Bladder cancer has the highest recurrence rate of any malignancy

1. Pathophysiology
Transitional (urothelial) cell carcinoma: 90%
Squamous cell carcinoma: 5%. persistent inflammation from long-term indwelling Foley catheters and bladder stones, as well as, possibly, infections. In developing nations, SCC is often associated with bladder infection by Schistosoma haematobium
adenocarcinomas: 2%
Small cell carcinoma: 0.3-0.7%

2. Signs and symptoms
Painless gross hematuria - Approximately 80-90% of patients; classic presentation
Irritative bladder symptoms (eg, dysuria, urgency, frequency of urination) - 20-30% of patients
Pelvic or bony pain, lower-extremity edema, or flank pain - In patients with advanced disease
Palpable mass on physical examination - Rare in superficial bladder cancer

3. Diagnosis
Urinalysis with microscopy: Standard noninvasive diagnostic method. Low sensitivity for low-grade and early stage cancers. Fluorescence in situ hybridization (FISH) may improve the accuracy of cytology
Cystoscopy: The primary modality for the diagnosis of bladder carcinoma. Permits biopsy and resection of papillary tumors
The diagnostic strategy for patients with negative cystoscopy is as follows: Negative urine cytology and FISH - Routine follow-up. Negative urine cytology, positive FISH - Increased frequency of surveillance. Positive urine cytology, positive or negative FISH - Cancer until proven otherwise
Upper urinary tract imaging: Necessary for the hematuria workup. American Urologic Association Best Practice Policy recommends computed tomography (CT) scanning of the abdomen and pelvis with contrast, with preinfusion and postinfusion phases. Imaging is ideally performed with CT urography, using multidetector CT. Ultrasonography is commonly used, but it may miss urothelial tumors of the upper tract and small stones
Urine culture to rule out infection, if suspected
Voided urinary cytology
Urinary tumor marker testing

4. Management
The treatment of non–muscle-invasive bladder cancer (Ta, T1, carcinoma in situ [CIS]) begins with transurethral resection of bladder tumor (TURBT). Subsequent treatment is as follows:
Small-volume, low-grade Ta bladder cancer - An immediate single, postoperative dose of intravesical chemotherapy
High-risk Ta, T1, and CIS urothelial carcinoma - Intravesical BCG vaccine
Persistent or recurrent high-risk disease - Repeat resection prior to additional intravesical therapy (eg, interferon alfa or gamma); consider cystectomy for high-risk disease
The treatment of muscle-invasive bladder cancer is as follows:
Radical cystoprostatectomy in men
Anterior pelvic exenteration in women
Bilateral pelvic lymphadenectomy (PLND), standard or extended
Creation of a urinary diversion
Neoadjuvant chemotherapy - May improve cancer-specific survival
Chemotherapeutic regimens for metastatic bladder cancer include the following:
Methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin (MVAC)
Gemcitabine and cisplatin (GC)

Low grade means that the cancer cells are well differentiated. They look and act much like normal cells. Lower grade cancer cells tend to be slow growing and are less likely to spread. Grade 1 is well differentiated and grade 2 is moderately well differentiated.

High grade means that the cancer cells are poorly differentiated, or undifferentiated. They look and act less normal, or more abnormal. Higher grade cancer cells tend to grow more quickly and are more likely to spread. Grade 3 is poorly differentiated and grade 4 is undifferentiated.


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