Bladder Cancer
Bladder cancer is the second most common urologic cancer. Bladder cancer occurs more commonly in men than women (2.7:1), and the mean age at diagnosis is 65 years. Cigarette smoking and exposure to industrial dyes or solvents are risk factors for the disease and account for approximately 60% and 15% of new cases, respectively.
Clinical Findings
A. Symptoms and Signs: Hematuria—gross or microscopic, chronic or intermittent—is the presenting symptom in 85–90% of patients with bladder cancer. Irritative voiding symptoms (urinary frequency and urgency) will occur in a small percentage of patients as a result of the location or size of the cancer. Most patients with bladder cancer will fail to have signs of the disease because of its superficial nature. Masses detected on bimanual examination may be present in patients with large-volume or deeply infiltrating cancers. Hepatomegaly or supraclavicular lymphadenopathy may be present in patients with metastatic disease, and lymphedema of the lower extremities may be present as a result of locally advanced cancers or metastases to pelvic lymph nodes.
B. Laboratory Findings: Urinalysis will reveal hematuria in the majority of cases. On occasion, it may be accompanied by pyuria. Azotemia may be present in a small number of cases associated with ureteral obstruction. Anemia may occasionally be due to chronic blood loss or to bone marrow metastases. Exfoliated cells from normal and abnormal urothelium can be readily detected in voided urine specimens. Cytology may be useful in detecting the disease at the time of initial presentation or to detect recurrence. Cytology is very sensitive in detecting cancers of higher grade and stage (80–90%) but less so in detecting superficial or well-differentiated lesions (50%). Sensitivity of detection using exfoliated cells may be enhanced by flow cytometry.
C. Imaging: Bladder cancers may be detected using intravenous urography, ultrasound, CT, or MRI where filling defects within the bladder are noted. However, the presence of cancer is confirmed by cystoscopy and biopsy, so imaging is useful primarily for evaluating the upper urinary tract and in staging the more advanced lesions.
D. Cystourethroscopy and Biopsy: The diagnosis and staging of bladder cancers is made by cystoscopy and transurethral resection. If cystoscopy—performed usually under local anesthesia—confirms the presence of bladder cancer, the patient is scheduled for transurethral resection under general or regional anesthesia. A careful bimanual examination is performed initially and at the end of the procedure, noting the size, position, and degree of fixation of a mass, if present. Any suspicious lesions are resected using electrocautery. Resection is carried down to the muscular elements of the bladder wall so as to allow complete staging. Random bladder and, on occasion, prostatic urethral biopsies are performed to detect occult disease elsewhere in the bladder and, therefore, identify patients at high risk of recurrence and progression.