What is the management approach for a patient with hematuria and a known bladder mass?

Management of Hematuria with Known Bladder Mass

A patient with hematuria and a known bladder mass requires immediate transurethral resection of the bladder tumor (TURBT) with bimanual examination under anesthesia to confirm diagnosis, determine depth of invasion, and guide definitive treatment. 1

Immediate Diagnostic Workup

Before proceeding to TURBT, obtain the following based on cystoscopic appearance:

• CT scan of abdomen and pelvis is mandatory if the tumor appears solid (sessile), high-grade, or suggests muscle invasion 1
• CT scan is not necessary for purely papillary-appearing tumors or suspected carcinoma in situ 1
• Evaluate upper urinary tracts with CT urography, intravenous pyelogram, retrograde pyelogram, renal ultrasound, or MRI urogram 1
• Obtain urine cytology to assess for field changes 1
• Check alkaline phosphatase levels; if elevated, perform bone scan to evaluate for metastatic disease 1

Transurethral Resection Requirements

The TURBT must be performed with specific technical considerations:

• Adequate muscle sampling is critical - a small tumor fragment with few muscle fibers is inadequate for assessing invasion depth 1
• Perform bimanual examination under anesthesia to assess for extravesical extension 1
• For large papillary lesions, multiple resection sessions may be necessary for complete tumor removal 1
• If carcinoma in situ is suspected, obtain biopsies adjacent to the tumor plus multiple random biopsies to assess field change 1
• Consider transurethral resection biopsy of the prostate in appropriate cases 1

Treatment Algorithm Based on Pathology

Management is determined by histology, grade, and depth of invasion:

Non-Muscle Invasive Disease (pT0, pT1, CIS)

• Follow with serial cystoscopies at 3-month intervals for the first year 1
• If negative at one year, continue cystoscopy every 6 months thereafter 1
• Upper tract imaging (IVP, retrograde pyelogram, or CT/MRI urography) at 1-2 year intervals 1

Muscle Invasive Disease (pT2, pT3, pT4) or Node-Positive

• Consider neoadjuvant chemotherapy before definitive surgery 1
• Definitive treatment typically requires radical cystectomy with pelvic lymphadenectomy 1
• Adjuvant chemotherapy should be considered for pathologic stage pT2 or higher, or node-positive disease 1
• Cisplatin-based regimens are preferred; carboplatin-based regimens reserved for patients who cannot tolerate cisplatin 1

Metastatic Disease

• Systemic chemotherapy with regimens effective for urothelial carcinomas 1
• Treatment focuses on prolonging life rather than cure 1

Critical Pitfalls to Avoid

• Do not delay evaluation even if hematuria resolves spontaneously - gross hematuria carries >10% malignancy risk 1, 2
• Do not attribute hematuria solely to antiplatelet or anticoagulant therapy without complete evaluation 1, 3
• Do not obtain urinary cytology or urine-based molecular markers for initial bladder cancer detection - these are not recommended in the initial evaluation 1, 3
• Ensure adequate muscle is obtained during TURBT - inadequate sampling leads to understaging and inappropriate treatment 1

Special Histologic Considerations

• Urothelial tumors with mixed histology (squamous, adenocarcinoma, micropapillary, sarcomatoid) should be treated as urothelial carcinomas 1
• Pure non-urothelial histologies (pure squamous cell carcinoma, pure adenocarcinoma) do not respond well to standard urothelial chemotherapy regimens 1
• After systemic treatment of mixed histology tumors, only the non-urothelial component may remain 1