Urology Info - Bladder Cancer

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