Chapter 6: Bladder Cancer

H&P, cystoscopy, TURBT, EUA, and cytology. In patients with high-grade and/or invasive tumors, radiologic assessment should be performed with high-resolution CT or MR of the abdomen and pelvis prior to TURBT. The TURBT specimen should include muscle to accurately assess the depth of tumor invasion. A repeat TURBT is recommended in the case of T1 high-grade disease, even if muscle is present in the specimen, as T1 tumors can be understaged by TURBT, and a repeat TURBT has prognostic value in predicting response to intravesical therapy. EUA is important in clinical staging as it can detect locally advanced bladder cancer by assessing for invasion into adjacent organs, extravesical extension, and abdominal or pelvic sidewall extension. A bladder fixed on EUA suggests that it may be surgically unresectable. Also consider a CT chest.

 A 99mTc bone scan is recommended for patients with elevated blood alkaline phosphatase or bone pain. NaF-PET/CT to assess bone disease is also under investigation in bladder cancer. Consider upper tract imaging with CT urogram, retrograde pyelogram, or MR urogram. This full investigation of the upper tracts is especially important in patients with positive cytology and normal cystoscopy.