Bladder Ca

• Bladder tumor


  A type of tumor that occurs in the bladder

  
• Bladder cancer


  • 2nd most common tumor in urology
  • Important symptom is hematuria (blood in urine)

  
• Not every red color urine is hematuria (important)
• Hematuria patient should be called up urgently
• Treatment for bladder cancer is done by urologist
• Differential diagnosis (DDx)


  The possible diagnoses to consider for a patient's symptoms
• Bladder cancer


  • 2nd most common urological malignancy (after prostate cancer)
  • Risk factors include: age, gender, race, smoking, occupational carcinogens, chronic inflammation, drugs, pelvic radiotherapy

  
• Bladder cancer is more aggressive in women due to thinner muscle bladder

  
• Smoking is a major cause of bladder cancer, increasing risk 2-5 fold
• 50% of bladder cancers occur in smokers
• Occupational carcinogens have a 25-45 year latency period before bladder cancer develops

  
• Chronic inflammation from bladder stones, catheters, and Bilharziasis can lead to squamous cell bladder cancer

  
• Cyclophosphamide and pelvic radiotherapy are risk factors for bladder cancer

  
• Benign bladder tumors


  Inverted papilloma & nephrogenic adenoma (rare)

  
• Malignant bladder tumors


  • Transitional (urothelial) - >90%
  • Squamous - 1-7%
  • Adenocarcinoma - 2%
  • Sarcomas (rare)
  • Metastasis (mostly from bowel)

  
• Consider any bladder tumor as bladder cancer until proven otherwise

  
• Transitional cell carcinoma is the most common histological type of bladder cancer

  
• Hematuria (blood in urine)


  • Most important and most common symptom of bladder cancer
  • Can be visible or non-visible
  • Suspicious features: visible, painless, intermittent, total, associated with clots

  
• Visible hematuria (VH)


  Blood in urine seen by patient or doctor
• Non-visible hematuria (NVH)


  Blood in urine detected by dipstick or microscopy
• Symptomatic NVH (s-NVH)


  NVH with associated symptoms like urgency, frequency, dysuria
• Asymptomatic NVH (a-NVH)


  NVH without associated symptoms, can be transient or persistent
• Hematuria is suspicious for bladder cancer if it is visible, painless (except for CIS), intermittent, total, and associated with clots

  
• Irritative urinary symptoms like suprapubic pain, dysuria and urgency are mostly seen in patients with carcinoma in situ (CIS)
• Think of bladder cancer in cases of sterile pyuria (positive WBCs in urine with negative culture)

  
• Symptoms of advanced bladder cancer


  • Lower limb swelling (lymphatic/venous obstruction)
  • Bone pain (metastasis)
  • Anuria (bilateral ureteric obstruction)
  • Weight loss, anorexia (metastasis)

  
• Approach to hematuria


  1. Exclude infection, menses, exercise

  2. Fully evaluate: all patients with visible hematuria, symptomatic NVH, persistent asymptomatic NVH, single episode of asymptomatic NVH in >40 years
• Urine cytology


  Examination of exfoliated cells in freshly voided urine to look for features of cancer

  
• Urine cytology has low sensitivity for low grade transitional cell carcinoma and high sensitivity for high grade transitional cell carcinoma and carcinoma in situ
• False positive urine cytology can occur with infection, stones, instrumentation
• CT urogram (CTU)


  Best tool to evaluate the upper urinary tract (kidney and ureters) as synchronous transitional cell carcinoma of ureter/renal pelvis is seen in 5% of bladder cancer cases

  
• CTU has high specificity (98%) for detecting cancer but is costly and exposes the patient to high radiation, so it is best reserved for high suspicion cases

  
• Alternatives to CTU include IVU, retrograde pyelogram, and ureteroscopy
• Diagnostic cystoscopy


  • Mandatory in all cases of hematuria as it can detect carcinoma in situ
  • Can determine number, site, size, shape of bladder tumors
  • Papillary tumors have better prognosis than nodular/sessile tumors
  • Carcinoma in situ appears as red patches, better visualized with fluorescent blue light and photosensitizer

  
• Diagnostic cystoscopy


  Tumor is then resected using electrical loop
• CT urography (CTU)


  • Provides 3-D images with high specificity (98%) for cancer
  • Costly and exposes the patient to high dose of radiation
  • Best reserved for selected cases with high suspicion of cancer (VH, >40, smoker, occupation)

  
• Alternatives to CTU


  • IVU
  • Retrograde pyelogram (RGP)
  • Ureteroscopy (URS)
• Bladder cancer on imaging


  1. Ultrasound (US) first

  2. Then do CT urography (CTU) for confirmation

  3. If no CT, wash bladder and repeat US

  
• Haematuria


  Presence of blood in the urine
• Haematuria: Approach


  1. Diagnostic cystoscopy (mandatory in all cases to detect CIS)

  2. Can determine number, site, size, shape of cancer

  3. Papillary tumors have better prognosis than nodular/sessile tumors

  4. CIS appear as red patches (better visualized using fluorescent blue light + photosensitizer like hexaminoleuvelinic acid HAL)

  5. Tumor is then resected using electrical loop (TUR-BT) and sent for histopathology