Diagnosis and Classification

Diagnosis

Diagnosis

Your doctor will take a detailed medical history and ask questions about your symptoms. You can help your doctor by preparing for the consultation.

  • Make a list of your previous surgical procedures.
  • Make a list of the medications that you take.
  • Mention other diseases and allergies that you have.
  • Describe your lifestyle, including exercise, smoking, alcohol, and diet.
  • Describe your current symptoms.
  • Note how long you have had the current symptoms.
  • Family history of other tumours, especially in the urinary tract.

Urine test

Because blood in the urine is the most common symptom when a bladder tumour is present, your doctor will test your urine to look for cancer cells and to exclude other possibilities like urinary tract infections. Your doctor may refer to this test as ‘urinary cytology’.

Physical examination does not reveal non–muscle-invasive bladder cancer, and seldom reveals a mass if cancer has advanced to the muscle-invasive stage. If muscle-invasive bladder cancer is suspected, your doctor should perform rectal and, for women, vaginal examinations by hand (bimanual palpation).

In addition, your doctor will do a series of tests to make the diagnosis. Advanced diagnostic tools are described in the next section.

Cystoscopy

Cystoscopy is the main test used to diagnose bladder cancer. It allows your doctor to look at the inside of your bladder and urethra using a thin, lighted tube called a cystoscope.

After the urethra is anaesthetised, the cystoscope—a flexible camera and instrument—is inserted into the urethra and the bladder. You can experience some urge to void when this is done. If a tumour can be seen or if a probe of fluid from the bladder (irrigation cytology) contains malignant cells, further diagnostic tests are needed.

Small biopsies can be taken immediately with the cystoscope. Larger biopsies or removal of tumours, called transurethral resection of bladder tumour (TURBT), must be done under general or spinal anaesthesia.

CIS is diagnosed by combination of cystoscopy, irrigation cytology, and evaluation of multiplebladder biopsies or biopsies under enhanced cystoscopy using violet light (see Photodynamicdiagnosis).

After the examination, you might have some blood in your urine for a few days. Drinking an additional 500 mL per day (eg, two extra glasses of water) will help dilute the urine and flush out the blood. You might also have painful urination or have to urinate more often or more urgently. These short-term effects will pass. If they persist for more than 3 – 5 days, you might have aurinary tract infection and should contact your doctor.

CT urography

Computed tomography (CT scan) urography gives your doctor information about possible tumours in the kidneys or ureters, furthermore information about the lymph nodes and abdominal organs. The scan takes approximately 10 minutes and uses x-rays. It is the most accurate imagingtechnique for diagnosing cancer in the urinary tract.

CT urography is non-invasive, so no instruments are inserted into your body. A contrast agent is injected into the body through a vein to improve the visibility of certain internal body parts and pathways during the CT scan. For this examination, your kidneys must function normally, so a blood sample is taken prior to the CT scan to check kidney function. Be aware that the contrast agent can cause an allergic reaction, so please let your doctor know if you have had any allergic reactions in the past. If you are taking any antidiabetic medications, your doctor might ask you to stop taking them for a few days.

If CT urography detects a tumour in the urinary tract, your doctor will recommend a biopsy to confirm the diagnosis. The biopsy is a surgical procedure to remove small piece of tissue for further examination. Bladder biopsy is performed through an endoscope, with the patient under general anaesthesia (combination of intravenous drugs and inhaled gasses; you are ‘asleep’) or local/epidural anaesthesia.

CT urography cannot detect small or superficial tumours (CIS). If small or superficial tumours are suspected further tests are needed.

MRI

Like CT scans, MRI scans show detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays.

MRI images are particularly useful in showing if the cancer has spread outside of the bladder into nearby tissues or lymph nodes. A special MRI of the kidneys, ureters, and bladder, known as an MRI urogram, can be used to look at the upper part of the urinary system in cases where IV contrast is not tolerated.

This examination is not suitable for patients with metal implants, artificial joints, screws and pace-makers).

Intravenous urography

Intravenous urography (IVU) is another imaging technique for examining the urinary tract. IVU may be used for the assessment of the upper urinary tract when CT-urography is not available. It cannot detect small or superficial tumours (CIS), and it’s not recommended for detecting lymph nodes or invasion of neighbouring organs.

In IVU, a contrast agent (dye) is injected into the body through a vein, and an x-ray of the abdomen is taken. The kidneys excrete the contrast agent into the urinary tract, which improves its visibility in the x-ray.

Because the intravenous contrast agent can cause an allergic reaction, your doctor will ask you about any allergies. Your kidneys must function normally for this examination, so a blood sample is taken prior to the CT scan to check kidney function. If you are taking antidiabetic medications, your doctor might ask you to stop taking them for a few days.

Transabdominal ultrasound

Ultrasound is a non-invasive diagnostic tool that can visualize masses larger than 5-10mm in a fullbladder. It cannot detect very small or superficial tumours (CIS). This study does not require intravenous contrast; however, ultrasound cannot replace CT urography or cystoscopy.

Transurethral resection of bladder tumour

TURBT is the surgical removal (resection) of bladder tumours. This procedure is both diagnostic and therapeutic. It is diagnostic because the surgeon removes the tumour and all additional tissue necessary for examination under a microscope (histological assessment). TURBT is also therapeutic because complete removal of all visible tumours is the treatment for this cancer. Complete and correct TURBT is essential for good prognosis. In some cases, a second TURBT is required after several weeks.

TURBT is performed by the insertion of a rigid endoscope through the urethra into the bladder, with the patient under general or spinal anaesthesia. TURBT usually takes no longer than 1 hour and requires a short hospital stay. After the operation, usually a transurethral catheter is placed for one or two days.

As in any surgical procedure, bleeding and infections may occur after the surgery. Symptomatic infections are treated with antibiotics and rarely require longer hospitalization. Perforation of thebladder during the operation is not very common but can occur and usually resolve with catheterization for a few days. In rare cases it may require open surgery and suturing of the bladder.

Photodynamic diagnosis

Photodynamic diagnosis (PDD) is an additional diagnostic method available at some centres. It is performed during the transurethral resection of a bladder tumour. Photodynamic diagnosis makes cancer cells visible under violet light to improve detection and removal of tumours and reduce the risk of recurrence.

Shortly before the operation a catheter is inserted and the bladder is irrigated with a solution of 5-aminolaevulinic acid or hexaminolaevulinic acid. The catheter is removed immediately after irrigation. Cancer cells in the bladder process the active compound in the solution and become fluorescent under violet light. No side-effects or complications have been reported for PDD.

Narrow-band imaging

Narrow-band imaging (NBI) is the application of light at specific blue and green wavelengths on the inner lining of the bladder during normal cystoscopy. This enhances the visual contrast between healthy tissue and cancer tissue and improves the detection of tumours in the bladder. This method does not require any bladder instillation.

FAQ – What is bladder instillation?

A combination of medicines put directly into the bladder using a flexible tube called acatheter.

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