The first step in evaluation of a patient with a suspected bladder mass is a careful cystourethroscopy and cytology from bladder wash. Imaging includes an initial computed tomography scan of the abdomen and pelvis with contrast to estimate bladder mass size, define local extension into adjacent tissues, and to evaluate upper urinary tracts. Magnetic resonance imaging of the abdomen and pelvis, especially in sagittal views, provides additional valuable information in suspected urachal adenocarcinomas. Bimanual examination under anesthesia, followed by transurethral resection/biopsy of the bladder mass, and random bladder biopsies of grossly normal bladder mucosa should be performed next.

Bladder lesions amenable to partial cystectomy are typically located in the dome. After appropriate informed consent is obtained, a partial cystectomy can be performed. The patient should be aware of the possibility of radical cystectomy and urinary diversion in case adequate resection or margins could not be achieved or if the remaining bladder is too small to be adequately functional. Excision of the urachus is standard, with excision of the umbilicus being reserved for urachal adenocarcinomas. Bilateral standard lymphadenectomy is performed when malignant lesions are suspected. The pelvis is then packed with towels. Two atraumatic clamps (Angled DeBakey vascular clamps, Satinsky vascular clamps, or Glassman bowel clamps) are sequentially applied underneath the mass while intraoperative flexible cystoscopy is performed, in order to ascertain complete inclusion of the mass beyond the clamps. A urethral catheter is then placed. Using Metzenbaum scissors, scalpel or electrocautery, the bladder is cut between the clamps, and the specimen is handed off for pathologic review and frozen sections after appropriate margin orientation. The bladder is then closed in 2 layers and a suction drain is placed in the pelvis. In this fashion, neither the tumor nor the remaining bladder was allowed to drain into the surgical field, therefore minimizing the risk of tumor spillage. Routine follow-up with cystoscopy and imaging is tailored depending on final pathology results.

Written by
Arthur I. Sagalowsky, MD, as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

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