Eduovisual
Renal & Urinary
Bladder cancer: presentation and workup
— 4th most common cancer in US men, ~83,000 new cases/year, median age at diagnosis 73
— Male:female ratio ~3–4:1, but women present at higher stage (delayed diagnosis—hematuria attributed to UTI)
— ~75% are non–muscle-invasive (NMIBC) at diagnosis; ~25% muscle-invasive or metastatic
— Urothelial carcinoma (~90%) in the US—arises anywhere urothelium lines (renal pelvis → urethra)
— Squamous cell (chronic inflammation, indwelling catheters, Schistosoma haematobium in endemic regions)
— Adenocarcinoma (urachal remnant, exstrophy), small cell, sarcomatoid (rare, aggressive)
— Tobacco smoking (50–65% of cases in men; 4× risk; risk persists decades after cessation)
— Occupational aromatic amines: rubber, dye, leather, painters, hairdressers, aluminum, textile workers (benzidine, β-naphthylamine)
— Cyclophosphamide / ifosfamide (acrolein metabolite) → also hemorrhagic cystitis
— Pelvic radiation (prior prostate, cervical CA), chronic catheter/stones, Schistosoma, aristolochic acid
— Lynch syndrome → upper-tract urothelial CA especially
— Any adult ≥35 with gross hematuria = bladder cancer until proven otherwise—even a single episode
— Microscopic hematuria (≥3 RBC/hpf on a properly collected specimen) in a smoker >50
— Recurrent "UTIs" in an older adult that culture-negative or fail to clear
— Irritative voiding (urgency, frequency, dysuria) without infection—classic for carcinoma in situ (CIS)
Board pearl: Painless gross hematuria in an older smoker = cystoscopy + CT urography, not another course of antibiotics. Attributing hematuria to BPH or UTI without workup is the most common missed-diagnosis trap on Step 3.
— Painless gross hematuria in 80–90%—often intermittent, which falsely reassures patients and clinicians ("it went away")
— Microscopic hematuria found incidentally on UA in 10–20%
— Clots → suggest brisker bleeding; "worm-like" clots may indicate upper-tract source
— Urgency, frequency, dysuria, suprapubic discomfort—hallmark of CIS or diffuse mucosal disease
— In an older adult with "refractory overactive bladder" or sterile pyuria, think CIS
— Flank pain → ureteral orifice obstruction → hydronephrosis
— Pelvic pain, bone pain, weight loss, lower-extremity edema (nodal/iliac vein compression) → metastatic
— Anemia, fatigue from chronic blood loss
— Smoking: pack-years, current vs former (counsel cessation regardless—reduces recurrence after treatment)
— Occupation: dyes, rubber, chemicals, painting, firefighting, diesel exhaust
— Prior pelvic radiation, chemotherapy (cyclophosphamide), indwelling catheter/stone history
— Travel/residence in schistosomiasis-endemic areas (Egypt, sub-Saharan Africa) → SCC
— Family history of urothelial, colon, endometrial CA → Lynch syndrome screen
— Anticoagulant use—does not explain hematuria; still requires full workup
— Gross hematuria any age
— Microhematuria + smoking, age >60, prior pelvic radiation, or occupational exposure
— Recurrent culture-negative cystitis
Step 3 management: A 68-year-old smoker with one episode of painless gross hematuria that "resolved"—do not stop at a normal UA. Order cystoscopy and CT urography. Anticoagulation does not exempt the patient from workup; the AUA explicitly states hematuria on anticoagulants still requires evaluation. This is the highest-yield outpatient triage decision on this topic.
