicated and often scary surgery such as cystectomy. And with modern techniques, most patients no longer have to contend with urinary leakage, except on rare occasions.

Even if you are disappointed because the creation of an internal urinary diversion system is not possible in your situation, keep in mind that there is also no question that cystectomy is a powerful weapon against invasive bladder cancer that can increase your odds of living a long, cancer-free life. Cystectomy is the most common treatment option for invasive blad­der cancer. In most cases, your medical team will recommend a com­plete (or radical) cystectomy. This means that your bladder, the lymph nodes tucked around your bladder in the abdomen, the prostate in men, and the uterus, ovaries, and part of the vaginal wall in women will be surgically removed. Depending on where the cancer is locat­ed, the urethra may also be removed.

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It’s easy to confuse some of the terms your doctors use, such as “cystoscopy”(a diagnostic pro- cedure that introduces a tube into the bladder so that the doctor can look at the inner surface and take a biopsy) and “cystectomy” (the surgical removal of the bladder). Don’t hesitate to ask your doctors for clarification. Cystectomy seems like a drastic surgery, doesn’t it? Why remove so many body parts? Why not just take the tumor and some surrounding tissue?

Depending on where your tumor is located, the cancer-causing substances responsible for the tumors in your bladder were also fil­tered through the kidney, ureters, and urethra, and there is a possibil­ity that tumors may be forming in those organs, too. In particular, the tissues lining the bladder, ureters, and urethra (known as the urothe­lial tissues) may be at risk from the after effects of cancer-causing substances, such as agents in cigarette smoke or industrial dyes. Also, because your cancer may have penetrated the muscle wall, it’s possi­ble that organs surrounding the bladder, such as the prostate, uterus, or vagina, may also be at risk from further growth of the cancer cells.

So in the case of bladder cancer, which often recurs or spreads to other organs, you’ll have a much better chance of a cure once organs and tissue have been removed in areas where the disease is likely to spread or where it may already have infiltrated. And a cure is what you and your doctors most definitely want to strive for. Sometimes, if the cancer is very localized and surrounded by plenty of healthy, noncancerous tissue, a partial cystectomy might be recommended, whereby only a portion of the bladder is removed and some or all of the surrounding organs may be saved.

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 : When an individual has gross hematuria or persistent microscopic hematuria, a complete assessment of the urinary tract is required. Although cystoscopy is the test of choice for examination of the bladder, imaging studies are required to make sure there is no disease in the upper tracts (kidneys and ureters). Bleeding can be caused from many different disorders including transitional cell carcinoma of the upper tracts, kidney or ureteral stones, or renal cell carcinoma (cancer of the parenchyma or fleshy part of the kidneys). Your urologist has a number of options to choose from. There are advantages and disadvantages of each.

Intravenous pyelogram (IVP) is accomplished by injecting a contrast agent into your vein and then obtaining X ray images. The contrast is excreted by your kidneys, subsequently filling the lumen of the kidneys, ureters and the bladder. The contrast allows one to see subtle filling defects within chambers of the urinary tract, possibly representing tumor, stone or blood clot. Tumors of the fleshy part of the kidneys can also be seen. The study also allows for an assessment of renal function. It is a sensitive test for renal obstruction, which can occur because of cancer. Disadvantages of the study include the possibility of an IV contrast agent allergy, which occasionally may be serious.

You will be asked whether you have a sea food allergy, a known allergy to iodine or to IV contrast. If this is the case, you may need to be premedicated prior to the exam to avoid a reaction. Although the study is quite useful at visualizing the upper tracts, it is not very good at picking up subtle tumors on the bladder surface. If your kidneys do not function well (you have renal insufficiency), the contrast may cause harm to your kidneys and the imaging will not be as good. For pregnant women, any X ray exam could be potentially damaging to the fetus and therefore, will not be performed.

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Ultrasonography can check for a kidney tumor, stone, or obstruction. Bladders filled with urine can be scanned. There is no contrast or X rays involved, and therefore the study can be accomplished in those with renal disease, contrast allergies or for women who are pregnant. Although larger tumors of the bladder are often visible, it is not a good study to rule out urothelial cancer (transitional cell cancer of the urinary tract lining) since smaller tumors or flat tumors in the lining are not visible. Also, other conditions such as enlarged folds in the bladder or enlarged prostates can be confused with bladder tumors. Ultrasound exams are generally fast, painless, and relatively inexpensive. An ultrasound combined with cystoscopy plus cytology (to rule out cancer cells) is a reasonable assessment for those with a low likelihood of having upper tract disease.

CT Scan or CAT (computerized axial tomography) provides a computerized cross sectional visualization of the abdomen and pelvis. X ray images are synthesized into exquisitely detailed images. The CT scan can be done with or without IV contrast, and therefore has the same limitations as IVP in those with allergies to contrast or renal insufficiency. These studies are excellent for finding renal cell cancers and stones within the kidneys and ureter, but not very good at delineating cancers of the lining. CT scan is often an important part of staging bladder cancer, determining whether the cancer has spread.

Magnetic Resonance Imaging (MRI) is a technology which uses strong magnets to provide detailed images of your internal organs. Like ultrasound, this study has no known harmful effects on the body. It does not require contrast injection like CT scan and can be done safely in patients with renal insufficiency. It is not generally used for initial screening. Many individuals find the test uncomfortable due to a loud noise heard throughout the test, in addition to the close quarters the machine requires, leading to feelings of claustrophobia. A mild sedative may be required if the test is necessary and the individual experiences these uncomfortable feelings.

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Initial treatment may eradicate an individual’s bladder cancer, however, for many, recurrent tumors may develop. Up to 70% of individuals will have recurrent bladder cancer after initial therapy. In approximately one third of patients, not only will tumors recur, but they will become more serious over time, developing a higher grade or stage. This chapter will review the importance of staging bladder cancer, the single most important predictor of future problems. In addition, we will review other important indicators that impact the prognosis.

After the diagnosis of cancer is made, it is critical to establish the stage of the cancer. Cancer stage quantifies the extent of cancer in the individual. The number of tumors, their size, whether or not they have grown into the wall of the organ or spread beyond, all fit into the various stages of a particular cancer. Most cancers can be found at an early, nonlethal stage. As they grow and worsen, they can invade the wall of the organ they lodge in, spread locally through the organ into surrounding tissue, or spread throughout the body via the lymphatic or blood system.

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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Actos Bladder Cancer 12/20/2011: During phase 1 of a cancer trial, the safety of the chemotherapy dose is being determined. During the early part of the trial, a lower dose may be used. The dose is gradually increased to determine the potential for side effects. Individuals entering the trial later may receive higher doses, more potentially serious side effects, and not necessarily more effective therapy. During phase 2, it is determined how often a particular cancer will respond to the chemotherapy at a fixed dose regimen. Lastly, during phase 3, the new drug which appears to be effective is compared to the current accepted chemotherapy for a particular cancer.

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