Bladder Tumors

Ultrasound is a diagnostic imaging technique that uses sound waves (ultrasound) emitted by a special probe to produce real-time images of internal structures on a monitor.

It is a simple, non-invasive examination performed by placing the probe on the patient’s abdomen.

Ultrasound enables the assessment of the size and morphology of the bladder and can help distinguish between benign and malignant lesions with good reliability. To obtain optimal images, the bladder should be well distended and therefore full of urine.

The examination is typically performed in a Radiology Department and usually takes about 10 minutes.

Computed Tomography (CT) is an imaging technique that uses X-rays to generate highly detailed, three-dimensional images of different parts of the body.

In the evaluation of bladder cancer, CT is used to determine the presence of a tumor and to assess whether it has spread to nearby lymph nodes or adjacent structures, including the ureters, the tubes that connect the kidneys to the bladder.

The examination requires the administration of an intravenous contrast agent and is typically performed on an empty stomach.

CT scans are usually carried out in a Radiology Department and take approximately 15 minutes. During the procedure, the patient is asked to remain as still as possible to ensure optimal image quality.

Histological examination plays a crucial role in the diagnosis and management of bladder cancer, as the disease can present with varying stages and biological characteristics that influence its aggressiveness and treatment strategy.

The examination is performed by a pathologist, who microscopically analyzes tissue samples obtained through a biopsy, either in an outpatient setting or during a surgical procedure.

Based on this analysis, the pathologist identifies the type of tumor. Approximately 75% of bladder cancers are non–muscle-invasive (superficial urothelial carcinomas), meaning they are confined to the inner layers of the bladder wall. The remaining 25% are muscle-invasive tumors, which have a greater tendency to extend beyond the bladder and invade surrounding tissues or organs.

Surgery for bladder cancer may involve either the removal of the tumor alone through transurethral resection of the bladder (TURBT), typically used for superficial and early-stage disease, or the removal of the entire bladder (radical cystectomy) in cases of more extensive or aggressive cancer.

Transurethral Resection of the Bladder (TURBT)

Transurethral resection of the bladder (TURBT) is a bladder-preserving procedure performed to remove tumors confined to the inner layers of the bladder.

The operation is carried out in the operating room under spinal or general anesthesia. A thin tubular instrument equipped with optical fibers is inserted through the urethra, allowing the surgeon to visualize the tumor and remove it from the bladder lining using an electrosurgical instrument.

Following the procedure, a urinary catheter is usually placed and remains in position for several days. Hospital discharge generally occurs within 48 hours, and most patients can resume normal physical activities after a few weeks.

Radical Cystectomy

Radical cystectomy involves the complete removal of the bladder, together with the surrounding lymph nodes.

When appropriate, the procedure can be performed using a minimally invasive robotic-assisted approach. Through several small abdominal incisions, laparoscopic instruments are inserted and controlled by the surgeon from a dedicated console. The combination of high-definition three-dimensional visualization and enhanced surgical precision allows for meticulous dissection while preserving healthy tissues whenever possible.

Potential benefits of this approach include:

• Faster recovery
• Reduced postoperative complications
• Shorter hospital stay

In many cases, robotic-assisted cystectomy enables preservation of the nerves responsible for erectile function in men and, in women, preservation of the uterus, ovaries, and vagina, helping maintain sexual function whenever oncologically feasible.

Urinary Diversion

Because the bladder is removed, a new pathway for urine drainage, known as a urinary diversion, must be created.

Options include:

• An ileal conduit, in which urine is diverted through an opening in the abdominal wall (stoma) and collected in an external pouch.
• An orthotopic neobladder, created from a segment of the intestine and connected to the urethra, allowing urine to be expelled through the natural urinary pathway.

Patients with a neobladder must learn a new method of bladder emptying and may require specialized rehabilitation and training to adapt to urinary function after surgery.

Radiation therapy can be an alternative to radical cystectomy for patients with muscle-invasive bladder cancer that remains confined to the bladder and has not spread beyond it, as well as for patients who are not suitable candidates for surgery because of other medical conditions.

Treatment is typically administered after transurethral resection of the bladder tumor (TURBT) and in combination with chemotherapy. This approach aims to eliminate any remaining cancer cells within the bladder while preserving the organ.

