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Urinary bladder carcinoma for surgery resident essy

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"Urinary Bladder Neoplasms"[MeSH Terms] AND surgery

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EAU Guidelines 2026 muscle invasive metastatic bladder cancer radical cystectomy urinary diversion

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diagram bladder cancer staging transurethral resection muscle invasive bladder wall

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https://uroweb.org/guidelines/muscle-invasive-and-metastatic…

Carcinoma of the Urinary Bladder

Introduction

Urinary bladder carcinoma is the most common malignancy of the urinary tract. More than 90% are urothelial carcinomas (transitional-cell carcinomas). It is characterized by a high recurrence rate, potential for progression to muscle-invasive disease, and field change in the urothelium, which can involve the renal pelvis, ureters, bladder, and urethra.
The clinical and surgical approach hinges on whether the tumor is non-muscle-invasive bladder cancer (NMIBC) or muscle-invasive bladder cancer (MIBC).

Risk factors

  • Cigarette smoking: most important modifiable risk factor.
  • Occupational aromatic amine exposure: dye, rubber, leather, paint, textile, printing, and chemical industries.
  • Chronic bladder inflammation: long-term catheter, vesical calculus, chronic infection.
  • Schistosoma haematobium: linked particularly to squamous-cell carcinoma.
  • Pelvic irradiation and cyclophosphamide exposure.
  • Increasing age, male sex, and family/genetic predisposition.

Pathology

Histological types

TypeApproximate frequency and associations
Urothelial carcinoma>90% in most regions; papillary or flat carcinoma in situ
Squamous-cell carcinomaChronic irritation, schistosomiasis, indwelling catheter
AdenocarcinomaPrimary vesical adenocarcinoma, urachal tumor, chronic irritation
Small-cell/neuroendocrine carcinomaRare, aggressive
OthersSarcoma, lymphoma, metastasis

Growth patterns

  1. Papillary tumors: Exophytic lesions, commonly low grade and non-muscle invasive.
  2. Flat lesions: Carcinoma in situ (CIS), usually high grade, often multifocal and with a high progression risk.
  3. Solid/infiltrative tumors: More likely to be high-grade and muscle invasive.

Staging

TNM staging

CategoryDescription
TaNoninvasive papillary carcinoma
TisFlat carcinoma in situ
T1Invades lamina propria/subepithelial connective tissue
T2aInvades inner half of muscularis propria
T2bInvades outer half of muscularis propria
T3aMicroscopic perivesical fat invasion
T3bMacroscopic extravesical mass
T4aInvades prostatic stroma, uterus, or vagina
T4bInvades pelvic wall or abdominal wall
N1-N3Regional nodal metastases
M1Distant metastasis
Surgical relevance: Accurate discrimination between T1 and T2 disease is fundamental. A TURBT specimen must contain detrusor muscle unless the lesion is clearly low-risk Ta disease.

Clinical features

  • Painless visible hematuria is the classic presentation.
  • Irritative lower urinary tract symptoms: frequency, urgency, dysuria, especially in CIS.
  • Clot retention or anemia in advanced disease.
  • Flank pain, hydroureteronephrosis, renal dysfunction due to ureteric obstruction.
  • Pelvic pain, edema, palpable mass, weight loss, bone pain, or supraclavicular nodes suggest advanced/metastatic disease.
Hematuria, pyuria, anemia, and azotemia may occur; urine cytology is most useful for high-grade tumor and CIS. Cystoscopy with biopsy establishes diagnosis, while CT urography assesses upper tracts and staging. Smith and Tanagho’s General Urology, 19th ed., Bladder Carcinomas section.

Evaluation

Initial work-up

  1. History: smoking, occupational exposure, previous urothelial tumors, radiation, cyclophosphamide, symptoms.
  2. Examination: abdominal/pelvic mass, bimanual examination under anesthesia, lymph nodes, edema, hepatomegaly.
  3. Urinalysis and urine culture.
  4. CBC, renal function, liver function, electrolytes.
  5. Urine cytology, especially where high-grade lesion or CIS is suspected.
  6. Cystoscopy and complete tumor mapping.
  7. Transurethral resection of bladder tumor (TURBT) for histological diagnosis, grading, and local staging.

