Bladder Cancer
Page updated Winter 2023.
Disclaimer: Medicine is an ever-changing science. We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, Smith's Textbook of Endourology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable sources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to take or administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original sources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.
Non-Muscle Invasive Bladder Cancer
Microhematuria
Definition:
>3 red blood cells per high-power field
Evaluation:
Low-risk patients: UA within six months vs. proceeding with cystoscopy and renal ultrasound
Intermediate-Risk: cystoscopy and renal ultrasound
High-Risk: cystoscopy and axial upper
tract imaging (CT urography (including
imaging of the urothelium), or MR urography))
In case of contraindications to CT and MR: retrograde pyelography + non-contrast axial imaging or renal ultrasound
CT Contrast in Kidney Failure
We advise IV isotonic saline administration if GFR< 44, unless it is contraindicated.
MRI Contrast in Kidney Failure
Contrast-enhanced MRI with a group II agent should not be withheld, regardless of renal function, if MRI is deemed clinically necessary.
TURBT
TURBT is performed to remove all visible tumors and to provide specimens for pathology to determine stage and grade of cancer.
Repeat TURBT within 6 weeks
Should be done in following situations:
- Incomplete initial resection in a patient with non-muscle invasive disease
- T1 disease
- High-grade Ta tumors
Adverse Events
Major Complications:
Uncontrolled bleeding, bladder perforation 1%–6.7%
TUR syndrome- Dilutional hyponatremia
Minor Adverse Events- Common:
Minor bleeding
Irritative urinary symptoms
Monopolar TURBT Setting
Cut: 70 to 90 W
Coag: 30 to 60 W
Irrigation: water
Bipolar TURBT Setting
Cut: 160 to 200 W
Coag: 100 to 120 W
Irrigation: Saline
Supplies
Standard 21 and 22 F Cystoscope Set
26 Fr Resectoscope (Monopolar or Bipolar) set
TUR Loop
Cold Cup Biopsy set
Flexible Biopsy Forceps
Bugbee Electrode
Lens: 30 degrees, and 70-degree
Light source and cable
Camera
Irrigation Bags, and Tubing
Glass Ellik Bladder Evacuator
Lubricant
10 and 20 cc Syringes
2 or 3 Way Foley Catheter
Sloan PP-300 - PROTECTORS, PANT
Alternative for Enhanced Detection
Blue Light Cystoscopy Set
Confirm Cysview® was given in Preop area
Additional Supplies for Urethral Stricture
Van Buren Sounds
Urethral Dilator Set- COOK MEDICAL
AMPLATZ 0.038 Guidewire
22 French Urethrotome Set
Straight Collins Cold Knife
Supplied for CBI on the Floor
Mask and Face Shield
Protective Gown
Non Sterile Gloves
Sterile Gloves
Catheterization Tray
Three-Way Foley Catheter (20-24 French)
URO-Jet
Sterile Water for Balloon
10 cc Syringe
4 Liter Urinary Drainage Bag
CBI Irrigation Set- Y Type
3 Liter Sodium Chloride 0.9% Bags
Bladder Irrigation Tray
Toomey Irrigation Syringe (Piston Syringe)
Saline for Bladder Irrigation
Blue Clamps
Foley Anchor (Sticker)
Non-Muscle Invasive Bladder Cancer
Intravesical Instillation
Low risk disease
We recommend a single postoperative instillation of gemcitabine or mitomycin C within 24 hours of TURBT, unless there is a suspected perforation or if we performed extensive resection.
Intermediate risk disease
We recommend a single postoperative instillation of gemcitabine or mitomycin C within 24 hours of TURBT, unless there is a suspected perforation or if we performed extensive resection.
We recommend a six week course of induction intravesical chemotherapy (Mitomycin C, Doxorubicin, Epirubicin) or BCG in this group.
In patients who completely respond to induction chemotherapy or BCG, we recommend a maintenance chemotherapy or BCG instillation for one year, if tolerated.
High risk disease
We recommend a six-week induction course of BCG in this group.
In patients who completely respond to induction BCG, we recommend maintenance BCG instillation for three year, if tolerated.
Second BCG Induction
Will be offered if there is persistent or recurrent Ta or CIS disease in an intermediate- or high-risk patient.
Please note we did not include high grade T1 disease here. We offer cystectomy for high grade T1 disease.
Contraindications to Intravesical Chemotherapy
Pregnancy
Lactating
Bladder perforation
Any allergy or adverse reactions to the chemotherapeutic agent
Contraindications to Intravesical BCG
Bladder or prostate surgery or biopsy - Within 7 to 14 days
Traumatic catheterization - Within 7 to 14 days
Gross hematuria at the day of treatment
Symptomatic urinary tract infection
Febrile illness
Personal history of BCG sepsis
Personal history of tuberculosis
Immunosuppressed patients
On certain antibiotics that may interfere with effectiveness of BCG
Total incontinence (patient will not retain BCG)
Liver disease (precludes treatment with isoniazid if sepsis occurs
Advanced age
Radical Cystectomy
Initial radical cystectomy
Will be offered in following settings:
-Persistent high-grade T1 disease on repeat resection
-T1 tumors with associated with CIS
-T1 tumors with associated with Lymphovascular invasion
-T1 tumors with associated with variant histologies. These include: micropapillary, nested, plasmacytoid, neuroendocrine, sarcomatoid, and extensive squamous or glandular differentiation
Radical cystectomy after intravesical therapy
Will be offered in following settings:
For a high-grade T1 disease after a single course of induction intravesical BCG
For a high-risk disease with persistent or recurrent disease within one year following treatment with two induction cycles of BCG, or on BCG maintenance.
