Bladder Cancer

Snapshot

• A 55-year-old man presents to the emergency department with painless hematuria. He denies any trauma to the abdomen or pelvis, as well as any signs of fevers or chills. He denies any dysuria, urinary urgency, or frequency. He has not started any new diets. He smokes 1 pack of cigarettes daily for the past 35 years. Physical examination is not notable for any abdominal masses or tenderness to palpation. Urinalysis demonstrates a large red blood cell count with normal red blood cell morphology. He eventually undergoes cystoscopy, which demonstrates a protruding mass from the bladder wall.

Introduction

• Overview
  • malignancy of the bladder 
    • the predominant histologic type is transitional cell carcinoma (~90% of cases)
    • bladder cancers can be superficial (non-muscle invasive), muscle-invasive, and metastatic in nature
• Epidemiology
  • risk factors
    • smoking
    • nitosamines
    • aniline dyes 
    • phenacetin
    • cyclophosphamide 
    • Schistosoma haematobium 
• typically leads to squamous cell carcinoma of the bladder

Presentation

• Symptoms
  • painless hematuria
    • can be microscopic or grossly visible
    • hematuria occuring towards the end of voiding typically suggests a bladder neck or prostatic urethra source
  • irritative voiding symptoms may be present
    • urinary urgency, frequency, and dysuria
• the presence of pain suggests invasive and/or metastatic disease

Imaging

• Cystoscopy
  • indication
    • gold standard for the initial diagnosis and staging of bladder cancer
    • assess if the bladder cancer is muscle-invasive or not
      • thus expedites treatment for non-muscle-invasive bladder cancer
• CT of the abdomen and pelvis 
  • indication
• performed with and without contrast and is considered the imaging study of choice to evaluate the local extent of disease and to assess the renal pelvis and ureters

Studies

• Urinalysis
  • indication
    • evaluates for the presence of blood in the urine
    • the morphology of the red blood cells (RBCs) suggests its source
      • normal shaped RBCs suggest an extra-renal bleeding source, like the bladder
• Urine cytology
  • indication
• used in combination with cystoscopy to determine if there is carcinoma in situ and the presence of upper urinary tract lesions

Differential

• Prostate cancer
  • differentiating factors
    • elevated prostate-specific antigen
• nodular and irregular prostate on digital rectal examination

Treatment

• Surgical
  • transurethral resection of bladder tumor (TURBT)
    • indication
      • initial treatment of non-muscle invasive bladder tumor
• provides histological confirmation of bladder cancer

Complications

• Urinary obstruction
• Surgical complications
  • urinary incontinence
  • sexual dysfunction
  • impaired bowel function