Diagnosis and treatment of bladder carcinoma

A variety of diagnostic techniques has enhanced our ability to detect and accurately stage urothelial carcinoma. Urine cytology is a sensitive method for detecting occult high-stage tumors in both the upper and lower tracts. Rigid ureteroscopy has extended direct visualization from the bladder (with cystoscopy) to the renal pelvis. The evaluation of metastatic disease has been improved by CT and MRI. However, caution must be applied in interpreting bladder masses demonstrated by these studies after transurethral resections. The mainstay of local therapy continues to be transurethral resection. This established technique has been aided by intravesical chemotherapy and immunotherapy. Intravesical instillation of chemotherapeutic drugs or BCG may help preserve some bladders that would otherwise be sacrificed. The appropriate role of laser therapy as a primary form of treatment remains to be defined. Photodynamic therapy appears to be a powerful new treatment modality for carcinoma in situ. However, photodynamic therapy should still be considered a clinical experiment at this time. Patients with more advanced local disease will require either cystectomy or definitive radiation therapy. The survival results with primary surgical therapy appear to be slightly better than radiation therapy, particularly when younger individuals are being treated. Persons with metastatic disease are best treated with chemotherapy. Combination cisplatin-based regimens appear to be particularly promising and offer a high incidence of objective remissions with good duration of response. Although the five-year survival of patients with bladder carcinoma has steadily improved, there is still room for additional progress. The basis for any such improvement rests in accurate diagnosis and treatment and careful surveillance for recurrent disease.