A cystoscopy is a medical procedure that uses a specialized diagnostic tool to visually inspect the bladder and urethra. This technique involves inserting a thin tube equipped with a camera and light, known as a cystoscope, through the urethra and into the bladder. Cystoscopy serves as a primary method for diagnosing, monitoring, and managing bladder cancer due to the high likelihood of recurrence. The procedure provides immediate visual evidence of abnormal growths, aiding in treatment planning.
Understanding the Cystoscopy Procedure
Preparation for a cystoscopy varies depending on the type of anesthesia used. For a flexible cystoscopy, which often uses a local anesthetic gel, patients can typically eat and drink normally beforehand and may not require a driver. A rigid cystoscopy, however, often requires general or spinal anesthesia, necessitating fasting for several hours prior to the procedure. The patient is positioned on their back, and a local anesthetic is applied to minimize discomfort as the scope is gently inserted.
Once the cystoscope is advanced into the bladder, sterile fluid is infused through the scope to distend the bladder walls. This stretching allows the physician to achieve a clear, unobstructed view of the entire bladder lining. The examination usually lasts between five and twenty minutes, though it may take longer if tissue samples are collected. The patient may feel a sensation of needing to urinate as the bladder fills with fluid.
Visual Indicators of Bladder Cancer
When a physician examines the bladder lining through the cystoscope, they look for specific visual characteristics that suggest cancerous growth. Bladder tumors generally present in one of two main morphological forms: papillary or sessile. Papillary tumors are the more common type, often appearing as growths with long, thin, finger-like projections extending into the bladder cavity. These growths tend to be associated with lower-grade, non-muscle-invasive disease.
In contrast, sessile or non-papillary tumors are flatter and spread out along the bladder lining, lacking the distinct stalk of papillary lesions. These tumors can appear as a thickened, reddened, or velvety area on the bladder wall. This flat appearance can make them more challenging to detect visually during a standard cystoscopy. A specific type of sessile lesion is carcinoma in situ (CIS), which is a high-grade, non-invasive cancer that presents as a flat patch.
Carcinoma in situ is particularly concerning because its subtle visual appearance, sometimes resembling an inflamed or irritated area, means it can be overlooked. CIS cells are highly abnormal and carry a significant risk of progression to more aggressive, muscle-invasive disease. Cancerous lesions are often pink or red due to increased vascularity. Tumors can form anywhere on the bladder wall, but the specific location may influence treatment planning.
Not all abnormal findings seen during the procedure are cancerous. Non-cancerous conditions, such as inflammation from a urinary tract infection (UTI), benign polyps, or changes like squamous metaplasia, can sometimes mimic malignancy. UTIs, which can cause symptoms like blood in the urine, may also coexist with bladder cancer, complicating the initial assessment. The visual examination is therefore a screening tool that identifies suspicious areas requiring further investigation.
Determining Grade and Stage
To confirm the presence of cancer and determine its characteristics, the next necessary action is usually a Transurethral Resection of Bladder Tumor (TURBT). This procedure involves using instruments passed through the cystoscope to surgically remove the entire visible tumor or a tissue sample (biopsy). The tissue is then sent to a pathologist for microscopic analysis.
The pathologist determines two distinct features: the tumor’s grade and its stage. Grade refers to how abnormal the cancer cells look under the microscope, which indicates their potential aggressiveness. Low-grade tumors have cells that look somewhat similar to normal cells, grow slowly, and are less likely to spread. High-grade tumors consist of cells that are highly abnormal, are more aggressive, and have a greater likelihood of recurring or progressing.
The tumor’s stage describes how far the cancer has grown into the layers of the bladder wall. Staging uses the TNM system, where ‘T’ indicates the depth of tumor invasion. Non-muscle-invasive bladder cancer (NMIBC), such as Ta or T1, means the tumor is confined to the inner lining or the layer just beneath it. Muscle-invasive bladder cancer (MIBC) is a more advanced stage, indicating the tumor has penetrated the deeper muscle layer of the bladder wall.