BCG Instillation 6 Week Series
BCG 50 mg in NaCl 0.9% 50 ml x 6
Intravesical Injection, Retain for 120 Min
GLYDO, 11 ml x 6
Intravesical Administration
Gemcitabine (Gemzar) One Time Dose
Gemcitabine, 2000 mg in NaCl 0.9% 50 ml
Intravesical Injection, Retain for 90 Min
GLYDO, 11 ml
Intravesical Administration
Gemcitabine (Gemzar) 6 Week Series
Gemcitabine, 2000 mg in NaCl 0.9% 50 ml X 6
Intravesical Injection, Retain for 90 Min
GLYDO, 11 ml x 6
Intravesical Administration
Mitomycin 6 Week Series
Mitomycin, 40 mg in Sterile Water 20 ml X 6
Intravesical Injection, Retain for 90 Min
GLYDO, 11 ml x 6
Intravesical Administration
Gemcitabine (Gemzar) Docetaxel (Taxotere) 6 Week Series
Gemcitabine, 1000 mg in NaCl 0.9% 50 ml X 6
Intravesical Injection, Retain for 120 Min
Docetaxel 37.5 mg in NaCl 0.9% 50 ml X 6
GLYDO, 11 ml x 6
Intravesical Administration
Notice: We administer the Gemzar first.
Muscle-Invasive Bladder Cancer
Radical Cystectomy Candidate
For clinically resectable stage cT2-T4a N0 M0 disease
Neoadjuvant Chemotherapy
We recommend cisplatin-based neoadjuvant chemotherapy to T2–T4a N0 M0 patients.
Cystectomy should then will be done within 12 weeks of completion of treatment.
Adjuvant Chemotherapy
We recommend adjuvant chemotherapy to pT3/T4 and/or N+ patients who have not received cisplatin-based neoadjuvant chemotherapy.
Multi-Modal Bladder Preserving Therapy
This is an option in highly selected patients.
This modality includes maximal TURBT, chemotherapy and external beam radiation therapy.
In case residual or recurrent muscle-invasive disease following bladder preserving therapy, radical cystectomy with bilateral pelvic lymphadenectomy should be done.
In case of non-muscle invasive recurrence following bladder preserving therapy, either TURBT with intravesical therapy, or radical cystectomy should be done.
Metastatic Bladder Cancer
First-line Treatment for Cisplatin-eligible Patients
GC, MVAC, HD-MVAC, PCG
First-line Treatment if Ineligible for Cisplatin
PD-L1-positive patients: Pembrolizumab or atezolizumab
PD-L1 negative patients: Carboplatin
Second-line Treatment
Pembrolizumab
Supportive Treatment in Case of Bone Metastasis
Zoledronic acid or Denosumab
Chemotherapy Regimens
GC: Gemcitabine + Cisplatin
MVAC: Methotrexate + Vinblastine + Doxorubicin + Cisplatin
HD-MVAC: High-dose-intensity chemotherapy MVAC
PCG: Paclitaxel+ Cisplatin + Gemcitabine
Ureteroscopy for Upper Tract Tumor
Holmium Laser Setting
Frequency: 6–10 or even 15 Hertz
Energy: 0.5 to 1 Joule
The laser fiber must be placed in contact with or very close to the tissue.
The laser energy is absorbed within less than 0.5 mm of tissue or fluid.
Bleeding can be controlled better at lower energies or by moving the fiber slightly away from the tissue
Supplies
Laser Fiber: 200 Micron
C-Arm
22 French Cystoscope
30-degree Lens
Rigid Ureteroscope
Flexible Ureteroscope
Pressure Bag
Saline for Irrigation
Irrigation Tubes
Camera, Light Source and Cable
Open-End Flexi-Tip Ureteral Catheter, 5 Fr
Contrast Dye and Saline
10 and 20 cc Syringes
Lubricant
Glidewire, Straight, 0.038
Glidewire, Straight, 0.035
Bard Solo Flex, Straight, 0.038
Dual-Lumen Ureteral Catheter
Flexor Ureteral Access Sheath, OD: 11.5 Fr, ID: 9.5 (with STORZ Flex X Flexible Ureteroscope
Brush Biopsy Set, 3.2 Fr
Halo, Nitinol Tipless Basket, 1.5 Fr
Cup Biopsy Forceps, 3.3 Fr
4.7 or 6 or 7 Fr X 24 or 26 or 28 cm JJ
Ureteral Stent
Foley Catheter