What is the recommended workup for a suspected bladder cancer patient, specifically an adult over 55 with a history of smoking or chemical exposure?

Workup for Bladder Cancer

Initial Evaluation

The workup for suspected bladder cancer begins with office cystoscopy to visualize the bladder, followed by transurethral resection of bladder tumor (TURBT) with bimanual examination under anesthesia for definitive diagnosis and staging. 1

Step 1: Clinical Assessment and Cystoscopy

• Office cystoscopy is the primary diagnostic procedure when bladder cancer is suspected based on hematuria (present in 80% of cases), irritative voiding symptoms (dysuria, frequency, urgency), or other concerning symptoms 1
• Urine cytology should be obtained around the time of cystoscopy, though it has high sensitivity for high-grade tumors (84%) but low sensitivity for low-grade lesions (16%) 1
• Smoking cessation counseling should be initiated during the initial evaluation, as smoking is the most significant risk factor 1

Step 2: Cross-Sectional Imaging

CT scan or MRI of the abdomen and pelvis should be performed before TURBT (if logistically feasible) to characterize the lesion and assess depth of invasion 1

• Upper tract imaging is mandatory for all patients to exclude synchronous upper urinary tract urothelial carcinoma, which occurs in approximately 2.5% of patients 1
• CT urography is the preferred imaging modality for patients who can safely receive intravenous contrast, as it provides superior visualization of papillary tumors throughout the urinary tract 1
• Alternative imaging options include MRI urography, renal ultrasound with retrograde ureteropyelography, or ureteroscopy 1

Step 3: Definitive Diagnosis with TURBT

TURBT with bimanual examination under anesthesia is performed to resect visible tumor and obtain adequate tissue for staging 1

• The goal is to completely resect all visible tumor while obtaining adequate muscle sampling (muscularis propria) in the resection specimen, particularly for high-grade disease 1
• Bimanual examination under anesthesia assesses for extravesical extension and helps identify clinical T3 or T4 disease 1
• For carcinoma in situ (CIS) or positive urine cytology with normal-appearing bladder, bladder biopsies from suspicious areas or mapping biopsies from normal-looking mucosa should be performed 1
• Adequate muscle sampling is critical—a small fragment with few muscle fibers is inadequate for assessing depth of invasion and will lead to understaging 1

Step 4: Laboratory Testing

• Complete blood work including hematology and biochemistry should be obtained 1
• Liver function tests are indicated for patients with high risk of metastases 1

Step 5: Metastatic Workup (When Indicated)

For patients with muscle-invasive disease or high-risk features, metastatic workup with CT chest, abdomen, and pelvis should be performed 1

• This is particularly important for patients presenting with bone pain, flank pain, or other symptoms suggesting advanced disease 1

Critical Pitfalls to Avoid

• Inadequate muscle sampling during TURBT is the most common error leading to understaging and inappropriate treatment decisions 1
• Failing to perform upper tract imaging can miss synchronous upper tract tumors in 2.5% of patients 1
• Random mapping biopsies of normal-appearing urothelium are not necessary for most patients with low-risk tumors, but are essential when CIS is suspected, high-grade disease is present, or cytology is positive with normal cystoscopy 1
• In patients with positive cytology and normal cystoscopy, the upper tracts and prostatic urethra (in men) must be evaluated, as positive cytology may indicate urothelial tumor anywhere in the urinary tract 1

Special Considerations

• Single-dose intravesical gemcitabine or mitomycin (gemcitabine preferred) within 24 hours of TURBT is recommended if non-muscle-invasive disease is suspected, particularly for low-volume, low-grade disease 1
• For high-risk non-muscle-invasive bladder cancer (high-grade, T1, CIS, multifocal disease, or tumor ≥3 cm), upper tract imaging should be repeated every 1-2 years during surveillance 2
• Variant histologies (micropapillary, plasmacytoid, sarcomatoid, etc.) should be documented with percentages in the pathology report, as they affect prognosis and treatment decisions 1