1. BLADDERBLADDER
CANCERCANCER

2. BACKGROUNDBACKGROUND
 The incidence of bladder carcinoma is rising in WesternThe incidence of bladder carcinoma is rising in Western
countries.countries.
 In 1996, approximately 53,000 patients were diagnosedIn 1996, approximately 53,000 patients were diagnosed
with bladder cancer in the USA, 9,000 in France, 2,000with bladder cancer in the USA, 9,000 in France, 2,000
in Sweden 8,000 in Spain and 1,120 in Belgium.in Sweden 8,000 in Spain and 1,120 in Belgium.
 Approximately 75-85% of patients present with diseaseApproximately 75-85% of patients present with disease
confined to the mucosa (stage Ta-Tis) or submucosaconfined to the mucosa (stage Ta-Tis) or submucosa
(stage T1). The other 15-25% have muscle invasion or(stage T1). The other 15-25% have muscle invasion or
nodal disease (stages T2-T4, N+) at presentation.nodal disease (stages T2-T4, N+) at presentation.

3. EpidemiologyEpidemiology
 Carcinoma of the bladder isCarcinoma of the bladder is
three times more commonthree times more common
among men then women.among men then women.
 Neoplasm of bladder canNeoplasm of bladder can
occur at any age of patientsoccur at any age of patients
but it is most common inbut it is most common in
elderly persons (55 years andelderly persons (55 years and
older) and incidence of bladderolder) and incidence of bladder
cancer increases directly withcancer increases directly with
age.age.
 The median age at the time ofThe median age at the time of
diagnosis is, depending on thediagnosis is, depending on the
country, 60-70 years.country, 60-70 years.

4. EpidemiologyEpidemiology
 The rise in incidence of bladderThe rise in incidence of bladder
cancers is observed in the last 20cancers is observed in the last 20
years.years.
 Bladder cancer is diagnosed 1,5 toBladder cancer is diagnosed 1,5 to
2 times more common among2 times more common among
whites then among blacks,whites then among blacks,
depending on gender.depending on gender.
 The bladder cancer was the causeThe bladder cancer was the cause
of death of 11 200 patient and thisof death of 11 200 patient and this
accounts for 2,6% all cancersaccounts for 2,6% all cancers
death in man and 1,4% in women.death in man and 1,4% in women.

5. BLADDER CANCERBLADDER CANCER
 During last 50 years incidence rate ofDuring last 50 years incidence rate of
bladder cancer has increased ofbladder cancer has increased of
approximately 50% but mortality hasapproximately 50% but mortality has
decreased of approximately 33%.decreased of approximately 33%.
 It is hard to state, to which factorsIt is hard to state, to which factors
changing in the biology of cancer,changing in the biology of cancer,
earlier diagnosis, better treatment orearlier diagnosis, better treatment or
alteration in risk factors thisalteration in risk factors this
phenomenon can be attributed.phenomenon can be attributed.

6. Histological grading of World Health Organisation andHistological grading of World Health Organisation and
International Pathology Concensus Committee 1988International Pathology Concensus Committee 1988
 PTNM pathological classificationPTNM pathological classification
 The pT, pN, and pM categories correspond to the T, N,The pT, pN, and pM categories correspond to the T, N,
and M categories.and M categories.
 GG -- Histopathological gradingHistopathological grading
 GXGX -- Grade of differentiation cannot be assessedGrade of differentiation cannot be assessed
 G1G1 -- Well differentiatedWell differentiated
 G2G2 -- Moderately differentiatedModerately differentiated
 G3G3-4 --4 - Poorly differentiated/undifferentiatedPoorly differentiated/undifferentiated