— Most patients with early bladder cancer have a normal exam—do not be reassured
— Pallor, cachexia, or lymphadenopathy suggests advanced/metastatic disease
— Tachycardia or orthostasis with brisk gross hematuria → assess for clot retention and hemorrhagic shock (uncommon but possible)
— Hypertension from pain or obstructive uropathy
— Suprapubic fullness/tenderness → urinary retention from clot or tumor at bladder neck
— Palpable flank mass or CVA tenderness → hydronephrosis from ureteral obstruction
— Hepatomegaly, ascites → hepatic metastases (late)
— Bimanual exam under anesthesia (EUA) at time of TURBT is the formal staging exam—palpable mass after resection suggests ≥T3
— DRE: assess for fixed pelvic mass, prostatic invasion
— In women: pelvic exam to rule out gynecologic source of bleeding mistaken for hematuria
— Supraclavicular, inguinal nodes—metastatic spread
— Unilateral leg edema → iliac vein or lymphatic compression by pelvic mass
— DVT risk elevated (Trousseau-like hypercoagulability with urothelial CA)
— Rare but tested: hypercalcemia (PTHrP from SCC variant), leukocytosis
— 3-way Foley with continuous bladder irrigation (CBI) to clear clots before imaging if frank hematuria with retention
— Hand-irrigate large clots; never just clamp
CCS pearl: For a CCS case of gross hematuria with clot retention: place a 3-way 22–24 Fr catheter, start continuous bladder irrigation with normal saline, order CBC, BMP, PT/INR, type and screen, then proceed to urology consult and cystoscopy. Do not discharge home until clots clear and the patient voids. Premature discharge with persistent clots is a classic Step 3 patient-safety distractor.
— Microscopic hematuria = ≥3 RBCs/hpf on a single properly collected specimen (AUA 2020 update)
— Confirm with microscopy, not just dipstick (dipstick detects myoglobin/hemoglobin → false positives)
— Look for dysmorphic RBCs/casts → glomerular source (then workup is nephrology, not urology)
— Pyuria without bacteria → consider CIS, TB, stones
— Rule out UTI first; if positive, treat and repeat UA after treatment—persistent hematuria still warrants workup
— CBC (anemia from chronic loss), BMP (renal function—dictates contrast and chemo eligibility), coags if anticoagulated
— LFTs and alk phos if metastatic concern
— High specificity (>90%) but low sensitivity for low-grade tumors (~30%); sensitivity ~80% for high-grade and CIS
— Best for surveillance and detecting CIS that's hard to see on cystoscopy
— Not a screening test in asymptomatic patients
— Not recommended as a replacement for cystoscopy; adjunct only in select surveillance scenarios
— Multiphase CT with IV contrast (non-contrast → nephrographic → excretory/delayed phases)
— Evaluates renal parenchyma, urothelium of upper tracts (renal pelvis, ureters), and bladder
— Detects synchronous upper-tract urothelial CA (2–5% of bladder CA patients)
— MR urography if iodinated contrast contraindicated (allergy)
— Retrograde pyelography + non-contrast CT/US if eGFR too low for contrast
— Renal ultrasound + cystoscopy is acceptable in low-risk microhematuria
Key distinction: CT urography evaluates the upper tracts; cystoscopy is required to evaluate the bladder. Neither alone is sufficient—they are complementary, not alternatives. Skipping cystoscopy is a board trap.
— Office flexible cystoscopy under local anesthesia—first-line for any suspected bladder tumor or unexplained hematuria
— Visualizes tumors, papillary lesions, erythematous patches suggestive of CIS
— Blue-light cystoscopy (hexaminolevulinate) and narrow-band imaging improve detection of CIS and small papillary lesions
— Both diagnostic and therapeutic for visible tumors
— Must include detrusor muscle in the specimen to assess for muscle invasion (no muscle = inadequate, mandates repeat TURBT)
— Performed under general/spinal anesthesia with concurrent EUA (bimanual)
— Single dose of intravesical chemo (mitomycin C or gemcitabine) within 24 hours post-TURBT reduces recurrence in low/intermediate-risk NMIBC
— High-grade T1 disease
— No muscle in initial specimen
— Incomplete initial resection
— Ta: non-invasive papillary
— Tis (CIS): flat, high-grade, confined to urothelium—aggressive despite being "non-invasive"
— T1: invades lamina propria (still NMIBC)
— T2: invades muscularis propria (muscle-invasive—MIBC, major prognostic threshold)
— T3: perivesical fat; T4: adjacent organs
— CT chest/abdomen/pelvis with contrast for metastatic survey
— Bone scan only if alk phos elevated or bone pain
— MRI pelvis can refine local staging (VI-RADS scoring)
— PET not routine
— Ureteroscopy with biopsy for suspected upper-tract urothelial CA
Board pearl: "No muscle in the TURBT specimen" is an automatic indication for repeat TURBT—the pathologist cannot exclude T2 disease, and understaging changes everything (intravesical therapy vs cystectomy).
