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Actos Side Effects : CAN CYTOLOGY BE USED INSTEAD OF CYSTOSCOPY TO RULE OUT BLADDER CANCER?

Urinary cytology is the examination of urine using special stains to look for cancer cells. These cells would have been those that have broken off (exfoliated) from the lining of the urinary tract. Voided urine is sent for analysis. First voided morning urine should not be used as there is a higher rate of cellular degeneration. To enhance the yield of cells, the bladder can be barbotaged (flushed). Cytology is most useful for high grade or aggressive tumors and for those with carcinoma in situ (CIS). In low to intermediate grade tumors, cytology may not be positive because these tumors may not exfoliate cells into the urine. In addition, if low grade tumor cells are exfoliated, they may appear to the pathologist to be identical to normal bladder cells. Due to the limitations of sensitivity of cytology, it is not a very good screening test, but proves to be valuable in following some individuals who have already been diagnosed and treated for bladder cancer.

Because a positive cytology is very specific for cancer, it is highly predictive of transitional cell cancer even if no tumor is visible during cystoscopy. Additional information can be obtained with urine cytology. The DNA content and measurement of the amount of abnormal DNA can be determined. In general, as the amount of abnormal DNA is increased, the prognosis is worsened.

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ARE THERE ANY OTHER URINE TESTS THAT ARE HELPFUL IN MAKING THE DIAGNOSIS?

There has been continued research and a subsequent array of urine tests to screen for bladder cancer. Some of these newer tests include:

Bladder Tumor Antigen (BTA): measures basement membrane protein antigen released into the urine, a protein from the bladder wall.

NMP22: measures nuclear matrix protein 22

Aura Teck FDP: measures fibrin, fibrinogen degradation

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Telomerase: measures the enzyme used to preserve telomeres (the ends of chromosomes required to continue cell division) Hyaluronic Acid, Hyaluronidase: substances which have a role in blood vessel growth in bladder tumors and tumor progression. ^[1] Research goes on and newer tests may prove to be both more sensitive (positive if cancer is present) and more specific (not positive for other reasons). At this time, none of the urine tests are sensitive enough to take the place of cystoscopy in the initial evaluation of an individual suspected to have bladder cancer. In general, cytology as an adjunct to cystoscopy is more helpful than any of the urine bladder cancer tests to date.

AS PART OF MY INITIAL WORK UP, MY PHYSICIAN HAS ORDERED A CAT SCAN. WHAT’S THE PURPOSE AND ARE THERE ANY ALTERNATIVES?

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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MY FAMILY WANTS ME TO GO FOR TREATMENT OF MY BLADDER CANCER TO THE “TEACHING HOSPITAL” IN THE CITY MY LOCAL UROLOGIST IS COMPETENT AND CARING AND I TRUST HIS JUDGEMENT SHOULD I LISTEN TO MY FAMILY AND SWITCH UROLOGISTS?

As we have discussed in the preceding questions, finding an excellent urologist to partner with is a must. A physician established at a “teaching hospital” (a hospital where physicians are trained in their respective fields of specialty) is at the minimum, competent. A large teaching or academic center would not risk its reputation on an individual who is sub par. Some individuals may be world class surgeons, but not all will be. An individual may be an average surgeon, but a gifted teacher or researcher, making them invaluable to their academic center. Your local community urologist will likely be an individual trained at one of these academic teaching hospitals. In addition, community hospitals also have credentialing and quality review programs to weed out incompetent physicians. In general, it is true the academic center will have more stringent standards and review of their staff. Nevertheless, excellent physicians can be found at the community hospital as well.

ISN’T IT TRUE THAT ACADEMIC OR TEACHING HOSPITALS WILL HAVE THE BEST TECHNOLOGY OR MOST UP TO DATE INFORMATION TO TREAT MY CANCER?

These hospitals generally are at the forefront of innovation regarding technological advances, testing and implementation of new surgical techniques and chemotherapeutic regimens. However, no one center can be excellent in all spheres of medicine. Each will have particular strengths and weaknesses. We are however, fortunate medical knowledge and innovation are shared openly via medical journals and conferences and other means of information exchange. New information and proven effective techniques are rapidly disseminated throughout the medical community. Some teaching hospitals may be “centers of excellence” for a particular procedure or innovative approach that is available at only a few sites in the country. There is naturally a lag time for some procedures to spread to the local level, and if in fact a new procedure carries substantial benefits compared to the standard, and is not available locally, then a referral may be appropriate.

Medical information is scrutinized in journals and reviewed at conferences. The newest treatment regimens for advanced cancer are explored in clinical trials to determine their efficacy and safety. It is only after they are proven that they become adopted as standard practice by most physicians. For the vast majority of individuals with bladder cancer, excellent, comprehensive treatment can be obtained at the local level. For those requiring more specialized care or for those unfortunate individuals with advanced cancer who desire experimental therapy via a clinical trial for their cancer, a referral to the appropriate center may be appropriate.

IF I HAVE MY MAJOR SURGERY PERFORMED AT A TEACHING HOSPITAL, WILL THE ATTENDING PHYSICIAN PERFORM MY SURGERY AND TAKE CARE OF ME AFTERWARDS?

At a teaching hospital, physicians are in training to master their skills before going out into “practice” in their respective fields. Interns are fresh out of medical school with limited practical training. Often they are referred to as PGY 1 (post graduate year 1). Years of training follow (PGY2, PGY3 etc.). Urology residents are required to generally have at least two years of training in a surgical program followed by four years in urology residency. It is the responsibility of the residency director to provide adequate training for these future urologists while assuring patient safety. Practically speaking, there are usually one or more attending physicians who supervise the work of the physicians in training. The attending physicians are board certified, experienced physicians who treat patients while simultaneously training physicians. The residents will be a key component in your care. They will be assessing you both pre- and post-operatively and will be writing orders directing your care. How much of the surgery they get to do is dependent on their years of training and their skills. They will be under the direct supervision of the attending physician. If you have concerns, you should address them with your attending physician.

MY UROLOGIST ALWAYS KEEPS ME WAITING, DOES THIS MEAN HE DOESN’T CARE?

Given the monetary pressures in today’s medical practice, some physicians are over booked and cannot see the allotted number of patients scheduled without delays. The theory behind this schedule is the expectation that a number of patients will not show for their appointment, allowing the physician to stay true to the schedule and not fall behind.

However, sometimes all of the patients do show, and the physician is delayed. Even with a carefully thought out schedule, emergencies may arise and some visits unexpectedly take longer than scheduled. The physician wants to devote the time and attention required for each individual. After all, you also expect the same time and attention during your visit. Even the most conscientious physician may find himself running behind in a busy medical practice. This lateness should be recognized by the physician who will often acknowledge it with an apology. If you find it distressing to wait more than fifteen minutes (a reasonable time to wait), you should discuss your feelings with your physician, who often can arrange an appointment at the beginning of the schedule when he will almost be guaranteed to be on time.

WILL THERE BE OTHER PHYSICIANS INVOLVED IN MY TREATMENT OF BLADDER CANCER?

You may need to be referred to an oncologist, a physician specialist in the medical therapy of cancer. At times, a referral to a radiation oncologist, a specialist who treats cancer with radiation, may be required. Other individuals may need to be consulted as well. It is important for your urologist to keep your primary care physician up to date so that he can coordinate your care and if required by your insurance plan, make the appropriate referrals.

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On a regular basis, magazine articles, books, and television shows implore those with major illnesses to seek out a second opinion. The general consensus is there is much to be gained and little to be lost, so why not seek out a second opinion? The issue certainly is more complicated than generally addressed, and deserves a review. The following chapter provides a second opinion on second opinions.

WHAT ABOUT SECOND OPINIONS?

In general, a competent physician will recommend a second opinion if there is uncertainty regarding your care. This uncertainty could involve the pathology report or debate regarding the most appropriate treatment options. Certainly if the pathology report is in question, a second opinion is mandatory! Your urologist should be able to spell out his treatment plans for you, what to expect and what alternatives may be required, depending on the seriousness of your disease. The plan may change over time as your disease improves or worsens.

You may need a second opinion if you are not doing well and your physician is unable to provide satisfactory explanations and solutions. Occasionally, your urologist may recommend a second opinion if your problem is unusual or particularly complicated. Having a physician you can trust is mandatory when dealing with cancer. Don’t let anyone pressure you into a second opinion if you feel confident in your physician’s abilities. On the other hand, if you are uncomfortable with your progress or a treatment recommendation, if you are not satisfied with the explanations given to you, don’t hesitate to seek out a second opinion. Your urologist should not feel threatened by this request as he wants you to feel comfortable with the plan of action. Only by partnering with your physician can he be most effective.

WILL MY UROLOGIST BE UPSET WHEN I REQUEST A SECOND OPINION?

Many physicians may feel slighted when a patient requests a second opinion. Your urologist may feel somehow you don’t trust his explanations, skill, or judgment. On the other hand, when a new patient faces a difficult or unexpected diagnosis, the urologist may find the request not at all unusual. It is important you explain to your urologist why you feel a second opinion is warranted. Urologists are professionals and will graciously facilitate your request. The experienced urologist comes to realize that despite his best efforts, some patients will seek a second opinion. If a patient is particularly concerned or nervous about a proposed treatment regimen, your urologist may welcome your request. Your urologist should facilitate your second opinion by sending appropriate records and telling you whether or not it is necessary for you to bring X rays or pathology slides with you. Your primary care physician may need to be contacted for the referral if your insurance requires it.

WHY DOESN’T MY UROLOGIST WANT ME TO GO FOR A SECOND OPINION?

Often, the urologist may believe the second opinion is unnecessary and will delay treatment. He may be concerned you will not only have a second opinion, but transfer your future care to the urologist providing the second opinion. He may believe that you may get bad advice. It is possible he may feel threatened the next urologist will not agree with his work up or care of you to date.

