Bladder Cancer Investigation

Due to the concerning nature of haematuria for patients and the value of making an early diagnosis, the concept of ‘One‐Stop’ clinics for the investigation of suspected urothelial bladder cancer is now well established.

A ‘One‐Stop’ service will normally aim to offer a patient all the necessary investigations with the minimum number of hospital attendances possible, with everything ideally being done for the patient on the same day. On receipt of a referral of a patient with haematuria, a urology department will normally organise:

• Upper Urinary Tract Imaging
  
• Clinical Assessment – urine dipstick test, history, and examination
  
• Flexible Cystoscopy
  
• Urine Cytology in some circumstances

Upper urinary tract imaging is normally dependent on the nature of the haematuria. Non‐visible haematuria (NVH) (microscopic haematuria) is investigated with a renal tract ultrasound scan, whereas visible (macroscopic) haematuria is investigated with a computerized tomography intravenous urogram (CT IVU), including excretory phase urography). This is based on the fact that visible haematuria (as compared to non‐visible) confers virtually twice the risk of finding an underlying urothelial tumour.

Clinical Assessment

Initial assessment requires determination of the type of haematuria:

• Visible haematuria
  
• Persistent non‐visible haematuria on multiple tests
  
• Symptomatic non‐visible haematuria (associated with pain or lower urinary tract symptoms)

Careful history‐taking is valuable, particularly in cases of symptomatic NVH, in order to determine whether urinary tract infections are a potential cause of the haematuria. Urine dipstick testing will help to identify patients with ongoing signs of infection; however, review of previous MSU microscopy and culture results, if available, can be more useful.

Urine dipstick testing also allows detection of proteinuria. This finding then requires further clarification with protein‐creatinine ratio testing but an abnormal level (>50 mg/mmol) can indicate the cause of haematuria being glomerulonephritis, IgA nephropathy, or another nephrological condition requiring renal medicine/nephrology specialist input.

Initial physical examination may suggest an underlying pathology – a ballotable renal mass may suggest renal cell cancer, a distended bladder may suggest bladder outflow obstruction and associated urinary tract infection (UTI). An abnormal prostate on digital rectal examination (DRE) is indicative of prostate cancer.

Particular attention should be paid to any history of tobacco usage and smoking as this may influence levels of suspicion and prompt more rigorous investigation (CT scanning or urine cytology) on the basis of the increased risk of urothelial cancer.

Cystoscopy

Ideally, the patient will attend for flexible cystoscopy after completion of necessary upper tract imaging. If imaging clearly demonstrates a urothelial bladder cancer, flexible cystoscopy is rarely required and the patient should instead be counselled to proceed directly to trans‐urethral resection in the operating theatre at the earliest opportunity.