— NMIBC (Ta, T1, Tis): ~75% of cases → bladder-sparing approach
— MIBC (≥T2): ~25% → radical cystectomy ± neoadjuvant chemo, or trimodal therapy
— Metastatic (N+/M+): systemic therapy
— Low risk: solitary, low-grade Ta, ≤3 cm, primary
→ TURBT + single post-op intravesical chemo; surveillance cystoscopy
— Intermediate risk: recurrent low-grade Ta, multifocal, >3 cm, or solitary low-grade Ta recurring within 1 year
→ TURBT + induction intravesical chemo or BCG
— High risk: any high-grade, T1, CIS, multifocal high-grade, BCG-failure, variant histology
→ TURBT + induction BCG + maintenance ≥1 year; consider early cystectomy if T1 high-grade with adverse features
— Cisplatin-eligible (eGFR ≥60, ECOG 0–1, no significant neuropathy/hearing loss/HF): neoadjuvant cisplatin-based chemo (dose-dense MVAC or gemcitabine-cisplatin) → radical cystectomy + pelvic lymph node dissection
— Cisplatin-ineligible: cystectomy alone or trimodal therapy
— Trimodal (bladder preservation): maximal TURBT + concurrent chemoradiation—for selected patients with solitary T2 tumor, no CIS, good bladder function
— First-line: cisplatin- or carboplatin-based regimen; maintenance avelumab if no progression
— Second-line: pembrolizumab, enfortumab vedotin, erdafitinib (if FGFR3 alteration)
Step 3 management: The single most important pathologic question driving the entire treatment algorithm is "Is muscularis propria invaded?" Memorize the NMIBC vs MIBC fork—every subsequent decision (intravesical BCG vs cystectomy, surveillance intensity, prognosis) hinges on it.
— Mitomycin C or gemcitabine, single instillation within 24 hours of TURBT
— Reduces recurrence ~35% in low/intermediate-risk NMIBC
— Contraindicated if bladder perforation suspected
— Standard for high-risk NMIBC and CIS
— Mechanism: local immune activation (Th1, IFN-γ, IL-2)
— Induction: weekly × 6 weeks, starting 2–4 weeks post-TURBT
— Maintenance: 3-weekly instillations at 3, 6, 12 months (and onward to 3 years for high-risk)
— Adverse effects:
· Common: dysuria, frequency, low-grade fever (<48 hrs)
· Serious: BCG sepsis (high fever, hypotension) → treat with isoniazid + rifampin + ethambutol ± steroids; do not give live BCG if traumatic catheterization, gross hematuria, active UTI, or immunosuppression
— BCG-unresponsive disease → pembrolizumab, nadofaragene firadenovec, or cystectomy
— Dose-dense MVAC (methotrexate, vinblastine, doxorubicin, cisplatin) × 4 cycles, or
— Gemcitabine + cisplatin × 4 cycles
— Improves overall survival ~5–8% absolute vs surgery alone
— Nivolumab for high-risk pathology post-cystectomy (ypT2+ or ypN+) who did not receive neoadjuvant or have residual disease
— 1st line: gemcitabine + cisplatin (or carboplatin if ineligible) → maintenance avelumab
— Or upfront enfortumab vedotin + pembrolizumab (now preferred in many guidelines)
— Targeted: erdafitinib for FGFR2/3 alterations
— Antibody-drug conjugates: enfortumab vedotin (nectin-4), sacituzumab govitecan (Trop-2)
Board pearl: Active UTI, gross hematuria, or recent traumatic catheterization are absolute contraindications to BCG—intravasation can cause disseminated BCGosis (miliary granulomatous disease).
