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Diagnostics of bladder cancer

Diagnostics and work-up for urothelial cancer is based on specific symptoms causing suspicion of a tumor.

Patient anamnesis

The patient's anamnesis and physical examination will decide the further investigation strategy.

A change in urination pattern, such as imperious urination, or pollakisuria should be investigated on patients over 45 to 50 years. In women, urothelial cancer is usually more advanced when diagnosed. This is because hormonal changes cause changes in urination, which is a relatively common problem in women of this age group, and may delay the diagnosis.  

Urine testing

  • Urine stick supplemented with microscopy of the urine pathology is present 
  • Urine cytology x 2
  • Test for bacteria if there is suspicion of associated infection

In 85% of cases, the patient seeks medical help for hematuria, often as a single symptom. If hematuria is macroscopic, urothelial cancer should be suspected. If hematuria is present, without finding cancer or other cause for this, the patient should be considered for further consultations. 

If the patient has microscopic hematuria with < 3–5 red blood cells per visual field, and without other additional symptoms from the urinary tracts, the probability of finding cancer is so small that further examination is not indicated. If the patient has additional symptoms such as dysuria, pollakisuria, urgency, or urinary tract infection, further investigations must be considered.  

If malignant cells are detected in urine and the findings are normal from cystoscopy and possibly CT urography, a bilateral ureter catheterization with collection of urine from each side should be performed. The urine is collected selectively form the renal pelvis and distal ureter. This catheterization is an attempt to localize the malignant cells and may be supplemented with ureteropyeloscopy. 

Endoscopy

If the patient has symptoms and/or findings which indicate urothelial cancer, cystoscopy is carried out. In most cases, cystoscopy reveals tumor changes in the urinary bladder. Detection may be less certain in cases of carcinoma in situ (CIS).

A biopsy from visible tumors is unnecessary during simple cystoscopy under local anesthesia. A biopsy must be taken under general anesthesia to assess the depth of growth and stage. A biopsy under local/superfical anesthesia should only be carried out if changes identified by endoscopy are uncharacteristic for malignancy. PDD (Photo Dynamic Diagnostics) has been employed.

Image diagnostic examinations

Urothelial cancer is considered a disease general disease of the urinary system. It therefore should obligatory to examine the upper urinary tracts by imaging (urography or CT urography).

For muscle-infiltrating cancer (T ≥ 2), bone scintigraphy, abdominal CT, and thoracic X-ray should be done with regard to indication for multimodal treatment.

  • CT urography is used for tumors in the bladder, upper urinary tracts, as well as for hydronephrosis. Larger tumors are seen as defects in the contrast medium. Hydronephrosis may indicate a ureter tumor or muscle-infiltrating cancer in the bladder with ureter involvement.
  • MRI are used for investigation of invasive tumors and evaluation of lymph nodes in the pelvis and retroperitoneum. MRI after TUR-B may cause overstaging of a tumor due to TUR-induced perivesical changes.
  • The benefit of routine bone scintigraphy before radical treatment of infiltrating cancer is uncertain, with the exception for when the patient has elevated alkaline phosphatase in serum and/or has skeletal symptoms. MRI may clarify uncertain findings from bone scintigraphy or skeletal symptoms. 
  • If the conclusion is still uncertain, ureteroscopy should be considered.

Specific examinations for urothelial cancer

Bladder cancer

Most bladder cancers are easily diagnosed with cystoscopy. By examination under superficial anesthesia, it is relatively simple to biopsy with regular cold biopsy forceps to verify malignancy, but the test should be done preferably under general anesthesia/spinal anesthesia. The biopsy is taken with a resectoscope loop deep into the bladder muscle under the tumor, such that a histopathological assessment of depth infiltration (pT) can be made. 

The final work-up of bladder cancer is painful, and the patient should be examined under general anesthesia. This is because diagnostic biopsies are taken in consideration for the WHO grade, as well as deep biopsies to assess depth infiltration (T stage), and digital exploration to assess the clinical T stage. 

  • Carcinoma in situ in the bladder (Tis) may be difficult to diagnose with regular cystoscopy applying white light. Cystoscopy with photodynamic diagnostics (PDD) may be useful. 
  • Before the treatment plan can be made, an exact stage determination is necessary. CT and  MRI of the pelvis are performed as a routine for evaluation of T-stage.

Urethral cancer

The examinations for urethral cancer are more or less the same as for bladder cancer. Most cancers in the prostatic urethra are found in association with bladder cancer. It is therefore sensible for the evaluation of bladder cancer to take biopsies of mucosa from the upper part of the urethra, even if the mucosa appears normal on endoscopy.  

Renal pelvis/ureter cancer

Small tumors in the upper urinary tracts seldom cause symptoms other than hematuria. If no explanation for the hematuria can be found, the renal pelvis/ureters must be examined with urography (preferably CT urography). If defects in the contrast image or other X-ray findings are identified, such as strictures or hydronephrosis, an ureteroscopy should be performed. 

If maligant cells are present despite normal conditions in the bladder/urethra on cystoscopy, as well as normal upper urinary tracts on X-ray, then urine is collected selectively from both urethers via urether catheters. The best information is obtained by collecting urine from different levels (renal pelvis, middle and distal urethers). If malignant cells are found in the renal pelvis or ureters, the examination is supplemented with ureteroscopy.

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