Pitfalls in clinical staging of bladder tumors

Errors in clinical staging of bladder carcinoma occur in about 50 per cent of patients. Sources of error include (1) a variable assortment of diagnostic studies performed, (2) inexactitudes inherent in the diagnostic measures employed, (3) insufficient corroboration by surgical and pathologic staging, (4) the lack of a satisfactory means for detecting micrometastases, and (5) a generalized confusion regarding the multiple classifications available for clinical staging. More precise clinical staging will be influential in treatment decision-making and in prognosis. Minimum requirements for clinical staging of the primary tumor currently include complete examination, excretory urography, cystoscopy, bimanual examination under anesthesia, and transurethral resection or biopsy. Polycystography, triple contrast cystograpy and arteriography may be helpful occasionally to document muscle invasion. Pedal lymphangiography and lymphography can in selected cases be helpful in detecting otherwise silent nodal involvement in spite of its inability to demonstrate many primary or regional lymph nodes. Familiarity with the above diagnostic options and the advantages and limitations of each is essential for each physician caring for a patient with bladder carcinoma. Conversion to TNM classification for bladder carcinoma that is similar to that of the UICC seems appropriate (1) because of its more rational approach to extent of involement by primary tumor, lymph node and distant sites, and (2) in order for our western hemisphere urologists to communicate better with our colleagues from around the globe. Such a system is now under consideration by a subcommittee of the American Joint Committee on Staging and End Result Reporting.