— Standard for MIBC, BCG-unresponsive high-risk NMIBC, recurrent high-grade T1
— Male: cystoprostatectomy
— Female: anterior exenteration (bladder, urethra, uterus, anterior vaginal wall—organ-sparing variants exist)
— Extended pelvic lymphadenectomy (obturator, internal/external/common iliac) — both staging and therapeutic
— Neoadjuvant chemo should precede surgery in cisplatin-eligible patients (do not skip)
— Ileal conduit (incontinent): segment of ileum → stoma + urostomy bag; simplest, fewest complications, preferred in older/comorbid patients
— Continent cutaneous reservoir (Indiana pouch): catheterizable stoma
— Orthotopic neobladder: ileal pouch anastomosed to native urethra → near-normal voiding; requires intact, cancer-free urethra and good renal/hepatic function; risk of incontinence (especially nocturnal) and need for self-catheterization
— Maximal TURBT + concurrent cisplatin-based chemoradiation
— Candidates: solitary T2, no hydronephrosis, no extensive CIS, good baseline bladder function, motivated for surveillance
— Survival comparable to cystectomy in selected patients
— ERAS protocols reduce ileus, length of stay
— Pre-op stoma site marking by WOC nurse
— VTE prophylaxis extended 4 weeks post-discharge (high VTE risk after pelvic surgery for malignancy)
— Nutritional optimization; smoking cessation ≥4 weeks pre-op reduces complications
— Urinary diversion or nephrostomy for obstructive uropathy
— Palliative TURBT or radiation for refractory hematuria
— Hyperbaric oxygen for radiation cystitis
CCS pearl: Always order extended VTE prophylaxis (enoxaparin 40 mg SC daily × 28 days post-discharge) after radical cystectomy. Stopping prophylaxis at discharge is a tested patient-safety error—this is the highest VTE-risk urologic surgery.
— Median age at diagnosis is 73—most patients are elderly with comorbidities
— Perform geriatric assessment (CGA, G8 screen) before major surgery or systemic therapy
— Frailty (low albumin, sarcopenia, ECOG ≥2) predicts cystectomy mortality and chemo toxicity
— Cognitive screening before discharge planning—neobladder management requires cognitive capacity for self-cath
— Cisplatin requires eGFR ≥60 (some centers accept ≥50 with split dosing)
— Cisplatin-ineligibility criteria (Galsky): eGFR <60, ECOG ≥2, hearing loss ≥grade 2, neuropathy ≥grade 2, NYHA ≥III HF
— Cisplatin-ineligible options:
· Gemcitabine + carboplatin (less effective but tolerable)
· Enfortumab vedotin + pembrolizumab (preferred 1st-line metastatic)
· Single-agent immune checkpoint inhibitor if PD-L1+ (pembrolizumab, atezolizumab)
— Adjust gemcitabine, methotrexate doses; avoid nephrotoxins
— Obstructive uropathy from tumor → percutaneous nephrostomy or ureteral stent to optimize renal function before chemo
— Methotrexate, doxorubicin require dose adjustment
— Atezolizumab/pembrolizumab use cautiously; monitor for immune hepatitis
— Workup still required—do not attribute to warfarin/DOAC
— Hold anticoagulation for TURBT per surgical team; bridge if mechanical valve or recent VTE
— Avoid concurrent nephrotoxins (NSAIDs, aminoglycosides) during cisplatin
— Review for QT-prolonging agents with antiemetics
Step 3 management: A 78-year-old with eGFR 45 and newly diagnosed MIBC—cisplatin-ineligible. Options: gemcitabine-carboplatin, enfortumab vedotin + pembrolizumab, or cystectomy alone with adjuvant nivolumab if high-risk pathology. Do not dose-reduce cisplatin to make it "fit"—use an appropriate alternative.
