Patients with bladder cancer classically present with painless blood in their urine, although irritative voiding symptoms such as frequency (urinating too frequently), urgency (always have the feeling of wanting to urinate), dysuria (painful urination) can be the initial manifestation. The diagnosis is often delayed due to the similarity of these symptoms to those of benign disorders such as urinary tract infection, kidney stones, prostate infection, and delays can lead to a worsened prognosis due to more advanced stage at diagnosis. Therefore, it is imperative to be referred to a urologist early when one is diagnosed with either microscopic blood in the urine (on routine urine analysis) or gross visible blood in urine.
However, 9 to 18 percent of apparently normal individuals have some hematuria, and hematuria is due to benign causes in most patients. The number of red blood cells in the urine is not predictive of the probability of cancer.
Cystoscopy is the gold standard for the initial diagnosis and staging of bladder cancer. This procedure is done in the office with a flexible cystoscope and only has minimal risks such as bleeding and infection. Risk of infection can be reduced by using sterile technique and peri-procedural antibiotics.
The cystoscope is then inserted into the bladder, and urine is obtained for cytology. The bladder is inspected visually, and a detailed description of the size, number, appearance, location, and growth pattern (papillary or solid) of all lesions is recorded. This information serves as a reference for subsequent cystoscopic examinations. The status of the uninvolved mucosa is also noted.
In general, low-grade, non-invasive tumors are papillary with a narrow stalk. High-grade, invasive tumors frequently can appear sessile, solid, or nodular. Carcinoma in situ (CIS) is a high-grade, non-invasive tumor, which can appear as a flat velvety lesion and can arise in patches. CIS sometimes involve large parts of the urothelial lining. The size, stalk and configuration of the cancer can be predictive of muscle invasion.
Visible tumors are either biopsied or resected transurethrally to determine the histology and depth of invasion into the submucosa and muscle layers of the bladder. For patients undergoing repeat diagnostic cystoscopy after a prior transurethral resection of bladder tumors (TURBT), repeat biopsy should be obtained from areas that were previously resected. Even if these areas appear uninvolved, muscle-invasive disease will be detected in about one-third of cases.
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Dr. Soloway credentials:
Professor and Chairman Emeritus of Urology
Board Certifications
American Board of Urology
Practice Locations
University of Miami Sylvester Cancer Center
Education
Northwestern University Chicago, IL
Undergraduate
Case Western Reserve Medical School Cleveland, OH
Graduate
Case Western Reserve Medical School Cleveland, OH
Residency
National Cancer Institute/National Institute of Health Bethesda, MD
