SIU 2017: SIU-ICUD Joint Consultation on Bladder Cancer - Epidemiology, Prevention, Screening, Diagnosis and Evaluation

Lisbon, Portugal (UroToday.com) Dr. Ashish Kamat had the unenviable task of presenting the Epidemiology, Prevention, Screening, Diagnosis and Evaluation Chapter. As he covered a large volume of recommendations, below are the highlights of his presentation.

Since the 2012 edition, there have been very few Level 1 studies in this field. There have been many Level 2 and 3 studies. As such, most of the new recommendations are Grade C, with a few being Grade B or D.

Prevention
1. Smoking Cessation continues to be recommended as a means to reduce BCa risk (Grade C)

Screening
1. Bladder Cancer screening – if undertaken – should be confined to high-risk patients (Grade C)
  • Cannot be recommended for the general population (Grade C)
  • There was some discussion on this in the Q&A. Overall evidence is low, but there are very small series suggesting increased diagnosis of BCa in high risk populations, but no evidence it correlates with different long term outcomes
2. Screening can consist of annual cytology and urinalysis (dipstick) (Grade C)

Evaluation
1. Hematuria evaluation requires upper tract imaging (Grade B)
2. Urine cytology and cystoscopy should be used for gross hematuria or symptomatic hematuria or in patients with risk factors for UC (Grade B)
3. Urine cytology or cystoscopy should be used for microscopic hematuria or in patients without risk factors for UC (Grade B)
4. Cystoscopy
     a. White Light Cystoscopy (WLC) is the gold standard evaluation (Grade B)
     b. A bladder diagram should be utilized at the time of first cystoscopy prior to TURBT to precisely locate tumor (Grade C)
     c. Photodynamic agents, ie hexaminolevulinate (HAL), may be used (Grade B)
            - As an adjunct to WLC for diagnosis of BCa
            - As an adjunct to TURBT for treatment of BCa
     d. Narrow band imaging (NBI) may be used (Grade C)
            - Not as useful as photodynamic agents
5. Cytology (discussed further in Dr. Comperat’s presentation)
     a. Voided cytology should be used for monitoring high-grade recurrence (Grade B)
     b. Voided cytology should be utilized to differentiate low and high grade tumors (Grade B)
     c. Bladder wash cytology (as opposed to voided cytology) may be considered for high-risk situations due to better diagnostic yield (Grade C) – but  minimize manipulation (LOE 4)

Urinary Markers
  • Separate chapter on urinary markers
  • However, in general, no recommendations (Grade D) for urinary markers for follow-up or diagnosis.
Imaging
1. Imaging of the upper tracts is necessary in patients with hematuria (Grade B)
2. CT Urography (triphasic CT) is gold standard test as part of initial staging and evaluation (Grade B)
     - Other tests, including IVU, non-con CT, ultrasound, MRU are options (Grade C)
3. Imaging should be obtained prior to TURBT or > 2 weeks post-TURBT (Grade C)
4. Metastatic staging workup should include CXR (Grade B) and bone scan for syptomatic bone pain OR elevated alkaline phosphatase (Grade B)
5. For patients on surveillance, they recommend a risk adapted strategy – which will be listed in the final chapter (LOE 4 – expert opinion)

TURBT
1. Prior to initial TURBT, complete thorough cystoscopy with 30-degree and 70-degree scope (or 12-degree instead of the 30) (Grade C)
2. Plan best method of maximal tumor burden resection prior to initiating TURBT (Grade C)
3. Give patients appropriate prophylactic antibiotics (Grade B)
4. Three key principles during TURBT: (Grade C)
     a. Limit cautery artifact
     b. Ensure adequate depth of biopsy
     c. Proper handling of tissue for pathologic processing after removal
5. Complete resection should be attempted (ideally in one-setting) in all patients except for those with diffuse CIS (Grade C)
6. The following should be documented in each procedure note for TURBT:
    a. Shape, size & location of tumor
    b. Papillary or sessile
    c. Suspected CIS in addition?
    d. Appearance at the base of tumor
    e. Visible muscle fibers or fat at completion at resection?
7. Separate specimen from the base should be sent when the tumor appears to be cT1+ (Grade C)
8. Use of cold cup biopsy is recommended for small papillary tumors to limit cautery artifact (Grade C)
9. For tumors in diverticuli, aggressive resection should be avoided to reduce risk of perforation and spillage (Level IV)
10. If UO’s resected, cutting current should be used AND functional imaging should be completed 3-6 weeks later (Grade C)
11. No specific recommendations regarding modality of resection – bipolar, monopolar, laser (Grade D)
12. Random biopsies:
      a. Not routinely recommended (Grade C)
      b. May be indicated in patients with:
           - Positive cytology but negative WLC                     
           - Partial cystectomy candidates
13. Prostatic Urethral biopsies
       a. Consider in patients with CIS or visible abnormalities in prostatic urothelium (Grade B)
       b. Not useful in counselling patients for neobladder (Grade C)
       c. Useful in counselling in patients considering NAC by identifying T4 disease (Grade C)
14. Repeat TURBT
       a. Second TURBT should be done in all patients with high-grade T1 lesions regardless of muscle presence in first biopsy (Grade B)
       b. Second TURBT should be considered for some patients with HG pTa lesions (Grade C)
       c. Optimal timing is 4-6 weeks (Grade C)

Presented by: Ashish M. Kamat 

Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, Twitter: @tchandra_uromd at the 37th Congress of Société Internationale d’Urologie - October 19-22, 2017- Lisbon, Portugal
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