History
Describe the importance of:
- Previous intravesical therapy
- Irritable bladder signs
- Pre-treatment bladder capacity and function
Presenting Complaint
Most patients will be referred by a urologist.
- Did the patient have any symptoms before diagnosis? If so, for how long?
- Haematuria is the most common symptom, although patients may also experience dysuria or poor flow due to obstruction. Uncommonly, patients may have presented with renal failure due to obstruction of both ureters by the tumour.
- Are there any symptoms currently?
- Signs of an irritable bladder mean that….
- What procedures have been performed so far?
- Urological procedures (TURBT or partial/complete resection of the bladder)
- Ileal conduit?
- Intravesical BCG or intravesical chemotherapy in the past
Past History
Previous pelvic radiotherapy is important to know about! There is a suggestion that previous radiotherapy can increase the risk of urothelial malignancies by 2-4 times.
Medications/Allergies
No specific questions to ask.
Family History
Bladder cancer is not thought to have a large familial component.
Social History
There are several risk factors for developing bladder cancer that are covered in the social history:
- Smoking is very important to ask about. Smoking accounts for about 50% of all bladder tumours.
- Occupational exposure to aromatic amines can occur in several professions, including dyeing, truck driving and some manufacturing jobs.
Other factors, such as the patient's ability to attend radiotherapy or cope with an ileal conduit should also be assessed.
Examination
There are no special examinations required (aside from examination under anaesthesia, see below).
Chest and abdominal examination should be performed. Supraclavicular lymph node examination is required.
Investigations
The trainee is able to:
- Evaluate the results of EUA, cystoscopy, bimanual palpation and TURB with bladder mapping and “random” biopsies
- Explain the importance of extent of CIS and presence of hydronephrosis
The most important determination is whether the tumour is non-invasive/superficially invasive (Ta - T1,) or if it invades the detrusor (T2+).
Pathology Investigations
Blood tests should include:
- FBE (to evalute amount of blood loss)
- UEC (to evalute renal function)
- CMP / LFT (may be abnormal if metastases present)
Urinalysis is helpful in the initial workup to exclude infection.
Urine cytology is helpful in poorly differentiated tumours (80%) but less effective for well differentiated tumours.
Imaging
CT scan is the most widely available method of staging patients with a bladder malignancy. It allows visualisation of macroscopically involved lymph nodes, which automatically stages that patient at Stage IV.
MRI is not as well studied as CT, but can provide important staging of the bladder wall and degree of invasion.
Bone scan is indicated for advanced disease to exclude distant bony metastases.
Surgical Investigations
Examination Under Anaesthesia
This is recommended by some specialists as it allows determination of the extent of disease. However, bimanual examination has also been described as of 'minimal assistance' - a negative finding on bimanual examination does not exclude invasive, unresectable disease.
Cystoscopy
Cystoscopy is important for:
- Biopsy of suspicious lesions, allowing staging
- Mapping of areas of suspicion
- Blind biopsies of normal-appearing mucosa (all four quadrants and urethra)
Mapping in concert with blind biopsies is important as carcinoma in situ and dysplasia may commonly appear normal macroscopically. Biopsy of the urethra is important for decision making regarding intravesical therapy, as these agents do not reach the urethra. Biopsies should be deep to allow determination of muscle invasion which changes the approach of treatment significantly.
Staging
Staging is performed using the AJCC guidelines on TNM staging (7th edition)
TNM Staging for Bladder Cancer
T Stage
| T stage | Characteristics |
|---|---|
| T0 | No tumour identified |
| Ta | Non-invasive papillary neoplasm |
| Tis | Carcinoma in situ |
| T1 | Invasion into the lamina propria but not detrusor |
| T2a | Invasion through the inner half of detrusor |
| T2b | Invasion through the outer half of detrusor, but not beyond |
| T3a | Microscopic invasion beyond detrusor |
| T3b | Macroscopic invasion beyond detrusor |
| T4a | Invasion of prostate (men) or uterus/vagina (women) |
| T4b | Invasion of abdominal or pelvic wall |
N Stage
| N Stage | Characteristics |
|---|---|
| N0 | No lymph nodes |
| N1 | Single external/internal iliac lymph node |
| N2 | More than one external/internal iliac node |
| N3 | Involvement of common iliac nodes |
M Stage
| M Stage | Characteristics |
|---|---|
| M0 | No distant metastases |
| M1 | Distant metastases |
Final Stage
| Stage | T | N | M |
|---|---|---|---|
| 0a | Ta | N0 | M0 |
| 0is | Tis | N0 | M0 |
| I | T1 | N0 | M0 |
| II | T2 | N0 | M0 |
| III | T3-4a | N0 | M0 |
| IV | T4b Tany Tany |
N0 N1-3 Nany |
M0 M0 M1 |