— Lower incidence but higher stage at diagnosis and worse stage-adjusted survival
— Hematuria frequently misattributed to UTI, gynecologic bleeding, or "menstrual irregularity"—delay averages 6+ months
— Step 3 trap: recurrent "UTIs" with negative cultures in a postmenopausal woman → cystoscopy, not another antibiotic course
— Anterior exenteration with vaginal-sparing techniques and sexual function counseling
— Rare; gross hematuria in pregnancy is usually NOT cancer (think UTI, stones, friable cervix)
— If suspicious: flexible cystoscopy is safe in pregnancy; MRI without gadolinium preferred over CT
— Defer definitive treatment when feasible; TURBT can be performed in 2nd trimester
— Cisplatin can be given in 2nd/3rd trimester if needed; avoid 1st trimester
— Rare; usually low-grade papillary urothelial neoplasms or rhabdomyosarcoma (botryoid) in young children—pelvic mass, urinary obstruction, "grape-cluster" tumor protruding through urethra
— Lynch syndrome (MMR mutations): increased risk of upper-tract urothelial carcinoma more than bladder; screen with family history of CRC/endometrial/ureteral cancers
· Refer for genetic testing if upper-tract UC <60, family history, or MSI-high tumor
· Annual urinalysis + urine cytology starting age 30–35
— Costello syndrome, retinoblastoma survivors—small increased risk
— Increased urothelial CA risk (especially post-cyclophosphamide for vasculitis)
— BCG contraindicated in immunosuppressed—use intravesical chemo or early cystectomy
— 2–4× increased bladder CA risk—lifelong vigilance with hematuria
Board pearl: Upper-tract urothelial CA + family history of colon/endometrial cancer → send for Lynch syndrome genetic testing. This is the single most testable hereditary association in urothelial cancer.
— Gross hematuria with clot retention → urinary obstruction, AKI
— Ureteral obstruction → hydronephrosis → post-renal AKI: tumor at trigone/ureteral orifice; manage with nephrostomy or stent
— Anemia from chronic blood loss
— Hypercoagulability: Trousseau-like syndrome, DVT/PE
— Cachexia, paraneoplastic hypercalcemia (especially SCC variant)
— Local invasion: vesicovaginal/vesicorectal fistula, pelvic pain
— Metastatic disease: bone (lytic), liver, lung, distant lymph nodes
— TURBT: bladder perforation (extra- vs intraperitoneal—the latter often needs laparotomy), hemorrhage, TUR syndrome (hyponatremia from hypotonic irrigation—now rare with saline irrigation in bipolar resection)
— Intravesical BCG: cystitis, hematuria, fever; rare but feared BCGosis/sepsis → antitubercular therapy + steroids; granulomatous prostatitis, epididymo-orchitis, hepatitis, pneumonitis
— Intravesical chemo: chemical cystitis, myelosuppression (rare with intravesical route)
— Cisplatin: nephrotoxicity, ototoxicity, neuropathy, nausea, electrolyte wasting (Mg, K)
— Immune checkpoint inhibitors: immune-related AEs—colitis, pneumonitis, hepatitis, hypophysitis, thyroiditis; treat with high-dose steroids ± infliximab/MMF for severe events
— Radical cystectomy: ileus (#1 complication), wound infection, anastomotic leak, VTE, sepsis, 30-day mortality 2–3%, 90-day morbidity 50–60%
— Urinary diversion: metabolic acidosis (hyperchloremic, non-anion-gap from urine reabsorption across bowel), vitamin B12 deficiency (terminal ileum used), stomal complications, stones, recurrent UTIs, ureteroileal stricture
— Sexual dysfunction (ED, dyspareunia, vaginal shortening)
— Body image issues with stoma
— Reduced GFR over time
Key distinction: Hyperchloremic, non–anion-gap metabolic acidosis with hypokalemia in a patient with an ileal conduit or neobladder = bowel reabsorption of urinary chloride and ammonium. Treat with oral bicarbonate; rule out obstruction or excessive urine retention in the pouch.
