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B Laboratory Findings
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Urinalysis will reveal microscopic or gross 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%) There are numerous new urinary tumor markers under intense investigation for screening, assessing recurrence, progression, prognosis or response to therapy None are yet in widespread clinical use
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A Intravesical Chemotherapy
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Immunotherapeutic or chemotherapeutic agents can be delivered directly into the bladder by a urethral catheter They can be used to reduce the likelihood of recurrence in those who have undergone complete transurethral resection Most agents are administered weekly for 6 12 weeks The use of maintenance therapy after the initial induction regimen may be beneficial Efficacy may be increased by prolonging contact time to 2 hours Common agents include thiotepa, mitomycin, doxorubicin, and BCG, the latter being the most effective agent when compared with the others BCG and mitomycin have similar efficacy in retarding disease progression and patient survival Side effects of intravesical chemotherapy include irritative voiding symptoms and hemorrhagic cystitis Systemic effects are rare Patients who develop symptoms from BCG may require antituberculous therapy
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preserve the bladder in those treated with radiation Chemotherapy should be considered before surgery in those with bulky lesions or those suspected of having regional disease Chemoradiation may be best suited for those with T2 or limited T3 disease without hydronephrosis Alternatively, chemotherapy has been employed postoperatively in patients who have undergone cystectomy and have been found to be at high risk of recurrence
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At initial presentation, approximately 50 80% of bladder cancers will be superficial: Ta, Tis, or T1 Lymph node metastases and progression are uncommon in such patients when they are properly treated, and survival is excellent at 81% Five-year survival of patients with T2 and T3 disease ranges from 50% to 75% after radical cystectomy Long-term survival for patients with metastatic disease at presentation is rare
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Carroll PR Urothelial carcinoma: cancers of the bladder, ureter and renal pelvis In: Smith s General Urology, 16th ed Tanagho EA, McAninch JW (editors) McGraw-Hill, 2003 Droller MJ Primary care update on kidney and bladder cancer: a urologic perspective Med Clin North Am 2004 Mar;88(2): 309 28 [PMID: 15049580] Habuchi T et al Prognostic markers for bladder cancer: International consensus panel on bladder tumor markers Urology 2005 Dec;66(6 Suppl 1):64 74 [PMID: 16399416] Kim HL et al The current status of bladder preservation in the treatment of muscle invasive bladder cancer J Urol 2000 Sep; 164(3 Pt 1):627 32 [PMID: 10953112] Krejci KG et al Immunotherapy for urological malignancies J Urol 2004 Feb;171(2 Pt 1):870 6 [PMID: 14713844] Shelley MD et al Intravesical bacillus Calmette-Gu rin versus mitomycin C for Ta and T1 bladder cancer Cochrane Database Syst Rev 2003;(3):CD003231 [PMID: 12917955] Sternberg CN et al Chemotherapy for bladder cancer: treatment guidelines for neoadjuvant chemotherapy, bladder preservation, adjuvant chemotherapy, and metastatic cancer Urology 2007 Jan;69(1 Suppl):62 79 [PMID: 17280909]
B Surgical Treatment
Although transurethral resection is the initial form of treatment for all bladder cancers as it is diagnostic, allows for proper staging, and will control superficial cancers, muscle infiltrating cancers will require more aggressive treatment Partial cystectomy may be indicated in patients with solitary lesions and those with cancers in a bladder diverticulum Radical cystectomy entails removal of the bladder, prostate, seminal vesicles, and surrounding fat and peritoneal attachments in men and in women also the uterus, cervix, urethra, anterior vaginal vault, and usually the ovaries Bilateral pelvic lymph node dissection is performed simultaneously Urinary diversion can be performed using a conduit of small or large bowel However, continent forms of diversion have been developed that avoid the necessity of an external appliance and significantly improve quality of life for patients who are candidates
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