History

Approximately 80-90% of patients with bladder cancer present with painless gross hematuria. Most patients with this classic presentation should be considered to have bladder cancer until proof to the contrary is found.

Hematuria is not the only manifestation of an underlying bladder cancer. Irritative bladder symptoms such as dysuria, urgency, or frequency of urination occur in 20-30% of patients with bladder cancer. Although irritative symptoms may be related to more advanced muscle-invasive disease, carcinoma in situ (CIS) is the more likely cause. Therefore, patients presenting with unexplained or refractory irritative symptoms should be considered for cystoscopy and urine cytology. The threshold for doing so should be especially low in persons who smoke or have other risk factors.

Patients with advanced disease can present with pelvic or bony pain, lower-extremity edema from iliac vessel compression, or flank pain from ureteral obstruction.

Physical Examination

Non ̶ muscle-invasive bladder cancer is typically not found during a physical examination. In rare cases, a mass is palpable during abdominal, pelvic, rectal, or bimanual examination. A bimanual examination may be considered part of the staging of such lesions. In women, a bimanual pelvic examination is done; in men, a bimanual examination is performed with one hand per rectum and the other on the lower abdominal wall.

Attention to the anterior vaginal wall in women and the prostate in men may reveal findings that suggest local extension of bladder cancer. Assessment of fixation of the bladder to the surrounding pelvic sidewall is also important when planning definitive management for locally advanced tumors that may not be surgically resectable.

Differential Diagnoses

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Media Gallery

In an ileal conduit, a small segment of ileum is taken out of continuity with the gastrointestinal tract but is maintained on its mesentery. Ureters are anastomosed to one end of this ileal segment, and the other end is brought out as a stoma to the abdominal wall.
In an Indiana pouch, a urinary reservoir is created from detubularized right colon and an efferent limb of terminal ileum. Terminal ileum is plicated and brought to the abdominal wall. The continence mechanism is the ileocecal valve.
In an orthotopic neobladder, a segment of ileum is used to construct a neobladder, which is connected to the urethra. Orthotopic neobladder most closely restores the natural storage and voiding function of the native bladder.
Bladder cancer. The classic appearance of carcinoma in situ is as a flat, velvety patch. However, using special staining techniques such as 5-aminolevulinic acid, it has been shown that significant areas of carcinoma in situ are easily overlooked by conventional cystoscopy. Courtesy of Abbott and Vysis Inc.
Bladder cancer. Papillary bladder tumors such as this one are typically of low stage and grade (Ta-G1). Courtesy of Abbott and Vysis Inc.
Bladder cancer. Sessile lesions as shown usually invade muscle, although occasionally a tumor is detected at the T1-G3 stage prior to muscle invasion. Courtesy of Abbott and Vysis Inc.
Bladder cancer. Photograph in which fluorescence in situ hybridization centromere staining identifies aneuploidy of chromosome 3. Multiple instances of overexpression of the chromosome (note the multiple red dots, which identify centromeres of this chromosome) prove aneuploidy.
Bladder cancer. Cross-section through the bladder, uterus, and vagina with squamous cell carcinoma of the bladder infiltrating through the bladder wall into the vaginal wall.
Bladder cancer. High power, Pap stain showing high grade urothelial carcinoma on a bladder wash cytology.
Bladder cancer, Intermediate power, H&E stain of urothelial carcinoma in situ. The superficial cells shed into the urine and correlate with those seen in cytologic bladder washing or urine cytology.
Bladder cancer. High power, H&E stain of high grade urothelial carcinoma. This tumor is now invasive into the muscularis propria (smooth muscle seen in center of image).
Bladder cancer. Histopathology of bladder shows eggs of Schistosoma haematobium surrounded by intense infiltrates of eosinophils and other inflammatory cells.
Bladder cancer. (A) When infused into the bladder, the optical imaging agent hexaminolevulinate (Cysview) accumulates preferentially in malignant cells. (B) On blue-light cystoscopy, the collection of hexaminolevulinate within tumors is visible as bright red spots. Courtesy of Gary David Steinberg, MD, FACS.

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Table 1. Clinical Findings and Recommended Action in Patients with Negative Cystoscopy

Cystoscopy Findings	Urine Cytology Findings	*FISH Findings**	Action
Negative	Negative	Negative†	Routine follow-up
Negative	Negative	Positive‡	Increased frequency of surveillance, whether FISH findings are false positive or anticipatory positive
Negative	Positive	Negative or positive	Cancer until proven otherwise Upper tract imaging with contrast Cystoscopy with random bladder and urethral biopsies, retrograde pyelography, selective ureteral washings, and/or ureteroscopy Evaluate urethra Increased frequency of surveillance upon negative findings
*FISH - Fluorescent in situ hybridization. †Negative predictive value 95%. ‡Positive predictive value 30%.