WHERE DO I FIND A SPECIALIST FOR A SECOND OPINION?

Start by asking your primary care physician. You may be able to see another urologist in your community. Do not see another urologist in the same group as a conflict of interest may deter a different opinion. If you are considering a different course of action, such as radiation or chemotherapy, a referral to the appropriate specialist should be made.

Many times your urologist will be highly supportive and suggest a second opinion. He will offer his recommendations and facilitate your visit to the appropriate physician. If there is an issue regarding the care given at your local hospital, you may wish a referral to a “tertiary” or teaching hospital. In most areas, a referral for this reason is unnecessary, as excellent care is obtainable in the community hospital.

Our use of the term or terms Actos Side Effects 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 Side Effects : WHAT IS THE FUNCTION OF THE BLADDER?

A bladder stores urine and expels it at a convenient time. The bladder is a very useful organ, (tissues working together to accomplish a function), but an individual can live a normal life without one, if required, by surgical creation of a substitute.

ARE THERE DIFFERENT TYPES OF BLADDER CANCER?

More than 90% of bladder cancers arise from the lining bladder cells called transitional cells. Bladder cancer is almost always transitional cell cancer. These cells are also present in the urethra (the body tube which drains the bladder), as well as the renal pelvis (inner lining of the kidneys), and the ureters (the body tube draining the kidneys).

Bladder cancer can vary from the non serious, low grade superficial type (approximately 70%), to the invasive, aggressive type that can spread and prove to be fatal (approximately 30%).

5% of bladder cancer is accounted for by squamous cell carcinoma. This cancer is usually secondary to long term inflammation or infection of the bladder. Even rarer is adenocarcinoma, which accounts for less than 2% of all bladder cancers.

HOW COMMON IS BLADDER CANCER?

The American Cancer Society estimates that in 2006,61,420 new cases of bladder cancer were diagnosed in the United States with approximately 73% of those occurring in men. In the same year, this cancer caused approximately 13,060 deaths with approximately two out of three of those being in men. The disease is more common in whites than blacks. The incidence of bladder cancer increases with age in both sexes. When bladder cancer occurs in young people, it tends to grow slower and not be as serious. In men, it is the fourth most common cancer. However, because of the rate of recurrences and long term survival, it is the second most prevalent cancer in middle aged and elderly men. In women, it is the eighth most common cancer. The average age at diagnosis is 65. Over the past decade, there has been both an increased incidence, but also an increased rate of survival for bladder cancer ^[1]

WHAT CAUSED MY CANCER?

A mutation is a disruption in the DNA of a cell, leading to a loss of regulated cell growth. Mutations can occur spontaneously as we age. It is truly amazing that all of us don’t develop cancer as we are composed of trillions of cells dividing regularly over decades. Fortunately, our cells have repair mechanisms which can often fix damaged cells before cancer arises. In addition, the immune system can destroy cancer cells before they have a chance to grow into tumors.

Mutations and cancer can also be triggered by environmental factors. Certain chemicals have been identified to be particularly effective at inducing mutations in our DNA and subsequent cancer. These chemicals are called carcinogens. Smoking is the most common culprit! Cigarette smoking has a strong link with bladder cancer. Studies have shown approximately 50% of bladder cancer is secondary to tobacco smoke. Smoking releases dozens of carcinogens into the lungs and then into the blood stream. Many of these carcinogens are excreted by the kidneys.

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IT IS TOO DIFFICULT TO QUIT SMOKING; IS THERE ANY SURE FIRE WAY TO QUIT?

Tobacco smoke contains nicotine, an extremely addictive chemical. Men overall find it easier to quit smoking than women. When facing the prospects of losing your bladder to cancer or possibly your life, most individuals will become convinced and many simply stop smoking “cold turkey.” Unfortunately, many choose not to quit until their cancer repeatedly recurs or becomes invasive, needlessly placing their health at risk. For those who need assistance in quitting, nicotine patches, gum, and lozenges are all available over the counter. These products allow the smoker to quit without experiencing the discomfort of withdrawal from nicotine. Many smokers also find hypnosis or support groups useful. In addition, prescription medication is available.

ARE THERE ANY OTHER KNOWN CAUSES?

Occupational exposure may account for up to 20% of bladder cancers. Those exposed to aniline dyes (used to color fabrics), aldehydes (used in chemical dyes and in the rubber and textile industries) and those using organic chemicals (used in a wide range of occupations) are all at increased risk. Individuals previously treated with radiation to the pelvis or having received cyclophosphamide (a type of chemotherapy) are at markedly increased risk for developing bladder cancer. If your well water is high in arsenic, your risk may also be increased. Studies have also correlated obesity and a high fat diet, especially with increased cholesterol, as a possible contributing factor.

CAN I HELP TO PREVENT BLADDER CANCER BY DRINKING MORE FLUIDS?