Staging investigations

  • CT urography or contrast CT abdomen/pelvis for upper tracts, nodes, local extension, and obstruction.
  • CT chest for MIBC.
  • MRI pelvis can assist local staging in selected cases.
  • Bone scan or PET/CT when symptoms, raised alkaline phosphatase, or imaging suggest bone/metastatic disease.

TURBT: key operative principles

TURBT is both diagnostic and therapeutic for NMIBC.

Aims

  • Complete visible tumor removal.
  • Obtain specimen containing detrusor muscle.
  • Define grade, stage, variant histology, CIS, lymphovascular invasion, and completeness of resection.
  • Control hematuria and relieve obstruction where needed.

Technique

  • Perform bimanual examination under anesthesia before and after resection.
  • Inspect urethra, trigone, ureteric orifices, bladder neck, dome, lateral walls, and anterior wall.
  • Resect exophytic component first, then deep tumor base separately.
  • Send labeled specimens: tumor, deep base, suspicious flat lesions.
  • Avoid deep perforation, especially at the lateral wall where obturator reflex can cause bladder perforation.
  • Consider obturator nerve block for lateral-wall tumors.
  • Use continuous irrigation and ensure hemostasis after resection.

Complications

  • Hematuria and clot retention.
  • Extraperitoneal or intraperitoneal bladder perforation.
  • Obturator nerve reflex.
  • Ureteric orifice injury/obstruction.
  • Infection and TUR syndrome, rarely.

Repeat TURBT

A repeat resection is generally indicated within about 2-6 weeks for:
  • Incomplete initial resection.
  • Any T1 tumor.
  • High-grade Ta tumor, particularly large or multifocal lesions.
  • No detrusor muscle in the specimen, except in clearly low-grade Ta or primary CIS.
  • Doubt about stage or completeness.

Management according to stage and risk

1. Non-muscle-invasive bladder cancer: Ta, T1, CIS

Low-risk disease

Typical features: solitary, small, primary, low-grade Ta tumor without CIS.
Treatment
  • Complete TURBT.
  • Single immediate postoperative intravesical chemotherapy, when no perforation, major bleeding, or concern about extravasation.
  • Cystoscopic surveillance.

Intermediate-risk disease

Usually recurrent, multifocal, or larger low-grade Ta tumors.
Treatment
  • Complete TURBT.
  • Intravesical chemotherapy or BCG based on recurrence/progression risk.
  • Regular cystoscopy and cytology.

High-risk NMIBC

Includes high-grade T1 tumor, CIS, recurrent high-grade tumors, and selected variant histology.
Treatment
  • Repeat TURBT where indicated.
  • Induction intravesical BCG followed by maintenance BCG.
  • Early radical cystectomy should be discussed for very-high-risk disease, BCG-unresponsive disease, persistent T1 high-grade disease, aggressive variants, extensive CIS, or where complete local control is unlikely.

2. Muscle-invasive bladder cancer: T2-T4a, N0M0

Standard treatment

Cisplatin-based neoadjuvant systemic therapy followed by radical cystectomy with bilateral pelvic lymph-node dissection and urinary diversion is standard treatment for fit patients.
Radical cystectomy is also indicated for:
  • BCG-unresponsive high-risk NMIBC.
  • Extensive or recurrent high-grade T1 disease.
  • Uncontrollable hematuria or contracted painful bladder.
  • Selected bladder tumors with aggressive histological variants.
Current 2026 EAU guidance retains radical cystectomy with lymph-node dissection as the central local treatment for nonmetastatic MIBC, while perioperative systemic regimens are evolving. The EAU MIBC guideline should be checked for current eligibility criteria and drug approvals.

Radical cystectomy: extent of resection

PatientStandard extirpative procedure
MaleBladder, prostate, seminal vesicles, distal ureters, and usually proximal urethra as indicated
FemaleBladder, urethra, distal ureters, anterior vaginal wall, uterus/cervix, and adnexa as appropriate
BothBilateral pelvic lymph-node dissection
Organ-preserving or sexual-function-preserving approaches are possible only in carefully selected patients, with negative margins and appropriate oncological assessment.

