Management of Cancer Involving the Bladder with Straining to Urinate
In a patient with cancer involving the bladder who must strain to urinate, immediately perform cystoscopy with bimanual examination under anesthesia and obtain cross-sectional imaging (CT or MRI of abdomen/pelvis) to assess for bladder outlet obstruction from tumor mass, followed by transurethral resection if feasible to relieve obstruction and obtain tissue diagnosis. 1, 2
Initial Diagnostic Evaluation
The straining to urinate indicates bladder outlet obstruction, which in the context of bladder cancer involvement suggests either:
- Direct tumor obstruction at the bladder neck or urethra 3, 4
- Advanced disease with extravesical extension causing mechanical compression 5
- Tumor-related bladder dysfunction 4
Immediate Workup Required
Cystoscopic evaluation with biopsy or TURBT is the primary diagnostic procedure, performed with bimanual examination under anesthesia to assess for extravesical extension and identify clinical T3 or T4 disease 5, 1, 2. The bimanual exam specifically evaluates for a fixed bladder mass, which would indicate unresectable disease 5.
CT scan or MRI of abdomen and pelvis must be obtained before TURBT to characterize the lesion depth of invasion and assess for nodal disease 1, 2. This imaging is critical because it identifies whether pelvic lymph nodes larger than 2 cm are present, which would require biopsy confirmation and alter the treatment approach 5.
Complete blood work including hematology, biochemistry, and liver function tests should be obtained, as these patients are at high risk for metastatic disease 5, 2.
Upper urinary tract imaging is mandatory using CT urography (preferred), MRI urography, or retrograde pyelogram to exclude synchronous upper tract urothelial carcinoma, which occurs in approximately 2.5% of patients 5, 2, 6.
Urine cytology should be obtained around the time of cystoscopy, with 84% sensitivity for high-grade tumors 1.
Staging and Risk Stratification
Look for these specific high-risk features during evaluation:
- Fixed bladder mass on bimanual exam (indicates T4a disease) 5
- Pelvic lymph nodes >2 cm on imaging (requires biopsy confirmation) 5
- Tumor extending beyond bladder wall (T3 disease) 5
- Variant histologies (micropapillary, plasmacytoid, sarcomatoid) which affect prognosis 1, 2
Initial Management Strategy
If Resectable Disease (No Fixed Mass, Nodes <2cm)
Perform TURBT with complete resection of all visible tumor to both relieve obstruction and obtain adequate tissue for staging 1, 2. The presence of lamina propria and detrusor muscle in the resected specimen is essential for accurate staging 5.
For T3a/T3b disease, radical cystectomy with consideration of cisplatin-based neoadjuvant chemotherapy is the primary treatment 5. Bladder preservation is not an option except in highly selected cases because the proportion rendered tumor-free is low 5.
If Unresectable Disease (Fixed Mass or Positive Nodes)
For patients with fixed bladder mass or pelvic lymph nodes >2cm, biopsy the nodes to confirm nodal spread, then initiate chemotherapy alone or chemotherapy with radiotherapy 5.
Treatment sequence: Give 2-3 courses of chemotherapy with or without radiotherapy, followed by cystoscopy and CT scan 5. If tumor responds, options include cystectomy or consolidation chemotherapy with or without radiotherapy 5. If no response, switch to a new chemotherapy regimen or add radiotherapy 5.
If Patient Cannot Tolerate Aggressive Treatment
For patients with extensive comorbid disease or poor performance status, options include chemotherapy alone, radiotherapy plus chemotherapy, radiotherapy alone, or TURBT for palliation 5.
Radiotherapy with radiation sensitizer (cisplatin on days 1 and 21, or 5-FU) can be used: 45 Gy to pelvis and bladder with approximately 20 Gy boost to disease sites 5.
Critical Pitfalls to Avoid
Do not attempt bladder preservation in T3 disease outside highly selected cases, as outcomes are poor 5.
Do not perform cystectomy in patients who received full-course radiotherapy (>65 Gy) with bulky residual disease, as this is not technically feasible; instead offer palliative chemotherapy 5.
Inadequate muscle sampling during TURBT leads to understaging and inappropriate treatment selection 2.
Failing to obtain upper tract imaging misses synchronous upper tract cancer in 2.5% of patients 2, 6.
Bladder outlet obstruction after cancer treatment can accumulate over time, particularly after combination radiotherapy and surgery (up to 26% incidence), requiring vigilant follow-up 3.