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Bladder Cancer
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Bladder cancer is the most common cancer of the genitourinary tract. Most patients have transitional cell carcinoma, which is the focus of this section. Common presenting symptoms include hematuria and irritative urinary symptoms.
It is important to assess for gross hematuria in review of systems questioning for all patients and confirm with a urinalysis if a patient does note hematuria. Any patient with gross hematuria should be referred for urologic evaluation, as should any patient confirmed to have persistent microscopic hematuria after evaluating benign causes, such as urinary tract infection, nephrolithiasis, or underlying kidney disease with a glomerular source of erythrocytes. Notably, use of anticoagulants does not alter these recommendations.
The primary modality of initial evaluation is cystoscopy, with biopsy of any visible tumor or mucosal abnormality. Random biopsy is performed if no abnormality is seen. If cancer is confirmed, then transurethral resection of the bladder tumor (TURBT) and examination under anesthesia is performed to determine histology and depth of invasion.
Most patients are found to have non–muscle invasive disease. This can include exophytic lesions (Ta, which can be low grade or high grade), carcinoma in situ (Tis, always high grade), or early-stage invasive cancer (T1). Small low-grade Ta tumors are treated with TURBT followed by observation or intravesical chemotherapy. All other noninvasive disease is treated with TURBT followed by either intravesical bacillus Calmette-Guérin or intravesical chemotherapy. After primary treatment, cystoscopic surveillance is indicated because of the risk for recurrent disease. There is a higher risk for muscle invasive recurrence for patients with larger tumors, less differentiated tumors, tumors that invade into the lamina propria, and tumors with multifocal or noninvasive recurrence. Most patients require cystoscopy 3 months after initial therapy, with subsequent cystoscopy at periodic intervals based on risk of recurrence. Cystectomy can be considered for patients at high risk for developing muscle-invasive disease.
If muscle-invasive disease is diagnosed, imaging studies are indicated for staging. Cystectomy is indicated, with or without neoadjuvant cisplatin-based chemotherapy. Partial cystectomy can be considered in very carefully selected patients. For patients unable or unwilling to undergo cystectomy, maximal TURBT can be combined with concurrent chemoradiotherapy for those with limited disease. Adjuvant chemotherapy after surgical resection is appropriate to consider in patients with high-risk features, such as positive nodes and extension beyond the bladder.
Treatment of metastatic disease requires systemic therapy, and treatment outcomes remain poor. Cisplatin-based combination chemotherapy remains the evidence-based choice, although immune checkpoint treatment can be given to patients with programmed death ligand 1–positive cancers. After further progression, single-agent therapy with either chemotherapy or an immune checkpoint inhibitor is recommended.
Key Points
Any patient with gross hematuria should be referred for urologic evaluation, as should any patient confirmed to have microscopic hematuria in the absence of an apparent benign cause; use of anticoagulants does not alter these recommendations.
Superficial bladder cancer does not invade the muscle, and treatment includes transurethral resection of the bladder tumor plus intravesical chemotherapy, usually bacillus Calmette-Guérin.
Amboss
| Location | Symptoms | Features of advanced/metastatic disease |
|---|---|---|
| Bladder carcinoma |
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