Bladder Cancer

Question 1

Initial workup

Answer 1

Thorough cysto and EUA
Complete resection + MMC if low risk
Upper tract imaging
If normal cysto but positive cytology, biopsy the prostatic urethra

Question 2

Low risk bladder cancer risk category

Answer 2

Single TaLG <3cm
PUNLMP

Question 3

High risk bladder cancer risk category (8)

Answer 3

Recurrent TaHG
TaHG >3cm (or multifocal)
T1HG
CIS
BCG failure in HG patient
Variant histology
LVI
HG prostatic urethral involvement

Question 4

Intermediate risk bladder cancer category

Answer 4

TaLG recurrence within 1 year
TaLG >3cm
Multifocal TaLG
TaHG <3cm
T1LG

Question 5

What should happen if variant histology?

Answer 5

Re-review path by GU pathologist

Question 6

Management of variant histology

Answer 6

ReTURBT within 6 weeks if desires bladder sparing (be careful)
Upfront cystectomy (except small cell)

Question 7

Do urine markers replace cysto

Answer 7

Na Brah

Question 8

What is the role of urine biomarkers

Answer 8

BCG response and equivocal cytology (FISH)

Question 9

When should a re-TUR be performed?

Answer 9

-6 weeks for variant histology desiring bladder preservation
-High risk TaHG, T1HG

Question 10

Who should get intravesical chemo after TURBT?

Answer 10

Low or intermediate risk (gem or MMC)
-SKIP if perf

Question 11

Management of index intermediate risk disease

Answer 11

Consider BCG or MMC is best

Question 12

How to give MMC

Answer 12

Dehydrate
Alkalinize urine
Empty bladder first

Question 13

Management of index high risk disease

Answer 13

BCG (any strain, any strength)

Question 14

Can an intermediate risk patient get BCG maintenance after responding?

Answer 14

Yes - for 1 year

Question 15

Can high risk BCG responders get maintenance?

Answer 15

Yes - 3 years

Question 16

BCG –> persistent/recurrent Ta/CIS management

Answer 16

BCG induction #2

Question 17

BCG –> persistent T1HG

Answer 17

Cystectomy
Clinical trial is optional
Pembro if CIS is optional

Question 18

Can TaHG patients get Cystectomy?

Answer 18

Yes but only after everything else has been exhausted

Question 19

Should blue light be offered?

Answer 19

Yes (or NBI)

Question 20

When should the first surveillance cysto happen?

Answer 20

3 months after treatment

Question 21

Low risk surveillance regimen

Answer 21

Cysto at 3 and 9 months, then annually for 5 years
No repeat upper tract imaging necessary

Question 22

TaLG recurrence management option

Answer 22

Office fulg or TURBT

Question 23

Intermediate risk surveillance

Answer 23

cysto at 3, 6, 12, 18, 24, then annually
Image upper tract every 1-2 years

Question 24

High risk surveillance

Answer 24

Cysto every 3 months for 2 years, then every 6 months for 2 years, then annually
Image upper tracts every 1-2 years

Question 25

Staging workup for MIBC

Answer 25

Cross-sectional imaging of the chest and abdomen with contrast CBC, LFTs, AP, BMP

Question 26

Bladder cancer T staging

Answer 26

Ta noninvasive papillary Tis CIS T1 Invades lamina propria T2 invades muscularis propria T3 invades perivesical tissue -pT3a microscopic -pT3b macroscopic T4 local invasion -T4a prostate, SVs, uterus, vagina -T4b pelvic or abdominal wall

Question 27

Bladder cancer N staging

Answer 27

N1 single node in true pelvis N2 multiple nodes in true pelvis N3 node in common iliac M1a is node above common iliac (tricky!)

Question 28

Cisplatin ineligible treatment for MIBC

Answer 28

Cx if candidate (e.g. skip carbo)

Question 29

How much time should pass between NAC and Cx?

Answer 29

12 weeks or less

Question 30

Management of cisplatin-naive pT3/pT4/N+ path on Cx

Answer 30

cisplatin adjuvant therapy

Question 31

what should be removed at the time of cystectomy?

Answer 31

Men - bladder, prostate, SVs Women - bladder, consider other organs

Question 32

When should sexual function sparing surgery be done at the time of Cx?

Answer 32

No bladder neck, urethra, or prostate involvement

Question 33

When planning an orthotopic diversion, what additional surgical step must be taken?

Answer 33

Urethral margin

Question 34

What is the minimum LND for Cx?

Answer 34

external and internal iliac LNs Obturator LNs

Question 35

Bladder sparing treatment steps

Answer 35

Max TURBT Check for CIS Radiation sensitizing chemo

Question 36

Surveillance for MIBC after treatment

Answer 36

CT q6months for 3 years then annually Labs q3months Monitor urethra for recurrence

Question 37

Is chest imaging required for NMIBC?

Answer 37

Nope

Question 38

Bladder cancer risk factors

Answer 38

Smoking Male Age Radiation Exposures (paints, dyes) Phenacetin Cytoxan Pioglitazone Schistosomiasis Chronic cystitis (catheter, stones, etc)

Question 39

Natural history of bladder cancer

Answer 39

Ta - 50% will recur, <5% will progress T1 - 80% will recur, 50% will progress CIS - 80% will recur, 20% will progress

Question 40

What is mitomycin C

Answer 40

-Alkylating agent, inhibits DNA replication -Better in alkaline urine -Can cause contact dermatitis, bladder irritation

Question 41

Treatment of CIS

Answer 41

Induction BCG

Question 42

Contraindications to BCG

Answer 42

Immunosuppressed Prior hypersensitivity reaction Traumatic Foley Recent resection (wait at least 2 weeks) UTI or fever

Question 43

BCG maintenance regimen

Answer 43

1 BCG per week for 3 weeks at 3 and 6 months, then every 6 months for 1-3 years

Question 44

Preop considerations for cystectomy

Answer 44

Almivopam Counsel on diversion options Mark stoma type and cross antibiotics

Question 45

Borders for extended lymph node dissection

Answer 45

Genitofemoral nerve lateral Bladder medial Common iliac artery proximal Femoral canal distal