Urinary Bladder Cancer

CLINICAL FEATURES AND NATURAL HISTORY

Bladder cancer occurs mostly in men (~ 80%), with ~80% of patients being >60 years old. The most common symptoms are gross hematuria with clots, often intermittent; urinary frequency; painful urge to urinate; urinary retention due to blood clots blocking the outflow of urine. Tumor infiltrating the ureteral opening can cause unilateral hydronephrosis.

DIAGNOSIs

Diagnostic Tests

1. Cystoscopy with specimen collection for histologic evaluation is the basic diagnostic modality.

2. Contrast-enhanced abdominal and pelvic computed tomography (CT) is used to assess lymph node involvement and invasion of surrounding tissues, detect metastases, and perform local staging of the upper urinary tract.

3. Cytology of voided urine or bladder-washing specimens can be diagnostic in cases where macroscopic changes of the mucosa are not visible. The study is also used in conjunction with cystoscopy for grade 3 (G3) and high-grade (HG) tumors.

Diagnostic Criteria

Diagnosis is based on histologic evaluation of specimens collected during cystoscopy. Staging is performed according to the tumor, node, metastasis (TNM) classification.

TREATMENT

Radical cystectomy is the treatment of choice for muscle-invasive bladder cancer. Conservative treatment with chemotherapy and radiation therapy is only justified if the patient does not consent or there are medical contraindications to surgery.

Radical Treatment

Radical treatment is possible in patients with stage 0, I, II, and III disease (the tumor does not invade the pelvic wall or abdominal cavity and there are no metastases). In case of superficial tumors (stages 0 and I), radical transurethral resection of tumor (TURT) or transurethral resection of bladder (TURB) is possible. In stages II and III, radical cystectomy (ie, removal of the bladder with adjacent organs [prostate gland, seminal vesicles, part of the urethra in men; uterus, fallopian tubes, ovaries, urethra in women] and pelvic lymph nodes) is pursued. Urinary diversion is obtained through direct implantation of the ureters into the skin or into an isolated loop of the small intestine anastomosed to the abdominal skin surface, or through bladder reconstruction from an isolated section of the intestine and its anastomosis to the spared section of the urethra (neobladder reconstruction).

Adjuvant Treatment

Intravesical administration of bacillus Calmette-Guérin (BCG) vaccine or a cytostatic in patients treated with TURT at high risk for disease recurrence.

Nonradical Treatment

In stage IV survival can be prolonged by radiotherapy, chemotherapy, or a combination of both.