Cystoscopy and TUR
- When bladder cancer is identified through cystoscopy, the location, number, and nature of tumors are recorded, as is involvement of areas likely to reflect extravesical extension such as the ureteral orifices and bladder neck/prostatic urethra.
- Urinary cytology is obtained as a baseline and to establish the likelihood of high-grade disease.
- Positivity will encourage random bladder biopsy at the time of TUR.
- Upper tract imaging is usually performed both to identify other sources of hematuria and to assess the extravesical urothelium.
- Expert consensus is that patients with solitary or limited low-grade Ta lesions do not need imaging, owing to the very low risk of extravesical disease.
- TUR of bladder tumor (TURBT) under regional or general anesthesia is the initial treatment for visible lesions.
- TUR is performed to (1) remove all visible tumors and (2) provide specimens for pathologic examination to determine stage and grade.
- Partial or radical cystectomy should be strongly considered for high-grade diverticular lesions.
- Minor bleeding and irritative symptoms are common side effects in the immediate postoperative period.
- Tumor cell implantation immediately after resection is responsible for many early recurrences.
- Mitomycin C (MMC) appears to be the most effective adjuvant intravesical chemotherapeutic agent perioperatively.
- In Europe epirubicin is used and direct comparative studies are lacking.
- Local irritative symptoms are the most common complications of postoperative instillation, when perforation is absent during the resection.
- BCG can never be safely administered immediately after TUR because the risk of bacterial sepsis and death is high.
Lasers
- Laser coagulation allows minimally invasive ablation of tumors up to 2.5 cm in size.
- The neodymium : yttrium-aluminum-garnet (Nd : YAG) laser has the best properties for use in bladder cancer.
- Lesions can be coagulated until nonviable through protein denaturation using a straight or 90-degree noncontact “free beam” laser using power output of up to 60 W.
- The most significant complication of laser therapy is forward scatter of laser energy to adjacent structures, resulting in perforation of a hollow, viscous organ such as overlying bowel.
- This is rare but most commonly occurs with the neodymium : YAG laser because of its deeper tissue penetration than with holmium : YAG and KTP lasers.
Office-based TUR
- Many patients with small (<0.5 mL) low-grade recurrences can be managed safely in the office setting using diathermy or laser ablation under intravesical local anesthetic
- A tissue diagnosis and a negative cytology for the initial tumor occurrence are mandatory to determine whether the tumor is of high or low grade.
- Many small, low-grade tumors can be safely observed until they exhibit significant growth due to the minimal risk of progression.
Fluorescence Cystoscopy
- Fluorescence cystoscopy with 5-ALA derivatives improves the ability to visualize inconspicuous tumors and appears to reduce recurrence rates following TUR.
Reference:
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