Surprisingly, the answer may be yes. In a recent study, the relationship of diet to cancer was analyzed in a group of47,000 health professionals.^[1] In the case of bladder cancer, those who drank the most fluid (greater than 10 cups/day) had half the risk as those who drank the least (less than 5 cups/day). The type of nonalcoholic beverage was less important than the total amount.

WILL MY CHILDREN BE AT HIGHER RISK OF DEVELOPING BLADDER CANCER?

Although there have been clusters of bladder cancer reported, most researchers believe these may be secondary to risk factors such as smoking and exposure to carcinogens. At this time, there is no convincing evidence bladder cancer risk is hereditary. If an environmental factor caused your cancer and your children are exposed as well, their risk of cancer may be increased.

WHAT IS CANCER?

The basic building block of the body is the cell. Cells are specialized to perform a particular function. Skin cells are distinctly different from liver cells which are different from bladder cells. An organ is composed of various cells working in unison to carry out a body function. Cells eventually get old and die. New cells are created by cell division. When cells are behaving normally, they only generate enough new cells to replace the old dying ones. Occasionally, cell growth becomes unchecked. As the cells continue to divide, a tumor (abnormal growth of cells) may form. Such tumors may be benign (no ability to spread beyond their organ of origin) or cancerous (a malignant tumor with the ability to spread beyond their organ of origin and cause harm and possibly death).

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HOW CAN I TELL IF MY BLADDER CANCER IS LIKELY TO SPREAD?

Larger tumors are more likely to spread than smaller tumors. Another critical concern is the grade of the tumor. Normal cells are specialized, differentiated to perform specific function, and have a typical structural arrangement with surrounding cells. As cancers worsen, the cells become less specialized, less differentiated, and lose their normal structural arrangement, resulting in a higher pathologic grade.

In the case of bladder cancer, pathologists classify them into 3 grades based on a number of criteria:

Grade 1: low grade, well differentiated Grade 2: intermediate grade, moderately differentiated Grade 3: high grade, poorly differentiated The higher grade tumors have a greater propensity to metastasize- spread throughout the body.

For bladder cancer, another key indicator for likelihood to spread is the depth of penetration into the bladder wall. The bladder wall is composed of an inner lining called the urothelium (made up of transitional cells) which rests on a membrane layer called the basement membrane, below which is the connective tissue layer (support tissues) called the lamina propria. Within the lamina propria lies a small amount of muscle called the muscularis mucosa. Deep to the lamina propria is the deep muscle of the bladder arranged in three layers. This layer is called the muscularis propria. Tumors located in the inside, superficial layers of the bladder wall are unlikely to spread. Tumors that grow into the deeper layers (down into the muscle of the bladder wall) are much more likely to spread. Furthermore, there is a definite link between the grade of the tumor and its likelihood of invasion. Low grade tumors are almost always noninvasive, while high grade tumors are usually invasive. In general, papillary tumors, which are delicate and frond like in appearance are usually low grade and superficial. This is to be contrasted to sessile tumors which appear solid, are often high grade and invasive. Depth of invasion is critical in establishing prognosis. The tumor which invades into the lamina propria is a far more serious tumor than the superficial tumor which demonstrates no invasion. It has a much higher propensity to progress to the muscle invasive tumor, a much more dangerous cancer, with a high risk for spreading beyond the bladder. For further information see Chapter 6.

Our use of the term or terms Actos Side Effects 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 Side Effects : The MRI machine is a big metal box with a tunnel through its middle and a narrow sliding table. You’ll lie on the sliding table, which will move you slowly through the electromagnetic field or “tunnel” of the MRI machine. An MRI can take anywhere from 15 to 45 minutes. Some MRI machines are closed cylinders; others have wider tunnels and open sides to reduce the claustrophobic feelings that some peo­ple experience. If you suffer from claustrophobia – the fear of close or enclosed spaces – you should warn your doctor that you might not be comfortable having an MRI scan.

You’ll wear a gown, and as with the CT scan, the radiology techni­cians leave the room during the scanning process, but you’ll be able to communicate with them through an intercom. Sometimes a friend or relative is permitted to sit in the room with you, particularly if you are claustrophobic. Sometimes if you are claustrophobic a gentle sedative is used to help you to feel comfortable in the machine. Sometimes a contrast medium is used, usually intravenous, in which case you might experience a cool sensation. YouTl be asked to remain very still for short periods while the images are being taken, usually anywhere from a few seconds to a few minutes at a time. You’ll be able to move slightly between “takes” or images.

Other than what many patients describe as a “closed-in” feeling, the single most uncomfortable part of an MRI is not being able to move about. Sometimes you’ll also hear a banging sound as the scans are being taken. This can be surprisingly noisy. Many physicians feel that the MRI scanner is a useful alternative to the CT scanner, but results can be more difficult to interpret when the MRI scan is focused on the back of the abdomen, the pelvis, and bladder, so generally CT scans are more frequently used.

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Usually performed under general anesthesia in a hospital, a biopsy via a rigid cystoscope allows the physician to examine your bladder manually for any abnormalities (again, by inserting a finger into the rectum and feeling the local tissues) and then to remove small amounts of tissue. These can then be examined microscopically and used to confirm the presence of cancer and the invasiveness of the disease, as well as to help determine the appropriate treatment.

