Staging of urinary bladder cancer
Bladder cancer staging differs from that of most other oncological diseases due to the specific categorization of superficial forms. If the tumor is located exclusively in the mucosal lamina propria without invading the mucosa and submucosa, this corresponds to stage Ta — completely superficial cancer.
Stage Tis (carcinoma in situ) is characterized by initial invasion into the epithelium. Subsequent grading is based on the depth of invasion:
- T1 — invasion into the submucosal layer;
- T2 — invasion into the muscular layer;
- T3 — invasion into the surrounding adipose tissue;
- T4 — invasion into adjacent organs.
For stage Ta, management is limited to active surveillance with follow-up cystoscopy. For Tis, approaches vary across clinical guidelines, but most commonly, a repeat transurethral resection (TURBT) of the bladder is performed after some time to assess the resection margin and rule out recurrence, or intravesical chemotherapy is administered. A high-grade (high grade) tumor in itself is an indication for intravesical chemotherapy regardless of the depth of invasion — usually a course of 6 intravesical instillations. Multiple bladder tumors also require intravesical chemotherapy to prevent recurrence.
Clinical cases from practice
The first case is a combined cancer of the urinary bladder and prostate gland, for which an en bloc cystoprostatectomy was performed; prostate adenocarcinoma was an incidental finding. Follow-up imaging (CT and MRI, with MRI being preferred for bladder evaluation due to better soft tissue visualization) is scheduled no earlier than 1–1.5 months after surgery, typically at 3 months, because postoperative changes mask potential recurrence. The patient was found to have total peritoneal involvement, peritoneal carcinomatosis, and a creatinine level of about 600 µmol/L (normal is around 100), which ruled out platinum-based chemotherapy due to nephrotoxicity. Despite the multidisciplinary tumor board's decision to prescribe single-agent gemcitabine, the patient died from disease progression before treatment could begin.
The second case demonstrates the consequences of an incomplete TURBT without muscular layer inclusion in a high-grade tumor: the lack of timely further evaluation and treatment led to total bladder involvement, a failed repeat TURBT (re-TURBT), and a transition to palliative chemotherapy.
The third case involves an 85-year-old female patient with a massive bladder mass of about 12 cm, macroscopically resembling a uterine myoma rather than the typical "cauliflower" appearance of bladder cancer. MRI revealed total replacement of the bladder with extension to the ureters, vagina, and uterine cervix. Given the age, radical surgical treatment was not considered. When another 77-year-old patient was found to have a PD-L1 mutation based on histology, immunotherapy was prescribed without the need for chemotherapy.
Diagnosis of hematuria and mass lesions
When presenting with gross hematuria, microhematuria, anemia, and general fatigue, a comprehensive workup is mandatory: cystoscopy (diagnostic cystoscopy is performed routinely regardless of age), pelvic MRI (provides better soft tissue visualization), and CT to evaluate other parts of the urinary system, including the kidneys. The source of hematuria can be any segment — kidneys, ureters, bladder, prostate gland, or urethra; therefore, diagnostic evaluation should not be limited to the bladder alone.
In men with hematuria, it is advisable to check for the presence of blood in semen: its absence in the presence of blood in the urine is more characteristic of kidney or bladder pathology than prostate pathology. The level of prostate-specific antigen (PSA) is also taken into account as a fairly specific marker of prostate pathology.
Any atypical lesion of the bladder mucosa, including ulcer-like defects, requires a mandatory biopsy, as benign lesions are much rarer than cancer. Morphological verification is mandatory before starting treatment: cases have been described where cancer-suspect lesions turned out to be hemorrhagic cystitis or a large polyp.
Management based on tumor size and localization
Small tumors (up to 4–5 cm) on a stalk or broad base can be resected en bloc during standard TURBT. For large masses (about 10–12 cm), only a TURBT biopsy is performed to obtain morphological material, as complete resection is technically impossible.
Determining the histological subtype is fundamentally important for selecting therapy: transitional cell carcinoma responds well to platinum-based chemotherapy, whereas squamous cell carcinoma responds better to radiotherapy. In young patients with papillary cancer and no comorbidities, surgical treatment with neoadjuvant gemcitabine + cisplatin chemotherapy is the priority.
If urinary outflow is impaired due to compression of the ureteral orifice by the tumor, placement of a ureteral stent or percutaneous nephrostomy (as opposed to nephrectomy — removal of the kidney) is indicated to decompress the upper urinary tract before further treatment.
Invasive cancer and extended surgeries
When muscular layer invasion is histologically confirmed (stage T2 and above), surgical treatment — cystectomy — is indicated, preceded by neoadjuvant chemotherapy to reduce tumor volume. Prior to surgery, pelvic MRI is mandatory to assess the extent of the process, including involvement of the uterus, cervix, and ureters.
In cases of massive local spread, combined en bloc removal of the bladder and adjacent pelvic organs (so-called "sterile pelvis") may be required, similar in scope to operations for gynecological malignancies. The decision on surgical treatment is always discussed at a multidisciplinary tumor board, while the right to refuse surgery remains with the patient; in such cases, alternatives including monoclonal antibody immunotherapy are considered.
Key points
- Bladder cancer staging includes stages Ta, Tis, T1–T4 depending on the depth of tumor invasion.
- High-grade tumors and multiple lesions are indications for intravesical chemotherapy regardless of invasion.
- Follow-up evaluation after surgery or intravesical chemotherapy is performed no earlier than 1–3 months.
- In hematuria, a comprehensive search for the source is necessary: kidneys, ureters, bladder, prostate gland, urethra.
- Any atypical bladder lesion requires a biopsy and morphological verification before treatment starts.
- The histological subtype of the tumor determines the choice between platinum-based chemotherapy and radiotherapy.
- When the muscular layer is invaded, surgical treatment preceded by neoadjuvant chemotherapy is indicated.
- The decision on the management strategy for urologic oncology patients is made collectively by a tumor board, taking into account the patient's age and preferences.