What is the next step in managing a bladder mass with internal vascularity?

Management of Bladder Mass with Internal Vascularity

Proceed directly to cystoscopy with transurethral resection of bladder tumor (TURBT) including bimanual examination under anesthesia to resect the visible tumor and obtain adequate tissue sampling that includes muscle from the tumor base. 1

Immediate Diagnostic Approach

The presence of internal vascularity in a bladder mass suggests a solid lesion that requires tissue diagnosis, as imaging alone cannot reliably distinguish benign from malignant pathology or determine depth of invasion. 2, 3

Pre-Cystoscopy Imaging

• Obtain CT scan of abdomen and pelvis before TURBT if the mass appears solid (sessile), suggests high-grade features, or indicates possible muscle invasion. 1
• CT or MRI is essential for local staging and detecting nodal disease or distant metastases, though neither can reliably detect microscopic perivesical fat invasion (T3a disease). 2
• Complete upper tract imaging with CT urography, MRI urography, or retrograde pyelogram to evaluate for synchronous upper tract lesions. 2, 1

Essential Baseline Studies Before Procedure

• Urine cytology 2, 1
• Complete blood count, creatinine/creatinine clearance, and liver function tests 2, 1
• Chest imaging (chest X-ray or CT) to evaluate for metastatic disease 2

Critical Technical Requirements for TURBT

The quality of the initial resection directly impacts staging accuracy and subsequent treatment decisions:

• Resect the tumor base and edges separately and send to pathology to ensure adequate staging. 2, 1
• Obtain adequate muscle sampling from within the tumor area—a small fragment with few muscle fibers is inadequate for assessing depth of invasion. 2
• Perform bimanual examination under anesthesia both before and after resection to assess for extravesical extension or fixed mass. 2
• For large papillary lesions, more than one session may be needed for complete resection. 2

Common Pitfall to Avoid

If no muscle (muscularis propria) is present in the initial specimen, 49% of patients will be understaged, necessitating repeat resection within 2-6 weeks. 1 This is particularly critical for high-grade tumors where the distinction between non-muscle-invasive (T1) and muscle-invasive (T2) disease fundamentally changes management from bladder preservation to radical cystectomy.

Risk Stratification Based on Pathology

Management diverges dramatically based on depth of invasion:

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

• High-grade Ta or T1 tumors: Strongly consider repeat TURBT within 2-6 weeks if no muscle in specimen, followed by intravesical BCG therapy (superior to chemotherapy based on 4 meta-analyses). 1
• Particularly high-risk T1 disease (multifocal, vascular invasion, or BCG failure): Consider early radical cystectomy rather than repeat TURBT due to high progression risk. 1
• Follow-up with cystoscopy and cytology every 3-6 months for first 2 years, then at increasing intervals. 1

Muscle-Invasive Disease (T2-T4a)

• Radical cystectomy is first-line treatment for muscle-invasive bladder cancer. 1
• Administer cisplatin-based neoadjuvant chemotherapy before cystectomy for T2-T4a tumors—this increases median survival and reduces residual disease rates. 1
• Include extended pelvic lymph node dissection as integral part of surgical management. 1

Special Consideration: Vascular Tumors

While rare, primary vascular tumors of the bladder (hemangiomas, arteriovenous malformations, angiosarcomas) can present with internal vascularity. 4 Benign vascular lesions consistently involve only the submucosa and spare the muscularis propria, while malignant vascular tumors (angiosarcomas) invariably involve the muscularis propria and have rapidly fatal outcomes (all patients dead at 6 months in one series). 4 This distinction can only be made histologically after adequate tissue sampling.

Key Clinical Caveat

Do not rely on imaging characteristics alone to determine management. While focal bladder masses on CT have higher malignancy rates (66.7%) compared to diffuse or focal wall thickening, 5 and MRI can suggest muscle invasion, 6 definitive diagnosis and accurate staging require cystoscopic evaluation with adequate tissue sampling including muscle. 2 The presence of internal vascularity does not distinguish benign from malignant pathology and should not delay definitive diagnostic intervention.