Endoscopic Management
After the initial office evaluation, the patient is taken to the operating room. While the patients muscles are completely relaxed by anesthesia, a pelvic and rectal examination may permit the physician to feel abnormalities he would not be able to in the office. The urethra and bladder are inspected with the cystoscope and the tumor size and location, number of tumors, and visual characteristics are recorded photographically or on a bladder diagram. The bladder may be vigorously irrigated with saline through the cystoscope for a bladder wash specimen. The vigorous irrigation's causes some of the cells lining the bladder to fall off much the same way as shaking apples off an apple tree. This specimen is optimal for DNA ploidy analysis. The tumor is removed through another telescopic instrument. Biopsies of normal-appearing bladder lining are performed to check for microscopic cancer that would otherwise be missed by the surgeon's eye.
Information obtained from the initial and cystoscopic
evaluation form the basis for clinical staging (Table 1.). At diagnosis
about 75% of patients have superficial bladder cancer (cancers in the lining
of the bladder [urothelium] or into the next layer [lamina propria] but
not into the muscle layer) and 25% have invasive (into the muscle layer)
or metastatic (into the lymph nodes or other organs usually the lungs,
bones or liver ) disease. Although superficial bladder tumors tend to recur
frequently, most of recurrent tumors stay in the superficial areas. However,
5-30% of superficial tumors progress to invasive disease. Invasive tumors
have a higher risk to metastasize. For untreated metastatic disease, the
2-year survival rate is less than 5%.
Table 1. TNM system for staging bladder cancer.
T: primary tumor
T0 No tumor present
Tis Carcinoma in situ
Ta Papillary tumor limited to mucosa
T1 Extension into but not beyond lamina propria
T2 Invasion into superficial muscle layer
T3a Invasion into deep muscle layer
T3b Invasion into perivesical fat
T4a Invasion into adjacent organ (prostate, vagina, uterus)
T4b Fixed to pelvic or abdominal wall
TX Minimum requirements to assess primary tumor not met
N: lymph node
N0 No evidence of lymph node involvement
N1 Involvement of single homolateral regional lymph node
N2 Involvement of contralateral, bilateral, or multiple
regional lymph nodes
N3 Involvement of regional lymph nodes creating a fixed
mass
N4 Involvement of juxta regional lymph nodes
NX Miminum requirements to assess lymph nodes not met
M: distant metastasis
M0 No evidence of distant metastasis
M1 Evidence of distant metastasis
MX Minimum requirements to assess presence of distant
metastasis not met
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