3Symptoms and signs of bladder cancer are often evident. In other cases, laboratory tests carried out on a routine basis or for the investigation of another pathology are the basis of this diagnosis.
When bladder cancer is suspected, a number of tests are required to confirm this diagnosis.
When the diagnosis is made and the cancer is confirmed, further tests are necessary for the tumour’s extension assessment. This determines the stage of the disease.
We will describe the contribution of imaging to diagnosis, extension assessment and bladder tumour monitoring in a future article.
Medical history and clinical examination
It is important to trace the medical history of the disease by analysing the clinical signs and symptoms the patient complains about. It is important to look for the presence of risk factors during this consultation, including family history.
The consultation also includes a clinical examination including pelvic, rectal, vaginal and possibly rectal examinations in women.
1) The urine strip
She can find blood in the urine in the doctor’s office.
2) Urinary cytology
A urine sample is examined by a trained cytopathologist under the microscope.
In fact, there are usually bladder cells in the urine. The cytopathologist looks for changes in the structure of these cells, suggesting the presence of cancerous cells.
Urinary cytology is also performed on the occasion of cystoscopy, in particular by taking urine for the cytopathologist to evacuate the bladder.
Cytology can diagnose a number of bladder cancers, but the test is not perfect. There are both false positives and false negatives.
3) Cytobacteriological analysis of urine
It is especially useful in the event of a lower urinary tract infection. She has little interest in diagnosing bladder cancer, apart from showing the presence of blood in the urine.
4) Urinary tumour markers
A number of urinary tests look for tumour markers that suggest bladder cancer.
These tests can be useful in addition to urinary cytology.
They are not currently performed in current practice and should not delay cystoscopy in any case.
When bladder cancer is suspected, the use of a lower urinary tract endoscopy is essential.
Usually, the imaging data, and in particular the uroscan, have already made it possible to diagnose this tumour, and endoscopy is carried out to confirm this diagnosis and treat the tumour by removing it by endoscopic resection.
It is an operating endoscopy performed under general or locoregional anaesthesia in the operating room under the usual asepsis conditions using an endoscopic resector, a rigid endoscope that allows the surgical gesture.
It is rare that an endoscopy performed for the sole purpose of seeing the tumour in order to make a diagnosis is necessary.
This low endoscopy is then performed under local anesthesia without hospitalisation using a flexible endoscope: a urinary fibroscope.
Whether exploratory or operative, using a flexible or rigid endoscope, the endoscopy of the lower urinary tract in both men and women is performed by a urological surgeon.
The endoscope is inserted into the urethra canal and progresses under control of the surgeon’s vision to the bladder. The examination is performed under continuous flow of a sterile solution that allows the bladder to expand and the urologist to examine the mucous membrane on all sides.
A relatively recent innovation is the blue light fluorescence cystoscopy, which can also be performed during a classical cystoscopy.
This cystoscopy is preceded 1 hour before the examination by intravesical instillation of Hexvix (hexyl aminolevulinate).
The realization of this cystoscopy in blue light requires the use of specific equipment.
The blue light examination enhances the contrast between the healthy bladder mucosa and the tumour mucosa. The product is more easily captured by tumour cells than by healthy bladder cells. Some tumours that are invisible in white light can thus be detected in blue light and completely resected.
Trans-urethral resection of bladder tumor
When a bladder tumour is detected by cystoscopy, it is necessary to remove the entire bladder tumour as far as possible for pathological examination.
These tissue samples are taken during a surgical procedure performed under general or locoregional anesthesia, which is an endoscopic bladder tumour resection.
The procedure removes all tumours or tumours in multiple locations.
This endoscopic resection is deep at the site of tumour implantation in the bladder wall to reach the bladder muscle and assess whether it is healthy or invaded by cancer cells.
Infiltration of the bladder muscle is indeed an important prognostic element in assessing the severity of the bladder tumour and the choice of treatment. In some cases, it is also necessary to take biopsies at the apparently healthy areas of the bladder, because even with a normal macroscopic appearance, the microscope can find cancerous urothelial cells, especially if there is a flat carcinoma in situ.
Tissues collected during endovesical transurethral resection are referred to a pathology laboratory.
In the case of bladder cancer, it is important to specify the cellular grade of the tumour and its invasive nature.
The invasive nature of bladder cancer depends on the depth at which the tumour is implanted in the bladder wall. This is an essential element in deciding how to treat this cancer.
Invasive cancers are those that implant themselves in the deepest layers of the bladder wall, especially the bladder muscle.
These invasive cancers have a high potential for spread and are more difficult and cumbersome to treat.
Cell grade is appreciated by the appearance of cancer cells under the microscope.
Low-grade cancers are cells that resemble normal bladder cells.
These are clearly differentiated cancers.
The prognosis for these low-grade tumours is usually good.
In high-grade malignancy cancers, cancer cells differ significantly from normal bladder cells, notably by the appearance of monstrous cell nuclei or large cells.
These undifferentiated or undifferentiated cancers are highly progressive, spread rapidly in the depths of the bladder wall and spread outside the bladder or in the organs at a distance.
Their treatment is more complex and cumbersome.
- Fontaniere – D. Ranchere-Vince – J.L. Landry – M. Colombel – D. Chopin – B. Gattegno . Critères de qualite de la cytologie urinaire pour le diagnostic tumoral – Progrès en Urologie (2001), 11, N°5, 867-875
- Résection endoscopique des tumeurs de vessie n’infiltrant pas la musculeuse avec HEXVIX®. T. Seisen, M. Rouprêt – Prog Urol, 2013, 23, 14, 1177-1180