Pelvic lymph-node dissection

At minimum, lymphadenectomy includes obturator, internal iliac, external iliac, and common iliac nodal regions. It provides staging information and may improve local disease control. A recent meta-analysis on the extent of lymph-node dissection is available as PMID 38715172, but its findings should be interpreted with the limitations of heterogeneous included studies.

Important intraoperative steps

  1. Exploration and assessment of resectability.
  2. Bilateral ureteric mobilization and division, with frozen section when indicated.
  3. Pelvic lymph-node dissection.
  4. Division/control of superior and inferior vesical pedicles.
  5. Posterior dissection with careful rectal protection in men.
  6. Anterior dissection and urethral division.
  7. Specimen removal with adequate margins.
  8. Creation of urinary diversion.
  9. Hemostasis, drain placement, and enhanced recovery protocol.
In male radical cystectomy, posterior dissection requires particular care near the seminal vesicles, Denonvilliers fascia, and rectum; sharp dissection is preferred when fibrosis or prior irradiation obscures the plane. Campbell-Walsh-Wein Urology, Radical Cystectomy: Male section.

Urinary diversion after cystectomy

1. Ileal conduit

  • Most common incontinent diversion.
  • Ureters anastomosed to an isolated ileal segment brought out as a stoma.
  • Reliable, shorter operative time, suitable for older/frail patients and those unable to perform self-catheterization.

2. Orthotopic ileal neobladder

  • Intestinal reservoir connected to urethra.
  • Suitable only if urethral margin is negative and patient has adequate renal, hepatic, cognitive, and functional status.
  • Requires motivated patient, good dexterity, and acceptance of possible intermittent self-catheterization.
  • Risks: nocturnal leakage, retention, mucus, metabolic acidosis, vitamin B12 deficiency, ureteroenteric stricture.

3. Continent cutaneous reservoir

  • Catheterizable abdominal stoma with an internal reservoir.
  • Used in selected patients unable or unsuitable for neobladder but capable of intermittent catheterization.

Diversion selection

Choice depends on renal function, liver function, bowel disease, previous irradiation, urethral involvement, tumor location, patient fitness, cognition, manual dexterity, preference, and expected oncological outcome.

Bladder-preservation therapy

For carefully selected MIBC patients who wish to retain the bladder or are unsuitable for cystectomy:
Trimodality therapy
  1. Maximal TURBT.
  2. Concurrent chemoradiation.
  3. Intensive cystoscopic surveillance.
  4. Salvage cystectomy for invasive recurrence or non-response.
Best candidates generally have:
  • Solitary, preferably unifocal T2 tumor.
  • Complete/near-complete TURBT possible.
  • No extensive CIS.
  • No severe hydronephrosis.
  • Good bladder capacity and function.
  • Capacity to comply with strict follow-up.
It is not simply “radiotherapy instead of surgery”; success depends on selection, adequate TURBT, radiosensitizing chemotherapy, and the availability of salvage cystectomy.

Metastatic disease

Management is multidisciplinary and primarily systemic:
  • Platinum-based chemotherapy if eligible.
  • Immunotherapy and antibody-drug conjugate based regimens according to current approvals and patient eligibility.
  • Molecular testing, including actionable alterations where appropriate.
  • Palliative TURBT, radiotherapy, diversion, nephrostomy, analgesia, transfusion, and bone-directed treatment may be needed for symptom control.

Follow-up

Follow-up is long term because recurrence may occur in the bladder, upper urinary tract, urethra, regional nodes, or distant sites.

After NMIBC

  • Cystoscopy at 3 months is fundamental.
  • Urine cytology for high-risk disease.
  • Subsequent frequency based on risk group.
  • Upper-tract imaging periodically in high-risk patients.

After radical cystectomy

Monitor:
  • Local and distant recurrence by imaging.
  • Renal function and hydronephrosis.
  • Electrolyte/metabolic disturbance.
  • Vitamin B12 in intestinal diversions.
  • Stoma, continence, sexual function, and diversion-specific complications.
  • Urethral surveillance in selected high-risk patients.