Radiation therapy uses a machine that delivers highly targeted radiation beams from outside the body directly to the bladder. Treatment is performed on an outpatient basis, usually five days per week (Monday to Friday) for 4 to 7 weeks. Each session lasts approximately 10 to 30 minutes, although the actual delivery of radiation takes only a few minutes.

Advanced radiation therapy technologies allow treatment to be delivered with greater precision, shorter treatment times, and reduced side effects. These include:

• Three-dimensional conformal radiotherapy (3D-CRT), which shapes the radiation beams to match the tumor’s anatomy.
• Intensity-modulated radiation therapy (IMRT), which delivers radiation with even greater precision by modulating the dose distribution around the tumor.
• Image-guided radiation therapy (IGRT), which uses imaging during treatment to account for normal body movements, such as breathing.
• Adaptive radiotherapy, which enables real-time adjustment of the treatment plan based on anatomical changes and the movement of surrounding organs.

These advanced techniques help maximize the radiation dose delivered to the tumor while minimizing exposure to healthy tissues.

Immunotherapy uses medications that help restore or enhance the immune system’s ability to recognize and destroy cancer cells.

For high-grade bladder cancer that remains confined to the bladder, treatment may include Bacillus Calmette-Guérin (BCG), a weakened bacterium originally developed for tuberculosis vaccination. When instilled directly into the bladder, BCG stimulates the patient’s immune system to attack cancer cells.

BCG may be administered after transurethral resection of the bladder tumor (TURBT), often in combination with other treatments, to reduce the risk of recurrence. In selected cases, it may also be used as part of a treatment strategy aimed at reducing the burden of disease before more extensive treatment.

The treatment is delivered directly into the bladder through a urinary catheter. The solution is retained in the bladder for several hours before being naturally expelled. Instillations are typically performed at weekly or monthly intervals and may continue for 1 to 3 years, depending on the treatment protocol.

For advanced or metastatic bladder cancer, other forms of immunotherapy are available and are usually administered intravenously.

Among these, Pembrolizumab has shown promising results. Studies suggest that, when administered before surgery in selected patients, it may help reduce tumor size or achieve complete tumor regression in some cases.

Chemotherapy refers to the use of drugs that destroy cancer cells by targeting their rapid rate of growth and division. Because these drugs also affect some healthy cells that divide quickly, treatment can cause side effects, which generally improve or resolve after therapy is completed.

For superficial (non-muscle-invasive) bladder cancer, chemotherapy is often used after transurethral resection of the bladder tumor (TURBT), sometimes in combination with immunotherapy, to eliminate any remaining cancer cells and reduce the risk of recurrence.

In these cases, chemotherapy is administered by intravesical instillation. The drug, in liquid form, is delivered directly into the bladder through a urinary catheter and retained for at least one hour before being expelled.

Treatment typically consists of multiple instillations, initially performed at weekly intervals and later at monthly intervals, although the schedule may vary depending on the characteristics of the tumor and the medication used.

The procedure is performed on an outpatient basis, is relatively quick, and is generally well tolerated.

For muscle-invasive bladder cancer, chemotherapy is usually administered intravenously. It may be given, alone or in combination with immunotherapy, either:

• Before surgery or radiation therapy, to reduce tumor size and improve treatment outcomes;
• After surgery, to decrease the risk of disease recurrence.

Intravenous chemotherapy is delivered in treatment cycles, which may be scheduled weekly or every few weeks, depending on the regimen used. Sessions are typically performed on an outpatient basis and can last from several minutes to several hours.

For advanced or metastatic bladder cancer, chemotherapy, often combined with immunotherapy, is used to slow disease progression, control metastatic lesions, and help maintain quality of life.

All cancer treatments can cause side effects that may affect the patient’s quality of life to varying degrees. In particular, treatments for bladder cancer, especially radical bladder removal in infiltrating disease, may lead to significant changes in daily life.

The Multidisciplinary Team (GIC), including physicians and nurses, provides ongoing support to help patients manage side effects both during treatment and throughout the recovery process. This includes assistance in resuming normal daily activities.

In particular, patients who have undergone cystectomy receive education and support on managing either an external urinary diversion (stoma) or a neobladder. They are also offered a structured rehabilitation program aimed at supporting recovery of urinary and sexual function.

