Persistent hematuria in middle aged and older patients should always be evaluated for bladder cancer. Any unexplained increase in frequency and irritative symptoms related to passing of urine should be checked for the possibility of the bladder cancer. Read more on bladder cancer symptoms.
The evaluation of suspected patients with bladder cancer usually includes cystoscopy and cytology. Some patients also require additional radiological investigations.
Screening for bladder cancer has not been found to be an effective approach. The only useful test for screening in asymptomatic patients is urinalysis for detecting microhematuria. More specific diagnostic tests are undertaken if microhematuria is detected. Only 0.1% to 6% of individuals having microhematuria have bladder tumors. Though this approach can increase the possibility of diagnosing the bladder cancer at an earlier stage, it has not been found to improve the survival.
Bladder Cancer Tests
Urine cytology, which is the standard noninvasive screening test, is performed in high-risk or microhematuria positive individuals. The cytology, which checks for presence of malignant cells in urine, has a sensitivity of about 50% and more than 90% specificity. Other noninvasive tests that can be performed in the urine sample are :
- fluorescence in situ hybridization (FISH) analysis
- nuclear matrix protein test
- telomerase reverse transcriptase determination test
- basic fetoprotein
- urinary bladder cancer antigen test
These tests have a similar or greater sensitivity that that of urine cytology but specificity is often less than cytology, ranging from 50 to 90%.
Bladder Cancer Cystoscopy and Biopsy
Cystoscopy and biopsy are required for definitive diagnosis of bladder cancer.
A cystoscope is a long device with a camera at the end (endoscope) that is inserted through the urethra and allows for visualization of the bladder. In cystoscopic evaluation the bladder is carefully inspected to assess the size and number of bladder lesions, their locations, and the growth pattern of the bladder lesions. It also includes examination of bladder under anesthesia to determine if the lesion is palpable and whether it is a mobile mass or fixed mass. A fixed or non-mobile growth is suggestive of invasion of structures beyond the bladder walls like pelvic muscles, prostate or vagina.
A transurethral resection of the bladder tumor (TURBT) is performed along with sampling of the muscularis propria for accurate pathological diagnosis. A biopsy is also obtained from the base of the resected area. Biopsy samples are also taken from all visible areas of suspicion. It is then examined to determine the histologic type and the depth of invasion by the growth. In patients with suspected urethral involvement, urethral biopsies are also taken.
Some patients with positive findings in cytology may not have any finding in the bladder on cystoscopy. Such patients should be evaluated for urothelial tumors of the urinary tract above the bladder (ureter and renal pelvis) with intravenous pyleogram or CT-urogram.
Bladder Cancer Scans
A CT or MRI scan of abdomen and pelvis may be performed in the patients based on the findings of a cystoscopy and biopsy. The scan helps to detect tumor invasion of the perivesical fat, prostate gland or vagina and the regional lymph nodes.
Detection and staging of metastatic cancers requires bone scan, liver function tests, serum electrolytes, serum creatinine and chest x-ray in addition to the CT or MRI scan of abdomen and pelvis. CT or MRI scans are not useful in differentiating Ta/T1 tumor from a T2/T3 tumor as it cannot help in visualizing the depth of invasion of the tumor into the bladder wall. Read more on bladder cancer staging.
These scans are better performed before TURBT as the reliability of the scan is impaired after TURBT. MRI lymphangiography is a new procedure to find the cancer involved lymph nodes more accurately.