Surgical Management of Bladder Carcinoma

Rafael Carrion, MD, John Seigne, MB


Cancer Control. 2002;9(4) 

In This Article

Endoscopic Approaches to Bladder Cancer

The majority of patients who are diagnosed with bladder cancer present with either hematuria or irritative voiding symptoms. The initial diagnosis of bladder cancer is usually suspected following flexible cystoscopy performed under local anesthesia by a urologist as part of an assessment of these symptoms. Although the gross appearance of the tumor is a guide to the probable tumor type and stage, a definitive diagnosis is established by formal transurethral tumor resection under either general or regional anesthesia. At the time of cystoscopy, an inspection of the bladder is performed documenting the number, location, size, and appearance of each of the tumors on a standard bladder template. As bladder cancer is a field disease of the urothelium, it is not unusual to find more than one tumor. In fact, the size and number of tumors are almost as important as the grade and stage in predicting tumor recurrence in the future.[1,2]

Following tumor mapping, a larger cystoscope/ resectoscope (24F to 26F or mm in circumference) is introduced into the bladder and the tumors are resected. It is important that the initial resection includes the underlying smooth muscle muscularis propria to allow for proper tumor staging. After tumor resection, additional biopsies may be obtained of any abnormal-appearing areas since these may be carcinoma in situ, which has important prognostic and therapeutic implications. The need for random biopsies of areas of the bladder that appear normal in order to assess for a field change is controversial. In general, most studies indicate that in patients with 1 to 2 bladder tumors, additional random bladder biopsies yield little important additional information and are probably unnecessary.[3] An obvious exception is for patients with a positive urine cytology in whom no obvious tumor is found. These patients require careful assessment of the renal collecting systems and ureters with selective ureteral washings for cytology and bilateral retrogrades, as well as random bladder biopsies and a TUR biopsy of the prostatic urethra.[4,5]


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