Sometimes, in the case of small or superficial tumors, the physician will remove the entire tumor and surrounding tissue for biopsy. As with all surgeries or invasive procedures, a biopsy may involve some pain as well as a brief recovery time that might call for some limita­tions on physical activities for a day or two. The urologist will pre­scribe pain-relieving medication to reduce the severity of discomfort.

A chest x-ray is a type of x-ray process that takes about 10 min­utes. You’ll wear a gown and remain standing during the x-ray. The radiology technician will ask you to stand in several positions and will take x-rays of the chest area. It’s a painless process and doesn’t require that you inject or drink any contrast medium. This test can indicate whether the cancer has spread to the lungs and also can reveal other, unrelated medical conditions, such as a chest infection. A bone scan uses a very small amount of a radioactive tracer injected into the bloodstream. Bone absorbs the tracer, which gives off gamma rays; these are then scanned to identify areas of abnormality. The purpose of this test is to monitor for the presence of cancer metastases in the bones, but it can also detect infection or arthritis sometimes.

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It’s a time-consuming test. It takes about three hours for the bone to absorb the tracer after it’s injected into your vein (usually in an arm). What usually happens is that after the tracer is injected, you’ll leave for a few hours or wait in the waiting room. (Bring a book.) The scan itself will take about an hour. For the scan, you’ll lie on a stationary table while a big cylinder ~ actually a gamma camera – moves up and down the table taking pictures. The cylinder doesn’t enclose you to the extent that an MRI machine does and usually doesn’t provoke a claustrophobic feeling. As with a CT or MRI scan, you’ll lie on a table, wearing a gown, and will have to remain still when the gamma camera is clicking away, sometimes for several minutes at a time. You’ll be asked to change positions several times during the scan, a welcome relief after you’ve had to remain motionless.

Sometimes tests on the urine are done to determine the presence of biomarkers. These are proteins that may be liberated by bladder-cancer cells into the urine. One example is the NMP22 or Bladder Check test For this, a few drops of voided urine are tested chemically on a glass slide. Some physicians believe that the NMP22 is more sensitive and more accurate than the more conventional cytology test, in which urine is examined for cancer cells under a microscope.

Our use of the term or terms Actos Side Effects 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 Side Effects: Roughly 5-10 percent of patients experience a fever after a transurethral procedure. This is almost always due to a urinary tract infection. The most common symptoms of a urinary tract infection in this setting are fever, chills, side pain, and frequent or painftil urination. If you experience a fever postoperatively, you should contact your physician immediately. The vast majority of infections can be treated as an outpatient with oral antibiotics and resolve in several days. Most urologists give you antibiotics during your procedure and for a few days thereafter to prevent infection, but unfortunately a small percentage of patients will still experience an infection despite taking antibiotics. It is important to note that most patients have lower urinary tract symptoms after surgery. This is directly related to the manipulation from the cystoscope and any biopsies or resection that were performed. These procedures cause bladder and urethral inflammation, which may cause you to experience painful urination, urinary frequency, and urgency for several days after the procedure. These symp­toms are very similar to that of a urinary tract infection and can be confusing, but they do not cause fever like a urinary tract infection. If you are unsure whether your symptoms are a result of an infection or the procedure, the safest bet is to consult your urologist as soon as possible.

Urinary retention (inability to pass the urine) is another uncommon and generally self-limiting complication one can experience after surgery. In men, this is often caused by swelling of the prostate due to manipulation from the cystoscope. Excessive bleeding may also result in clot formation that can obstruct the flow of urine. Patients who experience this side effect urinate in small volumes or not at all, even though their bladder is uncomfortably full. The treatment for this is simple; a catheter is placed in your bladder for a few days to allow any edema (swelling) to resolve. The catheter can then be removed several days later and most patients void without difficulty at that point.

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Radical cystectomy and associated urinary diversion is a complex procedure. Even in the best of hands, the potential for side effects and complications is significant. The most common side effects and complications related to this procedure are discussed below. Although this will give you a good understanding of what to expect after surgery, it is very important that you discuss the risks of cystectomy with your urologist before surgery to be as fully informed and prepared as possible.

As with any major surgery, there is potential for bleeding during your surgery. Twenty-five to 50 percent of patients need a blood transfusion either during surgery or in the immediate postoperative period. Your surgeon may ask you to donate your own blood before surgery, so that it can be given back to you at the time of your operation. This is to minimize the risk of infection with transfusion-related bloodbome illnesses such as HIV and hepatitis. Because this risk is extremely low, many surgeons do not require you to donate your own blood. Your blood count will be monitored for the first several days after surgery because in rare circumstances bleeding can occur after surgery. Depending on your blood count at the time of discharge, your physician may send you home on iron supplementation.

