Bladder cancer: symptoms and diagnosis

Symptoms


The main symptom of bladder cancer is hematuria, which is the presence of blood in the urine. It is found in about 90% of patients.


The bleeding often appears at the end of the urination. The urine may be slightly pink, dark red or burgundy depending on the intensity of the bleeding. There is no link between the importance of bleeding and the severity of cancer.

Hematuria are sometimes too weak to be seen with the naked eye. They can also be interrupted for a while and intercalated with urine of normal appearance. It is therefore recommended to systematically consult a doctor from the first hematuria identified. This approach makes it possible to carry out the examinations necessary to make the diagnosis of bladder cancer or, on the contrary, to direct towards other diseases that can also cause haematuria (kidney stones, chronic infections, cancer or kidney diseases ...) .

Other local symptoms may alert the patient: more frequent urination, burning or pain when urinating ... Whether or not associated with hematuria and if they persist, these events should encourage the patient to consult his doctor.


Diagnostic examinations


The symptoms of bladder cancer are not specific: other diseases can be evoked in the presence of hematuria or painful urination.


To confirm the diagnosis, several examinations are necessary.
Clinical examination


During a first consultation, the doctor examines the patient's abdomen. He usually practices a rectal examination, associated with a vaginal touch in the woman. These gestures make it possible to search for a possible abnormality in the bladder. If the results of these examinations are generally normal for people with superficial tumors, an abnormality can be identified in case of advanced form.
ECBU (Cytobacteriological examination of urine)


ECBU consists of microscopically analyzing a urine sample previously collected from the patient. This examination can identify bacteria that could be responsible for urinary tract infection and hematuria.
Urinary cytology


Like the skin, the urothelium (inner layer of the bladder wall) desquamates naturally: dead cells are then released into the urine. Urine cytology is a test that examines the normal or cancerous appearance of these cells from a simple urine sample. If this examination identifies high-grade tumors, it is not always suitable for the detection of low-grade tumors. These are indeed formed of cancer cells quite similar to normal cells.
ultrasound


An ultrasound can be used to observe the urinary system - bladder, kidneys and ureters - and the functional abnormalities that can affect them. It is performed on full bladder, which requires drinking about one liter of water, one hour before the exam. It lasts about twenty minutes and is painless. It is performed in an extended position: the doctor applies the ultrasound probe next to the bladder after applying a cold gel on the skin.
Cytoscopy


Cystoscopy is a very effective test for making a diagnosis. A thin and flexible optical system is introduced inside the bladder (via the urinary meatus and then the urethra) to identify and observe any cancerous abnormalities. To avoid discomfort related to the examination, anesthetic gel can be injected into the urethra at the beginning of the procedure. Sterile water is also injected to round the bladder and facilitate observation of the internal walls. The doctor then observes the number, location, size and appearance of the abnormality (s). If the surgeon deems it necessary, a tissue sample can be taken and analyzed by microscopy: it is the biopsy that confirms the diagnosis.

In some cases, the doctor may strongly suspect the cancerous nature of the detected abnormalities even before performing cystoscopy. For these patients, the examination is done under general or locoregional anesthesia (spinal anesthesia); the goal is for the surgeon to immediately remove the tumor by transurethral resection (which passes through the urethra). The tumor is then analyzed to confirm the diagnosis. If it is a cancer, this resection is the first time of treatment.


Extension assessment reviews


When previous examinations have revealed an infiltrating tumor or a superficial tumor with poor prognosis, additional examinations are prescribed; they make it possible to assess how far the cancer has spread.


Computed tomographic urography (uroscanner or uro-CT) is an imaging test that can visualize the entire urinary system, local lymph nodes and neighboring organs. It helps assess how far the disease has spread beyond the bladder. This examination makes it possible to identify cancers of the kidney or ureter that coexist in 2 to 4% of patients with bladder cancer.

The examination is painless. It usually lasts one to two hours and is preferably used when the patient is fasting. At first, a reference scanner is made in a supine position. A contrast product is then injected intravenously: this iodine product will pass into the urinary tract and make it visible to imaging.

Other imaging studies may also be considered. Bladder cancer, which may give rise to bone or liver metastases, bone scintigraphy or hepatic ultrasonography, are prescribed, respectively, if the patient complains of symptoms that may be related to these conditions. The thoraco-abdominopelvic CT scan provides information in case of suspicion of pulmonary metastases.The prognosis of the disease

The prognosis of the disease is determined by:
the number and nature of tumors in the bladder;
the degree of aggressiveness and evolution of the tumor: this is called the grade. The more the cells that make up the bladder multiply rapidly and are abnormal, the more the cancer - said to be of high grade - is of poor prognosis;
the degree of extension of the tumor in the bladder, or even neighboring or distant organs (metastases). This is called the stage of cancer. The more advanced the stage, the more the prognosis is reserved.

In practice, the stage of bladder tumors is described through a letter T (for Tumor):
a Tis (carcinoma in situ ) is a cancer of plane aspect which touches only the superficial cells of the vesical wall;
a Ta, called papillary type , is a cancer of budding appearance not invading the chorion;
T1 cancer is a cancer invading the chorion but not the bladder muscle;

We group Tis, Ta and T1 under the term superficial tumors (sometimes called TVNIM). However, in the absence of diagnosis and treatment, some of them, especially Tis, can evolve into an infiltrative form.
From the T2 stage , the tumor invades the bladder muscle.
Stages T3 and T4 correspond to tumors that have passed through the bladder muscle wall and have spread to neighboring organs or distant organs. They are said to be infiltrating tumors (or TVIM) . They represent 30 to 40% of cases. They are usually more complex to manage than superficial tumors. Metastatic bladder cancer has a reserved prognosis.