— Gross hematuria with clot retention or hemodynamic instability
— Obstructive AKI from bilateral ureteral obstruction
— BCG sepsis: fever >39°C, hypotension, hypoxia after instillation → ICU, broad-spectrum antibiotics + isoniazid + rifampin + ethambutol + corticosteroids
— Febrile neutropenia during chemotherapy
— Severe immune-related adverse events (grade ≥3 colitis, pneumonitis, hepatitis) from checkpoint inhibitors
— Any gross hematuria
— Microscopic hematuria meeting AUA risk thresholds (intermediate or high risk)
— Newly diagnosed bladder mass on imaging
— Post-op complications (urine leak, hematuria, stomal issues)
— MIBC for neoadjuvant chemo decision
— Metastatic disease
— BCG-unresponsive NMIBC considering systemic therapy
— Trimodal therapy candidates
— Palliative radiation for hematuria, bone metastases, pelvic pain
— Nephrology: AKI, CKD complicating chemo decisions
— Stomal therapy nurse: pre-op marking and post-op education
— Palliative care: symptom management in advanced disease, goals-of-care discussions
— Social work, financial counseling—pelvic exenteration is life-altering
— Hemodynamic instability, sepsis, anastomotic leak with peritonitis, respiratory failure
— Most uncomplicated cystectomies recover on a urology floor with ERAS protocol
CCS pearl: In a CCS case of post-BCG fever, stop further BCG instillations permanently, draw blood and urine cultures, give empiric broad-spectrum antibiotics, add isoniazid + rifampin (± ethambutol) for suspected disseminated BCG, and start steroids if hemodynamic compromise. Resuming BCG after sepsis is contraindicated.
— Dysuria, frequency, positive UA/culture
— Treat infection, then repeat UA—persistent hematuria after eradication requires full workup
— Hemorrhagic cystitis: post-cyclophosphamide, post-radiation, BK or adenovirus in immunocompromised
— Colicky flank pain radiating to groin, hematuria (gross or microscopic)
— Non-contrast CT KUB is diagnostic
— Common but a diagnosis of exclusion—never attribute hematuria solely to BPH without ruling out cancer
— May cause gross hematuria from prostatic varices
— Hematuria less common; PSA elevation, abnormal DRE
— 5% of urothelial CA; hematuria, flank pain, "worm-like" clots
— Diagnosed on CT urography + ureteroscopy with biopsy
— Strong Lynch syndrome association
— Classic triad (hematuria + flank pain + mass) is rare
— Renal mass on CT; not urothelial origin
— IgA nephropathy, post-infectious GN, thin basement membrane, Alport
— Dysmorphic RBCs, RBC casts, proteinuria, HTN → nephrology workup, not cystoscopy
— Sickle cell, analgesic abuse, diabetes, TB
— Family history, flank pain, hypertension, cyst hemorrhage
— Cyclic hematuria in reproductive-age women
— Diagnosis of exclusion in young women
Key distinction: Dysmorphic RBCs + RBC casts + proteinuria = glomerular source → nephrology consult, do not pursue cystoscopy as first step. Isomorphic RBCs without casts or proteinuria = urologic source → cystoscopy + CT urography.
— Myoglobinuria (rhabdomyolysis): dipstick positive for blood, no RBCs on micro, elevated CK
— Hemoglobinuria (intravascular hemolysis): dipstick+, no RBCs, schistocytes/elevated LDH/low haptoglobin
— Beeturia (beets, blackberries): dipstick negative
— Rifampin, phenazopyridine, senna, levodopa metabolites: orange-red urine, dipstick negative
— Porphyria: red-brown urine, urinary porphobilinogen
— Menstrual contamination, vaginal/cervical lesions, postmenopausal bleeding
— Pelvic exam essential in women with new "hematuria"
— Rectovesical fistula (advanced pelvic malignancy, Crohn disease, diverticulitis)
— Munchausen variants—rare but documented
— Anticoagulant overdose, hemophilia, severe thrombocytopenia
— Important: coagulopathy alone does not cause hematuria from a normal urinary tract; presence of hematuria on anticoagulants still mandates evaluation
— Long-distance running, contact sports
— Resolves within 48–72 hours; must repeat UA after rest—if persistent, full workup
— Endemic exposure; terminal hematuria, eggs on urine microscopy
— Chronic infection → squamous cell bladder carcinoma decades later
— Sterile pyuria, hematuria, "putty kidney" on imaging, history of TB exposure
— Acid-fast urine cultures × 3
— Ketamine, cyclophosphamide, ifosfamide, pelvic radiation
Board pearl: Sterile pyuria + hematuria + irritative LUTS in an older smoker = carcinoma in situ until proven otherwise. The same triad in a young patient from an endemic region = GU tuberculosis. Both demand cystoscopy and tissue diagnosis.
