What workup is warranted for a patient presenting with symptoms suggestive of bladder cancer, such as hematuria or unexplained pelvic pain?

Diagnostic Workup for Suspected Bladder Cancer

A patient presenting with hematuria or unexplained pelvic pain should undergo a comprehensive bladder cancer workup including cystoscopy, urine cytology, upper urinary tract imaging, and blood work to accurately diagnose and stage the disease.

Initial Presentation and Symptoms

Bladder cancer commonly presents with:

• Painless hematuria, occurring in approximately 80% of patients, which warrants investigation in all cases 1
• Irritative voiding symptoms including dysuria, increased frequency, and urgency, particularly in invasive or high-grade tumors 1
• Less commonly, urinary tract infection, upper tract obstruction, or pain in advanced lesions 1
• Bone pain (suggesting bone metastasis) or flank pain (from retroperitoneal metastases or ureteral obstruction) in advanced cases 1

Diagnostic Algorithm

Step 1: Initial Evaluation

• Office cystoscopy to determine if a lesion is present 1
• Urine cytology should be obtained around the time of cystoscopy 1

Step 2: Imaging

• If cystoscopy reveals a solid (sessile), high-grade tumor, or suggests muscle invasion, CT scan or MRI of the abdomen and pelvis should be performed before TURBT 1
• Bladder ultrasonography or cross-sectional imaging can identify intraluminal masses but cannot replace cystoscopy 1
• Upper urinary tract imaging is essential and should include one of the following 1:
  • CT urography (preferred approach if patient can receive IV contrast)
  • MRI urography
  • Intravenous pyelogram
  • Retrograde pyelogram
  • Renal ultrasound with retrograde pyelogram

Step 3: Definitive Diagnosis

• Transurethral resection of bladder tumor (TURBT) with bimanual examination under anesthesia 1
  • Complete resection of all visible tumor tissue should be attempted
  • Adequate muscle sampling is critical for accurate staging
  • The presence of lamina propria and detrusor muscle in the specimen is essential
• Bladder biopsies from suspicious urothelium or mapping biopsies from normal-looking mucosa in patients with positive urine cytology or history of high-grade NMIBC 1
• Transurethral resection biopsy of the prostate may be considered in men 1

Step 4: Laboratory Testing

• Complete blood work including hematology and biochemistry 1
• Liver function tests for patients with high risk of metastases 1

Step 5: Additional Testing for Suspected Advanced Disease

• Metastatic workup for patients with high risk of metastases: CT chest, abdomen, and pelvis 1
• Bone scan if elevated levels of alkaline phosphatase are detected 1

Important Considerations

• When a patient presents with hematuria and normal cystoscopy but positive cytology, consider prostatic urethral biopsies, upper tract imaging, enhanced cystoscopic techniques (blue light cystoscopy when available), ureteroscopy, or random bladder biopsies 1
• The management of bladder cancer is based on pathological findings with attention to histology, grade, and depth of invasion 1
• Approximately 75% of patients present with non-muscle-invasive bladder cancer (NMIBC), while the remainder have muscle-invasive disease (MIBC) 1
• Concurrent carcinoma in situ (CIS) is an adverse prognostic factor requiring additional evaluation 1

Common Pitfalls to Avoid

• Inadequate muscle sampling during TURBT can lead to understaging 1
• Failing to perform upper tract imaging, which is necessary to exclude synchronous upper tract urothelial cancer (present in approximately 2.5% of patients) 1
• Neglecting to obtain urine cytology, which can detect malignant cells from anywhere in the urinary tract 1
• Overlooking variant histologies, which may affect prognosis and treatment decisions 1