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Key Features

Essentials of Diagnosis

  • Gross or microscopic hematuria

  • Irritative voiding symptoms

  • Positive urinary cytology in most patients

  • Filling defect within bladder noted on imaging

General Considerations

  • Second most common urologic cancer

  • More common in men than women (3.1:1)

  • Mean age at diagnosis is 73 years

  • Risk factors: cigarette smoking, exposure to industrial dyes and solvents

Pathology

  • Urothelial cell carcinomas: ~90%

  • Squamous cell cancers: ~7%

  • Adenocarcinomas: ~2%

  • Bladder cancer staging is based on the extent (depth) of bladder wall penetration and the presence of either regional or distant metastases

  • Natural history is based on cancer recurrence and progression to higher stage disease. Both are related to cancer grade and stage

Clinical Findings

Symptoms and Signs

  • Hematuria is the presenting symptom in 85–90%

  • Irritative voiding symptoms in a small percent

  • Masses detected on bimanual examination with large-volume or deeply infiltrating cancers

  • Lymphedema of the lower extremities with locally advanced cancers or metastases to pelvic lymph nodes

  • Hepatomegaly or palpable lymphadenopathy with metastatic disease

Diagnosis

Laboratory Tests

  • Urinalysis—hematuria; on occasion, pyuria

  • Azotemia

  • Anemia

Imaging Studies

  • Ultrasound, CT, MRI show masses within the bladder

Diagnostic Procedures

  • Cytology useful in detecting disease at initial presentation or recurrence

  • Cytology very sensitive (80–90%) in detecting cancers of higher grade and stage

  • Imaging done primarily for evaluating the upper urinary tract and staging

  • Diagnosis and staging are by cystourethroscopy and tumor biopsy, as well as random bladder and, on occasion, transurethral prostate biopsies

  • Transurethral resection of bladder tumor (TURBT)

  • TURBT can be done under general or regional anesthesia

  • Resection down to muscular elements of the bladder

Treatment

Medications

  • Patients with superficial cancers (Ta, T1) are treated with complete TURBT (and selective use of intravesical chemotherapy)

  • Patients with large, high-grade, recurrent Ta lesions, T1 cancers, and carcinoma in situ are treated with TURBT and intravesical chemotherapy

  • Patients with more invasive (T2, T3) but still localized cancers require more aggressive surgery (radical cystectomy), or the combination of chemotherapy and selective surgery

  • Patients with muscle invasive (T2 or greater) urothelial cell carcinoma should receive neoadjuvant systemic chemotherapy prior to radical cystectomy

  • Intravesical chemotherapy

    • Immunotherapeutic or chemotherapeutic agents administered weekly for 6–12 weeks

    • Maintenance therapy after the initial induction regimen includes intravesical

      • Thiotepa

      • Mitomycin

      • Doxorubicin

      • Valrubicin

      • Bacillus Calmette-Guérin (BCG) instillation

    • BCG is the only effective agent in reducing disease progression

Surgery

  • Transurethral resection is diagnostic, allows for proper staging, and controls superficial cancers

  • Partial cystectomy is indicated in patients with cancers in a bladder diverticulum

  • Radical cystectomy with urinary diversion—a conduit of small or large bowel

  • Continent forms of diversion available, improve ...

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