— Reduces recurrence and progression in NMIBC and improves cystectomy outcomes
— Use 5 A's: ask, advise, assess, assist, arrange
— First-line: varenicline + behavioral counseling, or combination NRT (patch + short-acting), or bupropion
— Document tobacco status at every visit
— Identify ongoing exposures; refer to occupational medicine
— PPE counseling for at-risk occupations
— Adequate fluid intake (≥2 L/day) may modestly reduce recurrence
— High vegetable intake associated with lower recurrence; no proven role for specific supplements
— Low risk: cystoscopy at 3, 12 months, then annually for 5 years; cytology not routinely needed
— Intermediate risk: cystoscopy + cytology every 3–6 months for 2 years, then less frequent
— High risk: cystoscopy + cytology every 3 months × 2 years, every 6 months years 3–4, then annually for life
— Upper-tract imaging (CT urography) annually for high-risk; every 1–2 years for intermediate
— CT chest/abdomen/pelvis every 6 months × 2–3 years, then annually to year 5
— Labs: CBC, BMP, LFTs, B12 (annually—ileal absorption), urine cytology of upper tracts
— Monitor for metabolic acidosis with diversion → oral bicarbonate as needed
— Urethral wash cytology if urethra preserved
— Extended VTE prophylaxis 28 days
— Sodium bicarbonate for diversion acidosis
— Vitamin B12 supplementation if terminal ileum used
— Antimuscarinics or alpha-blockers for neobladder voiding dysfunction
— Bowel regimen, pain control with opioid taper
— Treatment summary, surveillance schedule, late effects counseling, primary care coordination
Step 3 management: Every bladder cancer follow-up visit must include tobacco cessation counseling and a review of surveillance cystoscopy timing—omitting either is a board-style quality gap.
— During BCG: pre-instillation UA + symptom check; hold for active UTI, gross hematuria, traumatic catheterization
— During cisplatin chemo: CBC, BMP, Mg, audiometry baseline; antiemetics, hydration; monitor for tinnitus/neuropathy
— During immunotherapy: CMP, TSH, cortisol every 3–6 weeks; monitor for irAEs; patient symptom diary
— Days 0–2: ICU/floor, ERAS pathway, early ambulation, gum chewing/early feeding
— Days 3–7: bowel function return, advance diet, transition to PO pain control
— 2-week post-op visit: wound check, drain/stent management, stomal care reinforcement
— 6-week visit: catheter/stent removal if not already, neobladder training begins
— Timed voiding every 2–3 hours initially, gradually extending intervals
— Pelvic floor physical therapy for continence (especially women)
— Self-catheterization training—patients must be cognitively and physically capable
— Nocturnal incontinence common; nighttime alarm/timed voiding
— Stomal therapy nurse follow-up at 2 and 6 weeks; appliance fit assessment
— Watch for parastomal hernia, stomal stenosis, dermatitis
— Counsel pre-op about ED, retrograde ejaculation, vaginal shortening, dyspareunia
— PDE5 inhibitors, vaginal estrogen, dilators, referral to sexual medicine
— Depression screening (PHQ-9), body image counseling
— Support groups (Bladder Cancer Advocacy Network)
— Annual B12, BMP for acidosis, eGFR, electrolytes
— Urine cultures only if symptomatic—asymptomatic bacteriuria in diversions is not treated routinely
CCS pearl: Asymptomatic bacteriuria in an ileal conduit or neobladder is expected and not treated. Treating it leads to antibiotic resistance without benefit. Treat only symptomatic UTIs (fever, flank pain, systemic illness).