7. 2002 TNM classification of urinary bladder cancer2002 TNM classification of urinary bladder cancer
 T - Primary tumourT - Primary tumour
 TTXX Primary tumour cannot be assessedPrimary tumour cannot be assessed
 T0T0 No evidence of primary tumourNo evidence of primary tumour
 Ta Non-invasive papillary carcinomaTa Non-invasive papillary carcinoma
 Tis CarcinomaTis Carcinoma in situin situ: 'flat tumour‘: 'flat tumour‘
 T1Tumour invades subepithelialT1Tumour invades subepithelial
connective tissueconnective tissue
 T2Tumour invades muscleT2Tumour invades muscle
 T2aTumour invades superficial muscleT2aTumour invades superficial muscle
(inner half)(inner half)
 T2bTumour invades deep muscle (outerT2bTumour invades deep muscle (outer
half)half)
 T3Tumour invades perivesical tissue:T3Tumour invades perivesical tissue:
 T3aMicroscopically T3bMacroscopicallyT3aMicroscopically T3bMacroscopically
(extravesical mass)(extravesical mass)
 T4Tumour invades any of the following:T4Tumour invades any of the following:
prostate, uterus, vagina, pelvic wall,prostate, uterus, vagina, pelvic wall,
abdominal wallabdominal wall
 T4aTumour invades prostate, uterus orT4aTumour invades prostate, uterus or
vaginavagina
 T4bTumour invades pelvic wall orT4bTumour invades pelvic wall or
abdominal wallabdominal wall

8. 2002 TNM classification of urinary bladder cancer2002 TNM classification of urinary bladder cancer
 N - Lymph nodesN - Lymph nodes
 NXNX Regional lymph nodes cannot be assessedRegional lymph nodes cannot be assessed
 N0N0 No regional lymph node metastasisNo regional lymph node metastasis
 N1N1 Metastasis in a single lymph node 2cm or less in greatestMetastasis in a single lymph node 2cm or less in greatest
dimensiondimension
 N2N2 Metastasis in a single lymph node more than 2 cm but not moreMetastasis in a single lymph node more than 2 cm but not more
than 5 cm in greatest dimension, or multiple lymph nodes, nonethan 5 cm in greatest dimension, or multiple lymph nodes, none
more than 5 cm in greatest dimensionmore than 5 cm in greatest dimension
 N3 Metastasis in a lymph node more than 5 cm in greatestN3 Metastasis in a lymph node more than 5 cm in greatest
dimensiondimension
 M - Distant metastasisM - Distant metastasis
 MXMX Distant metastasis cannot be assessedDistant metastasis cannot be assessed
 M0M0 No distant metastasisNo distant metastasis
 M1M1 Distant metastasisDistant metastasis

9. CLASSIFICATIONCLASSIFICATION
 More than 90% of bladderMore than 90% of bladder
cancers are transitionalcancers are transitional
cell carcinoma (TCC); thecell carcinoma (TCC); the
remainder are squamousremainder are squamous
cell or adenocarcinoma.cell or adenocarcinoma.
 Bladder tumours areBladder tumours are
considered superficial (Tis-considered superficial (Tis-
Ta-T1) or infiltrative (T2-T3-Ta-T1) or infiltrative (T2-T3-
T4) based on cystoscopy,T4) based on cystoscopy,
transurethral resectiontransurethral resection
(TUR), imaging studies and(TUR), imaging studies and
histopathological findings.histopathological findings.

10. RISK FACTORSRISK FACTORS
 Aromatic amines were the first to be recognized. AtAromatic amines were the first to be recognized. At risk groupsrisk groups
include workers in the following industries: printing, ironinclude workers in the following industries: printing, iron
foundry, aluminium smelting, industrial painting, gas and tarfoundry, aluminium smelting, industrial painting, gas and tar
manufacturing.manufacturing.
 Another prominent risk factor is cigarette smoking. SmokingAnother prominent risk factor is cigarette smoking. Smoking
leads to higher mortality from bladder cancer during long-termleads to higher mortality from bladder cancer during long-term
follow-up, even though in a multivariate analysis, the prognosticfollow-up, even though in a multivariate analysis, the prognostic
effect of smoking was weaker than that of other factors, such aseffect of smoking was weaker than that of other factors, such as
stage, grade, size and multifocality of the tumour . Patients withstage, grade, size and multifocality of the tumour . Patients with
initial grade III tumours were significantly more likely to be heavyinitial grade III tumours were significantly more likely to be heavy
smokers than those with less aggressive disease .smokers than those with less aggressive disease .

11. SymtomatologySymtomatology
 Haematuria is the mostHaematuria is the most
common finding in bladdercommon finding in bladder
cancer. The degree ofcancer. The degree of
haematuria does not correlatehaematuria does not correlate
with the extent of the disease. Itwith the extent of the disease. It
may be grossly visible to themay be grossly visible to the
patient or simply found onpatient or simply found on
routine urinalysis.routine urinalysis.
 Bladder cancer may alsoBladder cancer may also
present symptoms of voidingpresent symptoms of voiding
irritability. Patients may complainirritability. Patients may complain
of urgency, dysuria andof urgency, dysuria and
increased urinary frequency.increased urinary frequency.
 Urinary tract infection isUrinary tract infection is
observed in 30% of patients.observed in 30% of patients.

