Diagnosis/Workup

Question 1

Definition of microscopic hematuria

Answer 1

> 2 RBC/hpf in 2 of 3 collected urinalysis

Question 2

Most common symptoms of bladder cancer?

Answer 2

1. Painless hematuria

2. irritative voiding symptoms (CIS, muscle invasive TCC)

Question 3

Sens/spec of cystoscopy for bladder cancer?

Answer 3

sensitive ~ 90%

specific ~ 100%

Question 4

Sens/spec of urine cytology for bladder cancer?

Answer 4

if high grade or CIS, sensitive ~75%, spec ~95%

Much less accurate for low grade/superficial TCC

*i.e., cytology is better for higher grade cancer or CIS

Question 5

Sens/spec of FISH?

Answer 5

Sensitive = 50-80%
Specific = 90%

Question 6

If FISH is positive, but cytology, CT urogram, and cystoscopy are negative, what do you do?

Answer 6

random bladder biopsies

Question 7

NMP22 is a quantitative/qualitative test, while BladderChek is a quantitative/qualitative test?

Answer 7

NMP22 = quantitative

• “nuclear matrix protein”
• ELISA test

BladderChek = qualitative
- also checks for NMP22, but simply checks presence of protein and not the concentration

*in combination with cystoscopy, these have about 99% NPV

Question 8

BTA (bladder tumor antigen) Trak vs BTA Stat?

Answer 8

BTA Trak is a quantitative test that is run in a laboratory, while BTA Stat is a qualitative test that can be done in the office

Question 9

All patient suspected of bladder cancer should get what additional follow-up examinations/tests/imaging?

Answer 9

Cystoscopy
*Bimanual exam (check for masses)
Upper tract imaging with CT urogram or Retrograde pyelogram if GFR < 60

Question 10

What is the clinical stage of bladder cancer if there is hydronephrosis and mass near orifice?

Answer 10

cT2+

Question 11

Clinical stage if there is a palpable mass after TURBT?

Answer 11

cT3

Question 12

Clinical stage if palpable, fixed mass after TURBT?

Answer 12

cT4

Question 13

If a mass is occluding the ureteral oriface, how should you approach it with TURBT?

Answer 13

Resect it with loop cautery, cut phase

Stents are controversial, likely not necessary

Question 14

If diverticular tumor present, how should you approach it?

Answer 14

cup biopsy only, b/c high perforation rate

if T1, then go with partial cystectomy (b/c by definition, diverticula do not have a muscle layer so T1 could be invasive)

Question 15

Why is restaging TURBT required for all high grade and T1 lesions?

Answer 15

• 20-30% of patients are overstaged
• 10-15% (if muscularis propria present) and up to 50% (if muscularis propria is absent) are understaged
• around 25% will have residual disease, which is a risk factor for progressiong and recurrence

Question 16

When are random biopsies indicated?

Answer 16

• if partial cystectomy considered
• if cytology shows high grade TCC despite low grade lesions on TURBT
• FISH positive but everything else negative

Question 17

When are prostate biopsies, taken at the 5 and 8 o’clock positions, indicated?

Answer 17

• r/o urethral involvement if considering a neobladder
• high grade tumor in close proximity
• TCC refractory to BCG
• unidentified source of positive cytology/FISH

Question 18

What do you do if you cause an intraperitoneal bladder rupture during TURBT?

Answer 18

Cystorrhaphy (primary repair)

• can Foley drain if small injury

Question 19

What do you do if you cause an extraperitoneal bladder rupture during TURBT?

Answer 19

foley drainage for 2 weeks then do a cystogram

• if not healed by 3 weeks, need to do cystorrhaphy

Question 20

What work up is needed for muscle invasive bladder cancer (metastatic w/u)?

Answer 20

1. CXR (CT chest if abnormalities on CXR)
2. CT Urogram
3. LFT’s
4. Bone scan (if bone pain or high ALP)
5. Albumin
   - hypoalbuminemia has greatest predictability regarding post-operative complications