There is a small risk of infection after surgery. Post- surgical infections can occur in the abdominal wound, intra-abdominally at the site of bladder removal, and also in the urine (urinary tract infection) or kidney (pyelonephritis). Most infections can be successfully treated with antibiotics. Wound infections can require a portion of your incision to be opened to allow drainage of infected material. This is easily done at the bedside and is not painful. Once the infection clears, the wound heals on its own without any further therapy.

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Sexual function is often affected after cystectomy and is a major quality of life issue for both men and women under­going this procedure. In men, the vas deferens (the tubes that carry sperm from the testicles) are cut, resulting in infertility. Although infertility is not a major issue for most men undergoing cystectomy, you should discuss this with your urologist before surgery if you are planning to have children in the future. Because the nerves responsible for erection are located along the base of the prostate, erectile dysfunction is a common side effect after surgery. In high­ly selected cases, these nerves can be spared at the time of surgery, leading to improved potency outcomes. Erec­tile function after surgery depends on three main factors: age, preoperative function, and nerve sparing at the time of surgery.

Young men who have good erectile function before surgery are much more likely to have erectile func­tion afterward than older men or those with preexisting erectile dysfunction. There are a variety of options to help with ED following surgery including the use of vacuum devices, oral medications (i.e., Viagra, Levitra, or Cialis), injection of medications directly into the penis, or a pe­nile implant. In recent years there has been a trend toward preservation of the female sexual organs at the time of cystectomy, including the uterus, ovaries, fallopian tubes, and vagina. Such organ preservation strategies have also led to improved sexual function in women undergoing radical cystectomy.

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Actos Side Effects: A diagnosis of urothelial cancer (also known as transitional cell cancer) can mean many different things. Urothelial can­cer is not a single type of cancer; it is classified by shape and whether it is restricted to the inner surface of the bladder (superficial to underlying tissues and muscle) or invasive, as well as by stage and grade of development.

The words transitional cells describe how the cells appear under the microscope. Transitional cells share features with various types of cells normally found near the bladder. Since 2009, pathologists have altered the common term to “uro­thelial cancer” to acknowledge the fact that all these cells arise from the lining of the ureters, bladder, and urethra, the urothelium.

The human bladder is composed of several layers. On the innermost surface (which is next to where urine is stored) is a layer of cells known as the transitional cell epithelium. This layer varies in thickness from three to seven cells.

If your doctor described your tumor as being confined to the transitional cell epithelium, the tumor is a superfi­cial tumor. About 74 percent of UCs are noninvasive and superficial when diagnosed, although superficial tumors may eventually progress to a more invasive stage. The word superficial has to be used carefully because it does not neces­sarily mean that the tumor is safe and doesn’t have a dan­gerous potential. In other words, some “superficial” tumors actually have a high malignant potential and the ability to spread elsewhere in the body. A diagnosis of invasive UC means that the cancer has progressed into other layers of the bladder wall, such as the intermediate ceil layer or the muscle.

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If the results of your tests-—-either scans or biopsies-—- show that cancer has spread to other tissue or organs, your doctor will want to confirm that. Clarification of the stage of your cancer comes through looking at the cancer cells from those organs under the microscope. Tissue samples may be taken at the time of your biopsy, or sometimes a needle biopsy is done, bypassing the need for additional surgery.

Pathologists stage bladder-cancer tissue by using a stan­dardized system known as TNM, which stands for tumor- nodes-metastases. A typical TNM might be “T2aNlM0” (T-two-a-N-one-M-zero). Looks like mumbo jumbo, doesn’t it? Try thinking of it as medical shorthand, with each letter and numeral having a defined value that gives doctors and pathologists a specific, consistent way to describe how deeply a cancer has invaded the body’s tissue and organs. The TNM system uses the letters T, N, and M followed by numerals to describe the stage of invasiveness of your cancer. The letter T followed by a numeral from one to four (1 to 4) describes the depth of invasiveness of your tumor. The lower the number, the less invasive the cancer.

The T scale has additional, more detailed levels as well. These levels add the lowercase letters a and b to the T score to delineate more precisely how far into the bladder your cancer has spread and whether it has moved into other areas of your body. It fine-tunes the pathology information to help your doctor make treatment recommendations.

The first T level refers to Ta or Tl tumors, which are superficial in nature. These noninvasive tumors can be pap­illary or carcinoma in situ (CIS), and have penetrated only the epithelium or intermediate cell layers of the bladder. This is an early, highly treatable stage of bladder cancer. The Ta tumor is the least invasive (or most superficial) variant, whereas theTl tumor shows the beginnings of invasion into the first layer of the bladder wall (before muscle is reached).

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Tumors that are invasive and have moved into the mus­cle layer of the bladder are classified as T2. The lowercase letters a and b are used to describe how far into the muscle the tumor has spread. A T2a tumor has not penetrated as deeply into the muscle as a T2b tumor.

