In the investigation of blood in the urine, the doctor images the whole of the urinary tubes and passages. An intravenous urogram is performed first, as this will show obvious intraluminal disease at one or more sites (and it is not uncommon for there to be more than one site) and abdomino-pelvic scanning.
The critical diagnostic test (and indeed the first therapy as resection of all visible disease is performed at the same time) is cystoscopy. Here, the specialist (urologist) looks into the bladder of the patient and resects (surgically removes) any tumour that he can see, sending the specimens that he resects to the pathology laboratory for examination under the microscope.
After resection, the urologist bi-manually feels the bladder to see if there is palpable abnormality (which is a feature of locally invasive/muscle invasive cancers) but, more accurately, he ensures that there is muscle in the deeper biospsies that he performs from the bladder wall tumour. Based on the pathological/ histological findings, the patient is staged according to the system that is shown in the figure. The earliest stage is where the tumour is confined to the bladder lining and does not invade deep (pT1) and the highest stage (pT4) is where there is invasion of the tumour deep and into adjacent tissues.