bladder%20cancer
BLADDER CANCER

Bladder cancer is a heterogenous neoplasm that ranges from non-life-threatening, low-grade, superficial papillary lesions to high-grade invasive tumors that often metastasizes at the presentation.

It is the most common cancer involving the urinary system and it is the 11th most commonly diagnosed in the world.

Microscopic or gross painless hematuria is the most common presenting complaint.

Surgical Intervention

Transurethral Resection of Bladder Tumors (TURBT)

  • Standard treatment for non-muscle-invasive bladder tumors (Ta, T1, Tis) & cTa low-grade tumors w/ the goal of removing all visible lesions
  • Therapeutic option in patients w/ muscle-invasive bladder tumor if tumor growth is limited to the superficial muscle layer & if re-staging biopsies are negative for invasive tumor
  • The strategy of resection depends on the size of the lesion
    • In small tumors (<1 cm in diameter), en bloc resection can be done, where the specimen contains the complete tumor plus part of the underlying bladder wall including muscle
    • For large tumors, resection is done in parts, which include exophytic part of the tumor, the underlying bladder wall w/ the detrusor muscle & the edges of the resection area
    • Separate resection of larger tumors provides good information about the vertical & horizontal extent of the tumor & helps to improve resection completeness
  • Complete & correct TURBT is essential to achieve a good prognosis
    • An absence of detrusor muscle in the specimen is associated w/ a significantly higher risk of residual disease, early recurrence & tumor understaging
  • Selected mapping biopsies & transurethral biopsy of the prostate must be considered if sessile lesion or Tis or high-grade disease is suspected
  • A second TURBT is performed:
    • After 2-3 wks of incomplete initial TURBT
    • If there is no muscle in the specimen after initial resection, w/ the exception of TaG1
    • When a high-grade, primary CIS, T1 tumor & possibly a Ta has been detected at the initial TURBT
  • A second TURBT can increase recurrence-free survival, improve outcomes after Bacillus Calmette-Guerin (BCG) treatment & provide prognostic information

Radical Cystectomy

  • Indicated in patients w/ non-muscle-invasive bladder cancer that have failed BCG treatment & in patients w/ highest risk of tumor progression
  • Standard curative treatment for patients w/ muscle-invasive bladder cancer
    • Appropriate procedure in men involves cystoprostatectomy
    • While in women a cystectomy & a hysterectomy
    • Followed by the formation of a urinary diversion
  • Should include the essential pelvic lymph node dissection
  • Immediate radical cystectomy is suggested in patients w/ non-muscle invasive bladder cancer if:
    • TURBT staging accuracy for T1 tumors is low
    • Patients w/ non-muscle invasive bladder cancer experience disease progression to muscle-invasive disease
  • Delaying cystectomy for >3 mths may increase the risk of progression & cancer-specific mortality

Partial Cystectomy

  • Indicated if the lesions develop on the dome of the bladder & have no associated Tis in other areas of urothelium
  • The procedure begins w/ a laparotomy (intraperitoneal) & resection of the pelvic lymph nodes
    • If the intraoperative findings preclude a partial cystectomy, a radical cystectomy is performed

Fulguration

  • Fulguration w/out biopsy is considered in patients w/ recurrent non-muscle-invasive bladder cancer if all of the following are present:
    • No previous bladder cancer that was intermediate- or high-risk
    • A disease-free interval of at least 6 months
    • Solitary papillary recurrence
    • A tumor diameter of <3 mm
  • In patients w/ a history of small, Ta LG/G1 tumors, fulguration of small papillary recurrences on an outpatient basis can reduce the therapeutic burden & can be a treatment option
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