12. SymtomatologySymtomatology
 Pain appears in advancedPain appears in advanced
stages of the tumour. When it isstages of the tumour. When it is
located in the suprapubic regionlocated in the suprapubic region
it signals that the tumourit signals that the tumour
infiltrates the perivesicalinfiltrates the perivesical
tissues.tissues.
 Flanc pain, often accompaniedFlanc pain, often accompanied
by fever, is due to the ureteralby fever, is due to the ureteral
obstructions.obstructions.

13. DIAGNOSISDIAGNOSIS Physical examinationPhysical examination
 Physical examination, includingPhysical examination, including
digital rectal examinationdigital rectal examination andand
bimanual pelvic palpation, isbimanual pelvic palpation, is
recommended when haematuriarecommended when haematuria
is found.is found.
 However, 85% of patients withHowever, 85% of patients with
bladder cancer initially presentbladder cancer initially present
with superficial disease.with superficial disease.
 Therefore, physical examinationTherefore, physical examination
plays a limited role in theplays a limited role in the
diagnosis, except to exclude co-diagnosis, except to exclude co-
existing pathologyexisting pathology..

14. DIAGNOSISDIAGNOSIS (Laboratory Findings)(Laboratory Findings)
 The most commonly assessedThe most commonly assessed
laboratory parameters are:laboratory parameters are:
 Haemoglobin and erythrocyteHaemoglobin and erythrocyte
sedimentation rate: prognosissedimentation rate: prognosis
 Creatinine: overall kidneyCreatinine: overall kidney
functionfunction
 Alkaline phosphatase: liverAlkaline phosphatase: liver
metastasis, bone metastasis.metastasis, bone metastasis.
 Serum calcium is frequentlySerum calcium is frequently
included in the preoperativeincluded in the preoperative
assessment because of itsassessment because of its
association with paraneoplasticassociation with paraneoplastic
manifestation, which may havemanifestation, which may have
clinical implicationsclinical implications..
 TheThe erytrocit-erytrocit-,, protein-protein- andand
leukocyturialeukocyturia are exposed in urine.are exposed in urine.

15. DIAGNOSIS ImagingDIAGNOSIS Imaging
 Urography with cystography areUrography with cystography are
performed in all patientsperformed in all patients
suspected of bludder tumours.suspected of bludder tumours.
 Filling defects in the central partFilling defects in the central part
of the cystogram can indicate theof the cystogram can indicate the
papillary growth of the tumour.papillary growth of the tumour.
 Marginal filling defects are typicalMarginal filling defects are typical
of flat tumours, which are alwaysof flat tumours, which are always
invasive.invasive.

16. DIAGNOSIS ImagingDIAGNOSIS Imaging
 Intravenous pyelography IVPIntravenous pyelography IVP
 Large tumours may be seen as fillingLarge tumours may be seen as filling
defects in the bladder or may restrictdefects in the bladder or may restrict
symmetrical bladder wall expansionsymmetrical bladder wall expansion
during filling in invasive tumours.during filling in invasive tumours.
 Intravenous pyelography (IVP) is alsoIntravenous pyelography (IVP) is also
used to detect filling defects in theused to detect filling defects in the
calices, renal pelvis and ureters, andcalices, renal pelvis and ureters, and
hydronephrosis, which may indicatehydronephrosis, which may indicate
the presence of a ureteral cancer or athe presence of a ureteral cancer or a
muscle-invasive bladder cancer at themuscle-invasive bladder cancer at the
ureteral orifice.ureteral orifice.
 The necessity to perform routine IVP atThe necessity to perform routine IVP at
initial diagnosis is now questionedinitial diagnosis is now questioned
because of the low incidence ofbecause of the low incidence of
important findings obtained with thisimportant findings obtained with this
methodsmethods..

17. DIAGNOSIS ImagingDIAGNOSIS Imaging

18. DIAGNOSIS ImagingDIAGNOSIS Imaging (metastasis)(metastasis)
 In order to specify staging of the bladder tumour, besides clinicalIn order to specify staging of the bladder tumour, besides clinical
examination, USG and bimanual investigation of patients, followingexamination, USG and bimanual investigation of patients, following
additional procedures are performed:additional procedures are performed:
 1. transurethral diagnostic (primary) resection1. transurethral diagnostic (primary) resection
 2. transurethral ultrasonography2. transurethral ultrasonography
 3. computed tomography of pelvis minor, retroperitoneum and liver3. computed tomography of pelvis minor, retroperitoneum and liver
 4. magnetic resonance of pelvis minor and bones - sites suspected4. magnetic resonance of pelvis minor and bones - sites suspected
of the metastases,of the metastases,
 5. chest radiograph.5. chest radiograph.

19. DIAGNOSIS ImagingDIAGNOSIS Imaging
 UltrasonographyUltrasonography
 Transabdominal sonography makes itTransabdominal sonography makes it
possible to identify exclusivelypossible to identify exclusively
exophytic tumours whose diameterexophytic tumours whose diameter
exceeds 10 mm.exceeds 10 mm.
 USG is more discriminationg method.USG is more discriminationg method.
It helps to determine the depth of theIt helps to determine the depth of the
tumour invasion into the bladder wall.tumour invasion into the bladder wall.
 Transabdominal ultrasound permitsTransabdominal ultrasound permits
characterization of renal masses,characterization of renal masses,
detection of hydronephrosis anddetection of hydronephrosis and
visualization of intraluminal fillingvisualization of intraluminal filling
defects in the bladderdefects in the bladder..

20. DIAGNOSIS ImagingDIAGNOSIS Imaging
 Computed tomography is of little use in the diagnosis ofComputed tomography is of little use in the diagnosis of
bladder cancers.bladder cancers.
 Computed tomography (CT) scanning may be part of theComputed tomography (CT) scanning may be part of the
evaluation of invasive bladder tumours and the evaluationevaluation of invasive bladder tumours and the evaluation
of pelvic and abdominal lymph node metastasis.of pelvic and abdominal lymph node metastasis.

21. DIAGNOSIS CystoscopyDIAGNOSIS Cystoscopy
 TheThe diagnosis of bladderdiagnosis of bladder
cancer ultimately depends oncancer ultimately depends on
cystoscopiccystoscopic eexamination of thexamination of the
bladder and pathologicalbladder and pathological
evaluation of the resected lesion.evaluation of the resected lesion.
 Cystoscopy shows the size ofCystoscopy shows the size of
the tumour, its appearance andthe tumour, its appearance and
surroundingsurrounding..

22. DIAGNOSISDIAGNOSIS BiopsyBiopsy
 Biopsy is also applied the histology of the tumour as wellBiopsy is also applied the histology of the tumour as well
as its grade can be determined.as its grade can be determined.
 The biopsy of non-affected parts of the bladder shouldThe biopsy of non-affected parts of the bladder should
be obtained in search of carcinoma in situ.be obtained in search of carcinoma in situ.

23. DIAGNOSISDIAGNOSIS BiopsyBiopsy and TURand TUR
 Biopsy specimens of the tumour andBiopsy specimens of the tumour and
suspected area should be taken tosuspected area should be taken to
map the extent of the disease.map the extent of the disease.
 Both cold cup biopsies to preserveBoth cold cup biopsies to preserve
the histological architecture and TURthe histological architecture and TUR
biopsies to determine the extent ofbiopsies to determine the extent of
the disease should be performed.the disease should be performed.
Random biopsies of normal mucosaRandom biopsies of normal mucosa
are indicated in the presence ofare indicated in the presence of
positive cytology, even in the absencepositive cytology, even in the absence
of a tumour, or in any non-papillaryof a tumour, or in any non-papillary
tumour.tumour.
 Prostatic urethra biopsies by TUR areProstatic urethra biopsies by TUR are
indicated if there is suspicion of Tis ofindicated if there is suspicion of Tis of
the bladder in view of the highthe bladder in view of the high
frequency of involvement of thefrequency of involvement of the
prostatic urethraprostatic urethra..

24. DIAGNOSISDIAGNOSIS Cytological examinationCytological examination
 Cytological examination isCytological examination is
particularly useful for patients whoparticularly useful for patients who
underwent treatment due to bladderunderwent treatment due to bladder
cancer. It may also be used as acancer. It may also be used as a
screening procedure for people whoscreening procedure for people who
are especially vulnerable to bladderare especially vulnerable to bladder
cancers because of theircancers because of their
professions.professions.
 The sensitivity of the methodThe sensitivity of the method
increases with the tumour grade. Inincreases with the tumour grade. In
grade 3 tumours it varies from 60 tograde 3 tumours it varies from 60 to
87%. The drawback of cytological87%. The drawback of cytological
examination is its low specificity.examination is its low specificity.