— Detailed discussion of diversion options—ileal conduit vs continent reservoir vs neobladder—including impact on continence, sexual function, body image, daily self-care
— Document understanding of operative mortality (2–3%), 90-day morbidity (~50%), permanent stoma if applicable
— Ensure decision-making capacity in older adults; involve family/caregivers when patient agrees
— Offer second opinion when uncertain—particularly between cystectomy and trimodal therapy
— Trimodal therapy vs cystectomy is genuinely preference-sensitive in selected MIBC
— Use validated decision aids; document patient values (organ preservation vs cancer-cure margin)
— Early palliative care integration improves QOL and may extend survival
— Address realistic prognosis in metastatic disease (median OS ~14–18 months even with modern therapy)
— Advance directives, surrogate decision-maker designation
— Post-cystectomy discharge: medication reconciliation (extended LMWH, bicarbonate, B12, bowel regimen, opioid taper, antibiotic prophylaxis if applicable)
— Confirm follow-up scheduled, stomal nurse contact, 24/7 callback line
— Teach-back method for stomal care and warning signs (fever, decreased output, leak)
— Bladder cancer in firefighters, rubber/chemical industry workers may qualify for workers' compensation—document occupational history; refer to occupational medicine
— Cancer registry reporting is required in all US states
— Refer for Lynch syndrome evaluation if upper-tract UC or suggestive family history—has implications for relatives
— Women and Black patients have delayed diagnosis and worse outcomes—maintain low threshold for hematuria workup in these populations
Board pearl: A firefighter with newly diagnosed urothelial carcinoma should be counseled about workers' compensation eligibility and referred to occupational medicine. Failure to document occupational exposure is both a clinical and medicolegal omission.
— Smoking (#1, ~50%)
— Cyclophosphamide / chemical exposure
— Radiation (pelvic)
— Aromatic amines (dyes, rubber, paint)
— Pioglitazone (modest signal—still on US label)
— Egypt / Schistosoma (SCC)
— Dye / textile industry
— Urothelial CA ↔ smoking, aromatic amines, cyclophosphamide
— Squamous cell ↔ Schistosoma haematobium, chronic catheter, chronic stones
— Adenocarcinoma ↔ urachal remnant, bladder exstrophy
Key distinction: Tobacco dominates urothelial CA epidemiology in the US; Schistosoma-related cancer is squamous cell and presents in endemic regions—do not confuse the histologies on a question stem.
— 68 y/o man, 40 pack-year smoker, one episode of painless gross hematuria, UA confirms RBCs without dysmorphism, no infection
— Answer: cystoscopy + CT urography. Distractors: repeat UA in 6 weeks, empiric antibiotics, renal US alone
— Irritative symptoms, sterile pyuria, hematuria
— Answer: cystoscopy with biopsy for CIS
— 70 y/o on warfarin or apixaban with microscopic hematuria
— Answer: full workup (cystoscopy + CT urography); do not attribute to anticoagulation
— Lupus or vasculitis patient years after treatment
— Answer: bladder cancer workup; do not attribute to "old hemorrhagic cystitis"
— Patient develops fever 39.5°C, hypotension hours after BCG instillation
— Answer: antitubercular therapy (INH + rifampin ± ethambutol) + steroids; stop BCG permanently
— High-grade T1 disease, pathology says no detrusor present
— Answer: repeat TURBT in 2–6 weeks
— Patient with conduit develops fatigue, K 3.2, Cl 112, HCO3 16, normal anion gap
— Answer: hyperchloremic non-AG metabolic acidosis from urinary reabsorption; treat with oral bicarbonate
— Renal pelvis urothelial CA in 55 y/o with family history of colon, endometrial cancer
— Answer: refer for MMR/MSI testing and genetic counseling
— Newly diagnosed MIBC with eGFR 48
— Answer: cisplatin-ineligible; use carboplatin-gemcitabine, enfortumab vedotin + pembrolizumab, or proceed to cystectomy
— Long-time rubber industry worker or firefighter with new urothelial CA
— Answer: document occupational history, refer for workers' compensation, occupational medicine
Board pearl: When you see "one episode of gross hematuria" anywhere in a Step 3 stem, the answer is virtually always cystoscopy + CT urography—not "repeat UA," not "trial of antibiotics," not "reassurance."
Painless gross hematuria in any adult—and especially in older smokers—is bladder cancer until proven otherwise; evaluate every patient with cystoscopy plus CT urography, regardless of anticoagulation status, and let muscle-invasion status drive the entire treatment algorithm.
Step 3 management: The two decisions that define excellent care of suspected bladder cancer are (1) never dismissing hematuria—anticoagulation, BPH, or a single resolved episode do not exempt evaluation—and (2) rigorously determining muscle-invasion status on adequate TURBT specimens, because every subsequent therapy, prognosis, and surveillance schedule hinges on that single pathologic feature.