Table 2. Recurrence and Progression Rates at 5 Years for Ta, T1, and CIS TCC of the Bladder Treated With BCG

Stage	Recurrence, %	Progression, %
Ta	55	11
T1	61	31
CIS	45	23
G1	61	2-4
G2	56	5-7
G3	50-70	30-40

Table 3. Most Common Complications of Radical Cystectomy

Early Complications	Rate, %	Late Complications	Rate, %
Ileus	10	Small-bowel obstruction	7.4
Wound infection	5.5	Ureteroenteric stricture	7.0
Sepsis	4.9	Renal calculi	3.9
Pelvic abscess	4.7	Acute pyelonephritis	3.1
Hemorrhage	3.4	Parastomal hernia	2.8
Wound dehiscence	3.3	Stomal stenosis	2.8
Bowel obstruction	3.0	Incisional hernia	2.2
Enterocutaneous fistula	2.2	Fistula	1.3
Rectal injury	2.2	Rectal complications	< 1

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#author-disclosures{display:block}#author-disclosures.modal-layer{position:relative}#author-disclosures .modal-content{max-height:none}#author-disclosures .close-modal{display:none}

Author

Kara N Babaian, MD, FACS Assistant Professor, Director of Urologic Oncology, Division of Urology, Southern Illinois University School of Medicine

Kara N Babaian, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society of Clinical Oncology, American Urological Association, European Association of Urology, North Central Section of the American Urological Association (AUA), Society of Urologic Oncology, Society of Women in Urology

Disclosure: Participation in a clinical trial for: Janssen.

Coauthor(s)

Parker G Adams, BS DO Candidate, Kansas City University of Medicine and Biosciences College of Osteopathic Medicine

Parker G Adams, BS is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Courtney McClure, DO Resident Physician, Department of Urology, Ascension Healthcare

Disclosure: Nothing to disclose.

Brandon Tompkins, BS DO Candidate, Kansas City University of Medicine and Biosciences College of Osteopathic Medicine

Disclosure: Nothing to disclose.

Megan McMurray, DO Resident Physician, Department of Urology, Southern Illinois University School of Medicine

Megan McMurray, DO is a member of the following medical societies: American Association of Clinical Urologists, American Urological Association, Association of Women Surgeons, Society of Women in Urology

Disclosure: Nothing to disclose.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Frank and Linda Vala Endowed Chair of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Division of Urology, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoscopic and Robotic Surgeons, Society of University Urologists

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Endourological Society Board of Directors<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical<br/>Received research grant from: Cook Medical.

Additional Contributors

Gary D Steinberg, MD, FACS Professor and Director, Perlmutter Cancer Center, Goldstein Bladder Cancer Program, NYU Langone Health, NYU Urology Associates

Gary D Steinberg, MD, FACS is a member of the following medical societies: American Association for Cancer Research, American College of Surgeons, American Society of Clinical Oncology, American Urological Association, International Society of Urology, Society of Laparoscopic and Robotic Surgeons, Society of Urologic Oncology

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Heat Biologics; CG Oncology; PhotoCure; Merck; Roche/Genentech; Ciclomed; Taris Biomedical (now Janssen); MDxHealth; Fidia Farmaceuticals; Urogen, Ferring; Aduro; Boston Scientific; Bristol Myers Squibb; Astra Zeneca; Pfizer, Janssen; others<br/>Member of Clinical Trial Protocol Committees for: for: Merck; BMS; Janssen; CG Oncology; Pfizer; PhotoCure; Fidia; Seagen; Protara.

Kush Sachdeva, MD Southern Oncology and Hematology Associates, Inspira Health Network

Disclosure: Nothing to disclose.

Bagi RP Jana, MD, MBA, MHA, FACP Professor, Medical Director, Department of General Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center-Houston; Professor, Department of General Oncology, The University of Texas Medical Branch; Medical Oncology Section Chief-MDACC/UTMB Health Galveston Medical Oncology and Hematology Program, Department of General Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center-Galveston

Bagi RP Jana, MD, MBA, MHA, FACP is a member of the following medical societies: American Cancer Society, American Medical Association, American Society of Clinical Oncology, SWOG

Disclosure: Nothing to disclose.

Acknowledgements

Sujeet S Acharya, MD Resident Physician, Department of Surgery, Section of Urology, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine