What to do if a urinary bladder mass is detected?

Management of Urinary Bladder Mass

When a urinary bladder mass is detected, proceed immediately with cystoscopy and transurethral resection of bladder tumor (TURBT) to establish diagnosis and determine depth of invasion, as this pathologic assessment is the cornerstone for all subsequent treatment decisions. 1

Initial Diagnostic Workup

Perform cystoscopic evaluation with biopsy or TURBT including bimanual examination under anesthesia to resect visible tumor and sample muscle within the tumor area. 1 The presence of lamina propria and detrusor muscle in the resected specimen is essential for accurate staging in most cases. 1

Pre-TURBT Imaging Strategy

• If the cystoscopic appearance shows a solid (sessile), high-grade tumor, or suggests muscle invasion, obtain CT scan of abdomen and pelvis before TURBT. 1
• For purely papillary tumors or suspected carcinoma in situ (CIS), CT scan is not necessary before TURBT. 1

Essential Baseline Studies

• Urine cytology 1
• Upper tract imaging with CT urography, MRI urography, intravenous pyelogram, retrograde pyelogram, or renal ultrasound 1
• Complete blood count, renal function (creatinine), liver function tests 1
• Bladder ultrasonography or cross-sectional imaging can identify intraluminal masses, but final diagnosis requires cystoscopy and histology 1

Critical Technical Points for TURBT

• Ensure adequate muscle sampling - a small fragment with few muscle fibers is inadequate for assessing invasion depth. 1
• For large papillary lesions, multiple sessions may be needed for complete resection. 1
• With CIS, perform biopsies of sites adjacent to tumor and multiple random biopsies to assess field change. 1
• Consider TUR biopsy of prostate in appropriate cases. 1

Risk Stratification and Treatment Based on Pathology

Non-Muscle-Invasive Disease (Ta, T1, Tis)

Low-Grade Ta Tumors (Low Risk)

• A single immediate intravesical chemotherapy treatment (typically mitomycin C) may be sufficient after complete resection. 1
• Avoid immediate intravesical treatment if TURBT was extensive or bladder perforation is suspected. 1
• Follow with cystoscopy at 3 months initially, then at increasing intervals. 1

High-Grade Ta Tumors (High Risk)

• Strongly consider or perform repeat resection if specimen contains no muscle, as 49% of patients without muscularis propria in initial TUR will be understaged (versus 14% if muscle was present). 1
• After TUR, treat with intravesical BCG (preferred) or mitomycin C - BCG is superior based on 4 meta-analyses showing better prevention of recurrences. 1
• Follow-up: cystoscopy and urinary cytology at 3-6 month intervals for first 2 years, then at increasing intervals. 1
• Perform upper tract imaging every 1-2 years for high-grade tumors. 1

T1 Tumors (Subepithelial Invasion)

• Repeat TURBT within 2-6 weeks is strongly advised for high-risk disease, especially if complete resection is uncertain, no muscle in specimen, lymphovascular invasion present, or inadequate staging suspected. 1 A prospective randomized trial showed 3-year recurrence-free survival of 69% with repeat TURBT versus 37% without. 1

• For particularly high-risk T1 disease (multifocal lesions, vascular invasion, or recurrence after BCG), consider early cystectomy rather than repeat TURBT due to high progression risk. 1

• If residual disease found after second resection, perform cystectomy or give intravesical BCG (category 1 recommendation). 1

• If no residual disease after second resection, treat with intravesical BCG (preferred, category 1) or mitomycin C. 1

Carcinoma In Situ (Tis)

• Treat with complete endoscopic resection followed by intravesical BCG (6-week induction course). 1
• If unable to tolerate BCG, use intravesical mitomycin C. 1
• Reevaluate at 12 weeks (3 months) after start of therapy. 1
• For persistent/recurrent disease at 12 weeks, give second course of BCG or mitomycin (maximum 2 consecutive induction courses). 1
• If residual disease persists after second BCG course at second 12-week follow-up, strongly consider cystectomy. 1

Muscle-Invasive Disease (T2-T4a)

Radical cystectomy is the first-line treatment for muscle-invasive bladder cancer. 2

Neoadjuvant Chemotherapy

• Administer cisplatin-based neoadjuvant chemotherapy before cystectomy for T2-T4a tumors without nodal involvement - this increases median survival and reduces residual disease rates. 2

Surgical Approach

• Perform cystoprostatectomy in men or cystectomy with hysterectomy in women. 2
• Include extended pelvic lymph node dissection (PLND) as integral part of surgical management - extended PLND increases number of nodes examined and may improve survival. 2
• Factors that may preclude PLND include severe scarring from prior treatments/surgeries, advanced age, or severe comorbidities. 2

Adjuvant Chemotherapy

• Consider adjuvant chemotherapy in patients with high risk of relapse (minimum 3 cycles of cisplatin-based combination). 2

Post-Cystectomy Surveillance

• Every 3-6 months for 2 years: urine cytology, liver function tests, creatinine, electrolytes, chest radiograph, and abdominal/pelvic imaging. 2
• Monitor vitamin B12 annually if continent diversion created. 2

Upper Tract Urothelial Tumors

• For high-grade upper tract tumors, perform nephroureterectomy with bladder cuff and regional lymphadenectomy. 3
• For well-differentiated tumors, consider nephron-sparing approaches (transureteroscopic or percutaneous) with possible post-surgical intrapelvic chemotherapy or BCG. 3

Common Pitfalls and Caveats

• Preoperative staging accuracy is modest - 42% of patients are restaged after cystectomy, with frequent understaging. 2 This underscores the importance of adequate tissue sampling during initial TURBT.

• Painless hematuria is the most common presentation (80% of patients), but irritative symptoms (dysuria, frequency, urgency) can indicate invasive or high-grade tumors. 1, 4

• Approximately 95% of bladder masses arise from epithelial layer (predominantly urothelial carcinoma in US/Europe accounting for 90%), but rare subtypes exist including squamous cell carcinoma, adenocarcinoma, small cell neuroendocrine tumors, and variant histologies. 5, 4

• Delayed diagnosis is associated with high-grade muscle-invasive disease with rapid progression potential and often fatal outcomes. 4

• Positive urine cytology with normal cystoscopy requires evaluation of upper tracts and prostate in men, with consideration of ureteroscopy. 1