A 50-year-old heavy smoker presented with painless hematuria. Evaluation revealed bladder cancer risks including smoking history and hematuria. Cystoscopy and biopsy were recommended to determine tumor histology, location, and stage. Treatment and prognosis depend on tumor stage - non-muscle invasive tumors carry a good prognosis and can be treated with transurethral resection, while muscle invasive or metastatic tumors require more aggressive treatment such as urinary diversion and carry a worse prognosis.

1. Bladder cancer
Mohammed AlHinai

2. • 50 yrs old gentleman was referred to urology for painless hematuria. He
noticed blood in the urine toward the end of micturition on two occasions
over the last 1 months. Urine stream is good except when he pass clot. He is a
heavy smoker for the last 20 yrs. Abdominal examination was normal.
Differential diagnosis

3. Bladder tumor :
• is the most common malignancy involving the urinary system.
Risk factors :
Environmental factors:
• Chemical carcinogensis :
- Cigarette smoke.
- Occupational exposure
include metal workers,
painters, rubber
industry.
• Chlorination or arsenic
in drinking water.
Genetic :
• For those whose
affected relatives were
diagnosed before age
60 years.
Miscellaneous factors:
• Chronic cystitis.
• HPV infection
• Bilhaziasis infection
• Upper urinary tract cancer
• Radiation therapy
• Cyclophosphamide.

4. Classification according to histology
Urothelial :
• Transitional cell carcinoma.
Non-urothelial:
• Epithelial in origin:
- Squamous cell carcinoma.
- Adenocarcinoma
- Small cell carcinoma.
• Non-epithelial:
- sarcoma, carcinosarcoma, paraganglioma,
melanoma, and lymphoma.

5. Clinical manifestation :
Local manifestation :
• Gross Painless hematuria which intermittent, gross and present terminal or
throughout micturition.
• Irritative voiding symptoms include daytime and/or nocturnal frequency, urgency,
dysuria, or urge incontinence.
• Obstructive voiding symptoms include straining, an intermittent stream, nocturia,
decreased force of stream, and a feeling of incomplete voiding.
• Constitutional symptoms include fatigue, weight loss, anorexia, and failure to thrive
Metastatic manifestation :
• Suprapubic pain for locally advanced tumor.
• Right upper quadrant pain for liver metastasis.
• Melena and tenesmus for rectum.
• Hemoptysis and chest pain for lung.
• Renal failure and colicky pain for ureteric
obstruction.

6. Approach to patient with
bladder tumor

7. • 50 yrs old gentleman was referred to urology for painless hematuria. He
noticed blood in the urine toward the end of micturition on two occasions
over the last 1 months. Urine stream is good except when he pass clot. He is a
heavy smoker for the last 20 yrs. Abdominal examination was normal.
 Full history and clinical examination.
 Laboratory test include :
• Urinalysis :
- RBC present in urine dipstick.
- Normally shaped RBC in microscopic.
• Urine cytology with present of malignant cells.
• Other laboratory test include CBC, coagulation
profile, RFT and LFT.
 Imaging studies :
• KUB x-ray to exclude other causes.
• Pelvic US may show bladder mass.

8.  Cystoscopy (gold standard) :
• Any visible tumor or suspicious lesion should be either biopsied or resected
transurethrally to determine the histology and depth of invasion.
• a positive urine cytology and whose initial cystoscopy showed no visible
tumor (or suspicious lesion) or normal biopsy appearing, upper tract
evaluation is needed by ureteroscopy.
The result of
cystoscopy guided
biopsy will give :
Pathology classification :
• TCC
• SCC
• Adenocarcinoma
Extent of tumor locally which
divide into :
• Non-muscle invasive.
• Muscle invasive.

9. Two type of bladder tumor

10.  For staging and metastatic workup :
• CT scan or MRI.
• Chest x-ray.
• Bone survey
• Brain scan

12. non-muscle invasive
tumor
Muscle invasive
tumor
Advanced tumor
with metastasis
Management

13. non-muscle invasive
tumor
Muscle invasive
tumor
Advanced tumor
with metastasis

14. Prognosis

15. Urinary diversion
• A method to replace the urinary bladder by diversion the ureter and
urine flow away from the bladder.
Indication
• Congenital by ectopic vesica with failed repair.
• Traumatic by vesico-uretero-vagina fistula.
• Infection including TB, bilharzia.
• Malignancy in muscle invasive bladder cancer.
• Functional by neurogenic bladder.

16. Urinary diversion methods
non continent Continent
Neobladder
diversion
Ileocaecal
bladder
Rectal diversion

17. Complication of Urinary diversion
Metabolic :
• Increased loss of K.
• Hyperchloremic
metabolic acidosis due
to :
- digestion of urea by
bacteria into NH4 → (↑
H+).
- Increased absorbed of Cl.
GI complication :
• Nutritional deficiency
esp Vit B12 due to ileum
resection.
• Loss of bile salt lead to
lipid malabsorption and
gallstone formation.
• Activation of pro-
carcinogen which lead to
intestinal
adenocarcinoma
include:
- Nitrite / Nitrate → colonic
bacteria → Nitrosamine
(active carcinogen).
Urinary tract
complication:
• Incontinence of
continent diversion.
• Obstruction of ureter.
• Infection
• Stone formation.
• Renal failure.

18. References
1. Principle and practice of surgery.
2. Toronto notes 2016
3. Uptodate.