26. Surgical treatmentSurgical treatment
 Three methods ofThree methods of
surgical treatment aresurgical treatment are
commonly used incommonly used in
bladder cancer.bladder cancer.
 These are: transurethralThese are: transurethral
resection, partialresection, partial
cystectomy and radicalcystectomy and radical
cystoprostatectomy.cystoprostatectomy.
 The choice of theThe choice of the
appropriate procedure isappropriate procedure is
determined by thedetermined by the
following factors: tumourfollowing factors: tumour
stage, grade andstage, grade and
multifocal growth.multifocal growth.

27. Transurethral resectionTransurethral resection
 Transurethral resection as primary therapy should beTransurethral resection as primary therapy should be
reserved for patients who have small, solitary, low gradereserved for patients who have small, solitary, low grade
superficial carcinomas and bladder papillomas. Thesuperficial carcinomas and bladder papillomas. The
procedure makes it possible to remove deep layers ofprocedure makes it possible to remove deep layers of
the bladder muscle, which renders the treatment morethe bladder muscle, which renders the treatment more
radical.radical.

28. Partial resection of the bladderPartial resection of the bladder
 Partial resection of the bladder isPartial resection of the bladder is
performed rarely.performed rarely.
 The treatment is reserved forThe treatment is reserved for
patients with solitary muscle-patients with solitary muscle-
infililtrative tumours localised oninfililtrative tumours localised on
top of the bladder, far from thetop of the bladder, far from the
trigone or vesicle neck. A tumour-trigone or vesicle neck. A tumour-
free margin of 1,5 to 2,0 cm mustfree margin of 1,5 to 2,0 cm must
be obtained. The results forbe obtained. The results for
patients selected carefully for thepatients selected carefully for the
procedure were not inferior toprocedure were not inferior to
those of cystectomy.those of cystectomy.
 In order to improve theIn order to improve the
therapeutic results partialtherapeutic results partial
resection was combined withresection was combined with
chemotherapy.chemotherapy.

29. Radical cystectomyRadical cystectomy
 indications for the operation.indications for the operation.
These are:These are:
 1 invasive bladder cancer1 invasive bladder cancer
irrespective of the tumour grade,irrespective of the tumour grade,
 2 recurrences of the tumour after2 recurrences of the tumour after
transurethral resection,transurethral resection,
particularly when the gradeparticularly when the grade
increases,increases,
 3 high grade tumours coexisting3 high grade tumours coexisting
with carcinoma in situ,with carcinoma in situ,
 4 multifocally growing superficial4 multifocally growing superficial
bladder cancers resistant tobladder cancers resistant to
intravesical chemo- orintravesical chemo- or
immunotherapy administeredimmunotherapy administered
after transurethral resection,after transurethral resection,
 5 recurrences of carcinoma in5 recurrences of carcinoma in
situ following chemo- orsitu following chemo- or
immunotherapy.immunotherapy.

30. Radical cystectomyRadical cystectomy
 At present radical cystectomy appears to be the most effectiveAt present radical cystectomy appears to be the most effective
therapeutic option for patients with invasive bladder cancer.therapeutic option for patients with invasive bladder cancer.
 Five-year survival is assessed by different authors as 30-54% ofFive-year survival is assessed by different authors as 30-54% of
cases. However, the operation is dangerous, technically difficult, forcases. However, the operation is dangerous, technically difficult, for
which the risk of perioperative morbidity is high.which the risk of perioperative morbidity is high.

31. RadiotherapyRadiotherapy
 Poorly differentiated or multiple T1-T2Poorly differentiated or multiple T1-T2
tumours may be treated by localtumours may be treated by local
radiotherapy to the bladder andradiotherapy to the bladder and
perivesical tissues with five- year survivalperivesical tissues with five- year survival
rates of 40-60%. Lymphatic involvementrates of 40-60%. Lymphatic involvement
occurs in about 60% of patients with T3occurs in about 60% of patients with T3
tumours and radiation is usually given totumours and radiation is usually given to
the whole pelvis. Five-years survival ratesthe whole pelvis. Five-years survival rates
after radiotherapy, however are less thanafter radiotherapy, however are less than
35%.35%.
 Brachytherapy should only be applied inBrachytherapy should only be applied in
selected patients with solitary tumours ofselected patients with solitary tumours of
less than 5 cm in diameter.less than 5 cm in diameter.
 External -beam radiotherapy is often firstExternal -beam radiotherapy is often first
line therapy in Great Britain and Europe,line therapy in Great Britain and Europe,
with salvage cystectomy reserved forwith salvage cystectomy reserved for
treatment failures.treatment failures.

