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Medical History and Physical Examination

The first step in the evaluation of patients with suspected bladder cancer is a comprehensive medical history and physical examination. During this initial evaluation, the physician will carefully evaluate:

• Signs and symptoms that may be suggestive of bladder cancer
• Review the patient's risk factors for bladder cancer
• Examine the rectum and, in women, the vagina to rule out the presence of a tumor

Cystoscopy

Cystoscopy is an important diagnostic tool that enables the physician to directly examine the urinary tract with an instrument called a cystoscope. During this procedure, which is usually performed by an urologist on an outpatient basis, the cystoscope - a long, flexible lighted tube - is inserted through the urethra (the tube that carries urine from the bladder to the outside of the body) and is advanced into the bladder. The cystoscope enables the doctor to view the bladder and urethra and look for any abnormalities including a tumor, infection, or obstruction. During this procedure, the physician may also remove a small piece of tissue from the bladder (biopsy) and submit the biopsy specimen to the pathology laboratory where it is examined under a microscope for the presence of cancer cells. If you have signs and symptoms suggestive of bladder cancer (hematuria and/or changes in bladder habits), your doctor will recommend a cystoscopy to rule out bladder cancer.

Although cystoscopy is a relatively safe diagnostic procedure, in some cases complications may occur and include:

• Infection
• Bleeding
• Bladder perforation
• Difficulty in urinating

Biopsy

A small piece of bladder tissue (biopsy specimen) is obtained by the urologist during cystoscopy for microscopic evaluation. During the biopsy procedure, muscle tissue must be obtained as it is important to determine the extension of the tumor (how far the tumor has spread) since the treatment of superficial bladder cancer differs from muscle-invasive bladder cancer. The biopsy specimen will then be examined under a microscope by another doctor known as a pathologist. The results of the biopsy evaluation provide the following important information:

• Whether or not cancer cells are present
• The extension of the cancer (how deep the cancer has spread)

• Specific subtype of bladder cancer:

  • transitional cell carcinoma
  • squamous cell carcinoma
  • adenocarcinoma
  • small cell

• Grade of the bladder cancer - grading is a description of how abnormal or aggressive the bladder cancer cells appear when viewed under a microscope. Bladder cancer is graded on a numerical scale ranging from 1 to 4. In general, the higher the grade, the more abnormal (aggressive) the nature of the cancer:

  • low-grade (grades 1 and 2) bladder tumors are less aggressive and have a better prognosis than high grade (grades 3 and 4) bladder tumors

  • high-grade bladder tumors are poorly differentiated, tend to be more aggressive, and are more likely to be invasive and spread to the bladder wall and outside the bladder.

Radiological Evaluation

Imaging studies that may be used in the evaluation of patients with suspected bladder cancer include:

• Intravenous pyelogram (IVP) - This is a specialized X-ray of the urinary tract which shows detailed pictures of the kidneys, bladder, ureters, and urethra.