What is the initial management and treatment approach for a male patient diagnosed with bladder cancer?

USMLE Step 3 CCS Case: Male Patient with Bladder Cancer

Initial Presentation and Immediate Orders

A 68-year-old male presents with painless gross hematuria for 2 weeks. 1

Immediate Diagnostic Orders (Day 1, Hour 0):

• Complete blood count (assess for anemia from chronic bleeding) 1
• Comprehensive metabolic panel including creatinine and electrolytes (baseline renal function critical before contrast imaging and potential cisplatin therapy) 1, 2
• Urinalysis with microscopy (confirm hematuria, assess for infection) 1
• Urine cytology (adjunctive diagnostic tool, particularly sensitive for high-grade disease and CIS) 1
• CT urography of abdomen and pelvis WITH contrast (preferred imaging modality to evaluate bladder mass and detect synchronous upper tract urothelial carcinoma, which occurs in 2.5% of patients) 1, 3
• Chest X-ray or chest CT (metastatic workup) 1

Consultations:

• Urology consultation (for cystoscopy and TURBT scheduling) 1

Day 2-3: Cystoscopy and TURBT Procedure

Pre-Procedure Orders:

• NPO after midnight 1
• Type and screen (prepare for potential bleeding) 1
• Anesthesia consultation (general or spinal anesthesia required) 1

Intraoperative Requirements:

The TURBT must be performed according to standardized protocol with complete documentation of: 1

• Tumor size, location, configuration, and number 1
• Bimanual examination under anesthesia (assess for extravesical extension, particularly if tumor appears invasive) 1
• Complete visual resection of all visible tumor (when technically feasible) 1
• Separate specimens sent to pathology: 1
  • Tumor edges
  • Tumor base (must include detrusor muscle for accurate staging)
  • Random bladder biopsies from any reddish/suspicious areas
  • Prostatic urethral biopsies (mandatory in males, as bladder TCC involves prostate in 12-40% of cases, especially if tumor at trigone/bladder neck) 1, 4

Post-Procedure Orders (Day 3):

• Three-way Foley catheter with continuous bladder irrigation 1
• Vital signs every 4 hours 1
• Strict intake and output monitoring 1
• Pain control: Acetaminophen 650mg PO q6h PRN 1
• Belladonna and opium suppository PRN for bladder spasms 1

Day 4-5: Pathology Results and Risk Stratification

Scenario A: High-Grade T1 Non-Muscle Invasive Bladder Cancer (NMIBC)

Risk stratification: HIGH-RISK (any high-grade non-muscle invasive tumor or CIS) 1

Management Orders:

• Schedule repeat TURBT in 2-4 weeks (reasonable option before intravesical therapy to ensure complete resection and accurate staging) 1
• Intravesical BCG therapy (first-line treatment for high-risk NMIBC): 1, 5
  • Induction course: 6 weekly instillations starting 2-4 weeks after repeat TURBT 5
  • Maintenance BCG: 3 weekly instillations at 3,6,12,18,24,30, and 36 months 5
• Upper tract imaging (CT urography) every 1-2 years (detect metachronous upper tract disease) 3, 4

Surveillance Schedule:

• Cystoscopy with urine cytology every 3 months for first 1-2 years 4, 5
• Gradually increase intervals after 2 years if no recurrence 5
• Lifelong surveillance required 4

Scenario B: Muscle-Invasive Bladder Cancer (T2 or higher)

Staging confirmed: T2N0M0 (Muscle-invasive disease) 1

Management Orders:

• Oncology consultation (for neoadjuvant chemotherapy discussion) 1
• Cardiology consultation (perioperative risk stratification, especially given patient age) 4
• Nutritional assessment 1

Treatment Plan:

Neoadjuvant chemotherapy BEFORE radical cystectomy (demonstrated survival benefit in randomized trials and meta-analysis) 1: 1

• Cisplatin-based combination chemotherapy (e.g., MVAC or gemcitabine-cisplatin) 2
• Verify adequate renal function (cisplatin contraindicated if creatinine clearance inadequate) 2
• Audiometric testing baseline (cisplatin causes cumulative ototoxicity) 2

After neoadjuvant chemotherapy (3-4 cycles):

• Radical cystoprostatectomy with bilateral pelvic lymph node dissection 4
• Urinary diversion (ileal conduit or continent diversion) 1

Patient Counseling Points

For Non-Muscle Invasive Disease:

• "You have bladder cancer that has not invaded the muscle wall. This requires removal of the tumor and then bladder instillations of BCG, a tuberculosis vaccine that stimulates your immune system to fight cancer cells." 5
• "You will need cystoscopy examinations every 3 months initially, then less frequently if no recurrence. This is lifelong surveillance." 4, 5
• "BCG can cause bladder irritation, flu-like symptoms, and rarely serious infections. Report fever over 101.5°F immediately." 5
• "If BCG fails, radical removal of the bladder may be necessary due to high risk of progression." 1, 5

For Muscle-Invasive Disease:

• "Your cancer has invaded the muscle wall of the bladder. The standard treatment is chemotherapy first, followed by surgical removal of the bladder and prostate." 1
• "Chemotherapy before surgery improves survival compared to surgery alone." 1
• "After bladder removal, we will create a new way for urine to leave your body, either through a bag on your abdomen or an internal pouch." 1
• "Without treatment, this cancer can spread to lymph nodes and distant organs." 1

Smoking Cessation (if applicable):

• "Tobacco smoking is the most significant risk factor for bladder cancer. Quitting now reduces your risk of recurrence and progression." 1
• Prescribe nicotine replacement therapy or varenicline 1
• Refer to smoking cessation program 1

Follow-up After Radical Cystectomy:

• "You will need regular imaging and lab work to monitor for recurrence, with most intensive follow-up in the first 2 years." 6
• "Upper urinary tract imaging should continue long-term." 3, 6
• "Complications from urinary diversion can occur and increase over time, requiring ongoing monitoring." 6

Critical Pitfalls to Avoid

• Never skip prostatic urethral biopsies in male patients (missing prostatic involvement significantly impacts treatment planning) 4
• Never perform TURP before establishing bladder tumor diagnosis and staging (complicates subsequent treatment) 4
• Ensure adequate muscle in TURBT specimen (understaging occurs in up to 70% of inadequate resections) 4
• Do not use cisplatin if creatinine clearance inadequate or pre-existing hearing impairment 2
• Do not delay radical cystectomy in BCG-unresponsive high-risk NMIBC (high progression risk) 5