Tumors classified as T3, which can be further classified by the letters a and b, have penetrated beyond the bladder wall and into the fatty tissue surrounding the outside of the bladder. A T3a tumor is visible only with a microscope. A T3b tumor is visible in scans or to the naked eye during surgery. AT4 tumor, the most serious and advanced of this local tumor grouping, has spread to other tissues or organs. A T4a tumor has inyaded the nearby uterus or vagina in a woman or the prostate in a man. A T4b tumor has spread through the pelvic or abdominal wall into the body.

The letter N, followed by a numeral from one to three (1 to 3), tells your doctor whether your cancer has spread to lymph nodes near the bladder and how deeply the cancer has penetrated the nodes. The higher the number, the more lymph nodes are involved and the more enlarged the nodes are. The letter Mfollowed by a one or a zero (1 or 0) indicates whether your cancer has spread to lymph nodes in other parts of the body (beyond the pelvis) or to other organs such as the lungs or liver. A zero indicates that the cancer has not spread to other organs; the number one means that it has.

Our use of the term or terms Actos Side Effects 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 Side Effects: Surgery is a skill which can only be mastered with experience. The saying “practice makes perfect” definitely pertains to surgery. Although a urology training program offers the new physician years of training, his surgical skills will continue to improve with further experience. However, each individual physician has his own innate skills. Some more quickly learn and are simply better at the technical craft of surgery than others. For the most part, urologists finishing an accredited urology program have the training and skill set required to care for patients with bladder cancer.

Experience also counts. As a physician practices the art of medicine, his depth of knowledge and ability to treat grows. Ask your physician how long he has been treating patients with bladder cancer. If you require major surgery ask how many he has performed and if his complication rate matches what is expected.

Physicians by and large do improve as they practice, and all physicians are required to show that they are continuing to learn by partaking in continuing medical education, a requirement to remain licensed. Most physicians are compulsive in their medical practice and care deeply in the care they deliver. They continually strive to improve.

Some physicians may become “burned out” over the years as they continue to face the pressures of a busy medical practice. Similarly, towards the end of a surgeon’s career, technical skills may slip due to aging. New urologists are trained in the latest techniques and are familiar with recent medical literature, but may lack practical experience. In the end, recommendations from others and reputation may be your best guide to finding a qualified physician.

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Ideally, you should have a competent, technically skilled surgeon who is also approachable and compassionate. You should be able to freely ask questions pertaining to your disease and treatment. Your physician should answer your questions forthrightly. Although some patients prefer a surgeon who will take over all aspects of care with no questions asked, most prefer in depth explanations, especially when alternatives exist and risks are involved.

Your urologist must be an individual who takes your concerns, priorities and values seriously. Your urologist should be a good communicator. It is his responsibility to keep you fully informed of your progress, make you aware immediately if things are not going well, and educate you fully in treatment alternatives. Your specific values should be incorporated into the decision process if alternatives are available. Even if your urologist makes a recommendation and you choose an alternative course (unless you are putting yourself in extreme jeopardy), he should honor your choice and continue his care of you. Becoming an educated patient will make your decision making process easier. Granted, your physician should provide you with the basics, however having time to review and digest the material will allow you to fully understand and accept your treatment regimen, providing you with peace of mind.

Beware of the physician who bombards you with statistics and studies and leaves the decision making to you. After all, you are not a physician and don’t have the practical hands on experience he does. Your physician should provide the facts and the statistics, guide you through the information, and make treatment recommendations based on your preferences.

You may find yourself emotionally distraught and overwhelmed. Having a physician on your side is invaluable. You should be able to trust your physician. Complete honesty on the part of your doctor in his care of you is a must. From the doctor’s point of view, trust is also a necessity. Physicians have an extremely difficult time dealing with individuals who do not trust them. Without trust, the physician patient relationship is extremely hindered.

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Given the monetary pressures in today’s medical practice, some physicians are over booked and cannot see the allotted number of patients scheduled without delays. The theory behind this schedule is the expectation that a number of patients will not show for their appointment, allowing the physician to stay true to the schedule and not fall behind.

However, sometimes all of the patients do show, and the physician is delayed. Even with a carefully thought out schedule, emergencies may arise and some visits unexpectedly take longer than scheduled. The physician wants to devote the time and attention required for each individual. After all, you also expect the same time and attention during your visit. Even the most conscientious physician may find himself running behind in a busy medical practice. This lateness should be recognized by the physician who will often acknowledge it with an apology. If you find it distressing to wait more than fifteen minutes (a reasonable time to wait), you should discuss your feelings with your physician, who often can arrange an appointment at the beginning of the schedule when he will almost be guaranteed to be on time.

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Actos Side Effects:Your procedure will likely be scheduled at the hospital surgicenter as an outpatient. Depending 011 the extent of surgery and your general health, you may be required to stay in the hospital afterwards. There will be numerous forms to fill out, including consents for surgery and anesthesia. You will be asked whether or not you have a living will or power of attorney. Both the expected surgery and anesthesia planned will be fully discussed with you, including potential risks and alternatives. Your urologist will perform a history and physical exam to make sure you are fit for surgery. If you have multiple potentially serious medical problems, you probably have already had a pre operative visit with your internist, cardiologist or appropriate primary care physician.

