Radical Cystectomy Workup

Updated: Jul 23, 2020
  • Author: Michael Christopher Large, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Workup

Laboratory Studies

Urinalysis

Urinalysis is used to identify or to confirm microscopic or gross hematuria. When hematuria is present along with bacteruria or pyuria, obtain a urine culture to rule out urinary tract infection. Urinalysis may yield false-negative results because hematuria associated with bladder cancer is often intermittent.

Urine cytology

Exfoliated urothelial cells are viewed using microscopy. In some urothelial cancers, cellular clumping, a high nuclear-to-cytoplasmic ratio, nucleoli, and atypia are seen.

Avoid the first morning sample because of cellular degeneration.

Cytology is useful for identifying carcinoma in situ (CIS) and high-grade tumors but is less useful for low-grade tumors. The sensitivity of cytology for grades 1, 2, and 3 disease is 20%, 50%, and 90%, respectively.

Tests that are used to assess for protein (NMP22), nucleic acid, or chromosomal abnormalities (chromosomes 3, 7, 9, 17) are emerging as possible urine-based adjuncts for the diagnosis of bladder cancer.

Bladder barbotage

Bladder barbotage consists of repeated washings of bladder urothelium with normal saline. This test has better sensitivity than urine cytology because the total yield of cells is higher.

Other tests

Liver function tests and bone fraction of alkaline phosphatase are used to evaluate for metastatic spread to liver and bone.

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Imaging Studies

An appropriate evaluation of hematuria includes radiographic (computed tomography [CT] scanning, ultrasonography, retrograde pyelography, intravenous pyelography [IVP]) or direct imaging (cystoscopy, ureteroscopy) of the entire urinary tract. A standard hematuria evaluation includes (1) CT scanning of the abdomen and pelvis, with and without intravenous contrast, often termed CT urography and (2) flexible cystoscopy. If a patient cannot receive intravenous contrast, the evaluation commonly consists of renal ultrasonography, cystoscopy, and retrograde ureteropyelography.

CT scanning and ultrasonography can reveal filling defects or masses in the urinary tract; however, they are frequently unable to demonstrate small urothelial tumors.

A bone scan is indicated if the patient has symptomatic bone pain, elevated calcium levels, or elevated alkaline phosphatase levels.

Magnetic resonance imaging (MRI) is used in some centers for evaluation of both local and metastatic disease; however, its staging accuracy is unknown. Therefore, the use of MRI is currently under investigation.

Ferumoxtran-10–enhanced MRI and 11C-choline positron emission tomography/CT are under investigation as potential modalities for improving preoperative nodal staging. [7, 8]

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Other Tests

Upon recognition of disease that may prove amenable to radical cystectomy, preoperative staging is essential for stratifying the chance of disease eradication and recurrence risk, as well as for identifying patients with metastatic foci who are not candidates for surgery. Preoperative staging involves the following:

  • The patient is examined under anesthesia to determine if the mass is fixed (pT4) or mobile. In women, this includes a bimanual pelvic examination; in men, this includes a bimanual examination with one hand per rectum and the other on the lower abdominal wall.

  • CT scanning of the abdomen and pelvis is performed. Both overstaging (20%) and understaging (50%) are common if only one study is performed.

  • Chest radiography is performed to assess for metastatic deposits.

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Biopsy and Histologic Findings

Biopsy - Transurethral resection of bladder tumor

The biopsy consists of cystoscopic resection of tumors with biopsy forceps or a resectoscope. Superficial-appearing papillary tumors, as assessed by an experienced urologist, are virtually always noninvasive lesions. As a rule, any lesion that may extend into the lamina propria or deeper should include deep resection specimens that incorporate muscularis propria.

The biopsy can be performed in an operating room under general or spinal anesthesia.

The site, size, and number of tumors and whether papillary tumors are sessile, solid, nodular, or pedunculated is documented.

A biopsy of the prostatic urethra may be considered in patients at high risk for urethral disease (extensive CIS, multifocal high-grade disease, disease at or near the bladder neck, an abnormal-appearing prostate); 10-40% of patients with bladder cancer have prostatic urethral involvement.

Histologic findings

In the United States, 90% of bladder cancers are transitional cell carcinoma (TCC), 5% are squamous cell carcinoma (SCC), and 2% are adenocarcinoma. Grades 1, 2, and 3 refer to well, moderately, and poorly differentiated microscopic classifications, respectively. Forty percent of newly diagnosed bladder cancers are high grade, and up to half of these are stage T2 or higher. [9, 10]

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Staging

Upon diagnosis of bladder cancer, accurately staging the cancer is essential for instituting appropriate therapy.

Table 1. Staging of Bladder Cancer (Open Table in a new window)

Disease Type

Stage

Characteristics

Superficial disease

Ta

Confined to mucosa

T1

Involving lamina propria and muscularis mucosa

CIS

Malignant cells still confined to the flat urothelial layer

Muscle-invasive disease

T2

Invasion of muscularis propria

T3

Extension into perivesical fat

T4

Invasion of pelvic sidewall or adjacent organs or metastatic disease

Lymph node stages include the following:

  • NX - Unknown lymph node status

  • N0 - No lymph node involvement

  • N1 - A single lymph node in the true pelvis

  • N2 - Two or more lymph nodes in the true pelvis

  • N3 - Lymph nodes along the common iliac artery or beyond

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