The impact of bladder cancer extends beyond physical health and also affects the psychological well-being of the patient. A cancer diagnosis is often a traumatic event that can lead to anxiety, fear, anger, and depression, affecting multiple aspects of a person’s life.

In addition, patients with bladder cancer may experience sexual dysfunction and urinary incontinence, which can further impact self-esteem and emotional well-being.

For this reason, alongside advanced medical treatments, psychological support is an essential part of the care pathway for bladder cancer, helping patients manage not only physical symptoms but also emotional distress.

At the Candiolo Cancer Institute, patients who need it are offered specialized psychological support to help them cope with diagnosis, treatment, and side effects, as well as to adjust to changes in their social and professional roles.

Patients may also take part in psychological support groups, where they can share experiences with others who are facing or have faced a similar condition.

To ensure timely and direct support and to provide rapid answers to patients’ concerns and questions, a dedicated helpline is available at the Canciolo Cancer Institute.

From Monday to Friday, 8:00 a.m. to 5:00 p.m., patients can contact the Oncology Day Hospital secretariat at +39 011.993.3775 to request an urgent consultation.

The patient is then quickly put in contact with their medical specialist to receive clear information and immediate support.

The cancer patient has complex needs and requires multidisciplinary support, not only for the treatment of the disease but also for the management of associated conditions.

At the Canciolo Cancer Institute, patients who need or request it can access specialists in different areas to receive nutritional support, physiotherapy, pain management, and care for other related conditions.

The Social Service Department of the Candiolo Cancer Institute provides information and orientation interviews for patients and their families on how to access local services and obtain welfare and social security benefits provided by law, including disability support, assistance for aids and prostheses, and work leave provisions.

The service is available on Wednesdays and Fridays, from 9:00 a.m. to 1:00 p.m., and can be contacted at +39 011 993 3059.

After completion of treatment, a follow-up period begins. During this phase, a series of clinical evaluations and diagnostic tests are performed to monitor the effectiveness of therapy, assess treatment-related side effects, and evaluate the patient’s recovery.

Follow-up visits are particularly important for the early detection of disease recurrence, allowing timely intervention with appropriate treatment. In fact, the risk of recurrence after a first bladder tumor is relatively high, making careful surveillance essential.

The frequency of follow-up depends on the stage of the disease, the treatments received, and the patient’s overall health status.

In general:

• After a superficial tumor, cystoscopy is performed every three months for two years, then every six months for the following two years, and subsequently once a year, each time combined with urinalysis.
• After radical cystectomy, follow-up includes a range of examinations tailored to the patient’s clinical condition. These are typically performed every six months initially, then annually.

Thanks to the large number of cases treated each year, the Candiolo Cancer Institute is a national reference center for the care of this disease. This extensive experience allows us to manage even the most complex cases, always using a personalized approach, tailored to the clinical and individual profile of each patient.

Establishing a treatment plan always begins with an accurate and timely diagnosis. Patients have access to state-of-the-art imaging technologies, such as ultrasound, contrast-enhanced CT, MRI, and cholangio-RM, which are critical for accurately assessing the extent of the tumor.

Advanced laboratory tests, including molecular analyses, are also available to help define biological features of the disease and guide treatment choices.

When appropriate, surgeries are performed using minimally invasive, laparoscopic or robotic techniques. These approaches involve the use of camera-equipped instruments introduced into the abdomen through small incisions, thus reducing surgical trauma. Benefits to the patient include shorter hospital stay times, faster recovery, and lower risk of complications compared with traditional open surgery.

As an IRCCS (Scientific Institute for Research, Hospitalization, and Healthcare), the Candiolo Cancer Institute combines clinical care with a strong focus on scientific research. Patients can be considered for participation in active clinical trials, offering access to innovative therapies not yet available in standard practice. This integration of care and research is a distinctive strength that translates into tangible benefits for patients.

The Interdisciplinary Care Group (GIC or MDT) supports the patient at every stage: from diagnosis, through treatment, to follow-up. Special attention is paid to nutritional support, psychological health and reintegration into daily life. The organization of checkups, examinations, and treatment is designed to ensure continuity, serenity, and a humane, caring approach to each patient’s needs.