You will be asked whether or not you have any drug allergies, artificial joints, or other medical devices implanted, such as a pacemaker. An IV (intravenous line) will be inserted into a vein in your hand or arm. You will be wheeled on your stretcher to the cystoscopy room and then positioned on the cystoscopy table. Small paste on leads will be placed to monitor your heart and a small device will be clipped over your finger to monitor the level of oxygen in your blood. You will then be given your appropriate level of anesthesia. Depending on the size and location of the tumor(s) and the difficulty of the procedure, your urologist will likely make a recommendation to you regarding the level of anesthesia required. He may give more than one choice. Risks of each will be reviewed with you by the anesthesiologist or nurse anesthetist (a nurse specialized in giving anesthesia).

Local with sedation: a numbing gel is squirted into your urethra and you are given intravenous sedation. Advantages include the lowest level of anesthesia, potentially with the least side effects and risks and quickest post op recovery from anesthesia. Many individuals are concerned they will experience pain. For small tumors and relatively minor surgery, this is an excellent form of anesthesia with very few patients experiencing pain or adverse reactions. If you do experience significant discomfort, your level of anesthesia can be changed to spinal or general.

Spinal anesthesia: accomplished by passing a fine needle into the lower spinal canal and injecting an anesthetic. Advantages include the ability to provide almost complete blockage of all pain and sensation during the surgery. The patient can continue to breathe on his own (a possible advantage for those with lung disease). Disadvantages include the occasional difficulty in giving the spinal (usually done rapidly with minimal pain, but sometimes difficult with pain), slower recovery from anesthesia (the length of spinal anesthetic is based on the amount and type of agent used and can generally be timed to match fairly closely the anticipated length of your procedure) and the possibility of a post spinal headache (not very common, but can last a day or more and be moderate to severe).

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General anesthesia: delivered through IV medications and anesthesia in a gaseous mixture via a mask or endotracheal tube (a tube inserted down your throat into your trachea, your main airway). The choice of mask or endotracheal tube is generally decided by the anesthetist. This decision is based on the length of the anticipated procedure, your general health, and how easy it is to “ventilate” or provide oxygen to you with a mask alone. The advantage of general anesthesia is total blockade of all pain and sensation (you are unconscious). For healthy individuals with large tumors or with expected difficult surgery, this method is often the best form of anesthesia. For those in whom spinal anesthesia is not possible and a large tumor is present, general anesthesia is the best option.

For many years, hospitals required indiscriminate preoperative testing, often including numerous lab studies, chest X ray and EKG. Today, the medical industry is more cost sensitive. Most centers will require only necessary tests based on your age, medical history, and medications. An EKG is often requested for those with heart disease and for individuals over the age of 50. Specific labs are required if you have a chronic illness or are taking medication which can change the bodies normal chemical balance. Reserving blood from the blood bank is rarely required unless you present with a low blood count from hematuria or from another illness.

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The urologist will often start by introducing a rigid cystoscope to examine the urethra and bladder. During the exam, your bladder will be filled with sterile water which travels through the scope. This is necessary to expand the bladder lumen fully, allowing a complete examination. Patients often are concerned too much fluid will be instilled, resulting in possible injury to the bladder or worse, a rupture. Because the water is instilled with only minimal pressure, bladder injury should not be a concern. The urologist can shut off the irrigation readily when the bladder is full and can empty the bladder at any time. After the cystoscopy is completed, the urologist then removes the bladder tumor(s).

If the tumors are small, he may simply use a biopsy forceps through the cystoscope (an instrument which has a small cup like end to remove pieces of tissue). Deep biopsies at the base of the tumor (especially when one is dealing with solid tumors as opposed to papillary variety) may be obtained using the same biopsy forceps. The tumors and deep biopsies are sent to the pathologist for examination. Additional biopsies from any suspicious areas or possibly the prostatic urethra may be done. After the tumor removal and biopsies are completed, electric current is used to stop any bleeding. The urologist steps on a pedal to turn the electric current on when the cable is touching the bleeding blood vessel.

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Actos Bladder Cancer 12/20/2011: The elderly, frail individuals with multiple coexisting chronic illnesses, individuals that are weakened through mahiutrition or who have compromised immunity all would face substantially increased risk of complications from standard chemotherapy regimens for bladder cancer. Unfortunately, cisplatin is toxic to kidneys, and many individuals with bladder cancer have compromised kidney function which effectively rules out the use of platinum based chemotherapy. Other treatment regimens exist and are being worked on for these individuals, but none show the efficacy of the standard therapy which includes cisplatin.

Most individuals treated with standard chemotherapy regimens with metastatic bladder cancer will have recurrence and progression of their disease. Multiple treatment regimens have been utilized with overall response rates of 10-40%.^[1] To date, regimens have generally used taxanes, both docetaxel and paclitaxel. Ifosfamide has been shown to have significant single agent activity as well, but is extremely toxic. Combination therapy with taxanes and ifosfamide are presently being tested.

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