32. Complication of radiation therapyComplication of radiation therapy
 Radiotherapy is generally wellRadiotherapy is generally well
tolerated, most patientstolerated, most patients
experience dysuria, urgency,experience dysuria, urgency,
urinary frequency, andurinary frequency, and
diarrhea as acute self limitingdiarrhea as acute self limiting
symptoms.symptoms.
 Late complication includedLate complication included
hematuria, bladder and rectalhematuria, bladder and rectal
ulceration, rectal stricture, andulceration, rectal stricture, and
small bowel obstruction.small bowel obstruction.
 Severe complication requiringSevere complication requiring
surgery occurred in 12%.surgery occurred in 12%.

33. Intravesical chemotherapyIntravesical chemotherapy
Table : Advantages and disadvantages of therapeutic compounds used in treatment of bladder cancer
Name
Molecular
weigh
t
Advantages Disadvantages
Therapeutic
use
Thiotepa Small Inexpensive
Systemic absorption leading to
myelosuppression and renal
failure
+/-
Epodyl Small Inexpensive
Systemic side-effects;
myelosuppression
+/-
Adriamycyn Large Minimal absorption Chemical cystitis; expensive + +
Epirubicin Large Minimal absorption Chemical cystitis; expensive + +
Mitomycin C Large Minimal absorption
Chemical cystitis, bladder ulceration;
expensive
+ +
Mitoxantron C Large Minimal absorption Chemical cystitis, expensive + +
BCG Large
Relatively
inexpensive
Local toxicity, BCG-itis (absorption) + + +
Cytokines Interferon Relatively
small
Effective Systemic toxicity; extremely
expensive
+

34. Intravesical Bacille Calmette-Guerin (BCG)Intravesical Bacille Calmette-Guerin (BCG)
therapytherapy
 In 1976 Morales et al. presented the first results ofIn 1976 Morales et al. presented the first results of
intravesical BCG instillation in the treatment of superficialintravesical BCG instillation in the treatment of superficial
bladder tumours.bladder tumours.
 BCG is commonly given in three clinical settings:BCG is commonly given in three clinical settings:
(1)prophylaxis in tumour-free patients, (2) treatment of(1)prophylaxis in tumour-free patients, (2) treatment of
residual tumour in patients with papillary TCC andresidual tumour in patients with papillary TCC and
(3)treatment of patients with carcinoma in situ.(3)treatment of patients with carcinoma in situ.

35. RECOMMENDATIONSRECOMMENDATIONS
 Mandatory evalutionsMandatory evalutions::
 Physical examination (including digital rectal and pelvic examination)Physical examination (including digital rectal and pelvic examination)
 Renal and bladder ultrasonography and/or IVPRenal and bladder ultrasonography and/or IVP
 Cystoscopy with description of the tumour: size, site, appearance (a diagram oCystoscopy with description of the tumour: size, site, appearance (a diagram o
 UrinalysisUrinalysis
 Urinary cytologyUrinary cytology
 TUR with:TUR with:
 biopsy of the underlying tissuebiopsy of the underlying tissue
 random biopsies in the presence of positive cytology, large or non-papillary tumourrandom biopsies in the presence of positive cytology, large or non-papillary tumour
 biopsy of the prostatic urethra in cases of Tis or suspicion of itbiopsy of the prostatic urethra in cases of Tis or suspicion of it
 When the bladder tumour is muscle infiltrative and radical treatment is indWhen the bladder tumour is muscle infiltrative and radical treatment is ind
 Chest X-rayChest X-ray
 IVP and/or abdominal/pelvic CT scanIVP and/or abdominal/pelvic CT scan
 Liver ultrasonographyLiver ultrasonography
 Bone scan if symptoms are present or alkaline phosphatase level is elevatedBone scan if symptoms are present or alkaline phosphatase level is elevated

36. THANK YOU FORTHANK YOU FOR
ATTENTIONATTENTION