Prognostic factors

  • Pathological T stage.
  • Tumor grade.
  • Presence of CIS.
  • Lymphovascular invasion.
  • Variant histology.
  • Nodal status.
  • Completeness of TURBT.
  • Response to neoadjuvant treatment.
  • Positive surgical margins.
  • Hydronephrosis and renal impairment.

Exam-oriented summary

  • Painless hematuria = bladder cancer until proved otherwise.
  • Cystoscopy with complete TURBT and detrusor muscle in specimen is the diagnostic cornerstone.
  • Ta/T1/CIS = risk-adapted TURBT plus intravesical treatment.
  • T1 high-grade requires repeat TURBT and BCG; early cystectomy is considered for very-high-risk or BCG-unresponsive disease.
  • T2-T4a N0M0 = neoadjuvant cisplatin-based therapy when suitable, then radical cystectomy plus pelvic lymph-node dissection and diversion.
  • Trimodality bladder preservation is an alternative for well-selected, compliant patients.
  • Diversion choice must be individualized and discussed preoperatively.

Include diagrams nd flowcharts

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EAU non-muscle invasive bladder cancer guideline 2026 risk stratification flowchart TURBT BCG

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"Urinary Bladder Neoplasms"[MeSH Terms] AND "Transurethral Resection of Prostate"

Diagram 1: Bladder wall invasion and T staging

Anatomical staging of urinary bladder cancer, showing urothelium, lamina propria, muscularis propria, perivesical fat, and progression from Ta/Tis through T4 disease

Quick staging diagram

BLADDER LUMEN
     │
     ▼
┌─────────────────────────────┐
│ Urothelium                  │  Ta = Papillary, non-invasive
│                             │  Tis = Flat carcinoma in situ
├─────────────────────────────┤
│ Lamina propria              │  T1 = Invades lamina propria
├─────────────────────────────┤
│ Muscularis propria          │  T2 = Muscle-invasive
│  • Inner half = T2a         │
│  • Outer half = T2b         │
├─────────────────────────────┤
│ Perivesical fat             │  T3 = Perivesical tissue invasion
├─────────────────────────────┤
│ Adjacent organs             │  T4 = Prostate/seminal vesicle,
│                             │       uterus/vagina, pelvic wall
└─────────────────────────────┘
Surgical point: The TURBT specimen must include detrusor muscle to distinguish T1 from T2 disease. This determines whether bladder-preserving intravesical treatment or radical treatment is required.

Flowchart 1: Evaluation of painless hematuria / suspected bladder tumor

Painless visible hematuria
            │
            ▼
History + examination
Urinalysis/culture + CBC + renal function
            │
            ▼
CT urography / CT abdomen-pelvis
            │
            ▼
Flexible cystoscopy
            │
     ┌──────┴────────┐
     │               │
No lesion         Bladder lesion
     │               │
Investigate        ▼
other causes     TURBT + bimanual examination under anesthesia
                     │
                     ▼
Histology: grade, stage, CIS, variant histology,
lymphovascular invasion, detrusor muscle present?
                     │
                     ▼
Risk-stratified definitive management

Flowchart 2: Treatment algorithm after TURBT

TURBT histopathology
        │
        ├──────────────────────────────────────────┐
        │                                          │
        ▼                                          ▼
NMIBC: Ta, T1, Tis                         MIBC: T2 or greater
        │                                          │
        ▼                                          ▼
Risk stratification                         Staging CT chest,
low / intermediate / high / very high       abdomen and pelvis
        │                                          │
        ├─────────────┬──────────────┬─────────────┘
        │             │              │
        ▼             ▼              ▼
Low risk       Intermediate risk   High-risk / CIS / T1 high grade
        │             │              │
Complete TURBT  TURBT + intravesical Repeat TURBT if indicated
+ immediate     chemotherapy or BCG       │
single-dose                                ▼
intravesical                        Induction + maintenance BCG
chemotherapy                              │
        │                                 ├─────────────┐
        ▼                                 │             │
Cystoscopic follow-up                 Response     BCG-unresponsive /
                                                    very-high-risk disease
                                                      │
                                                      ▼
                                              Early radical cystectomy
The current EAU NMIBC recommendations support risk-adapted intravesical treatment. High-risk disease is treated with BCG for 1-3 years, with discussion of immediate radical cystectomy.

Flowchart 3: When to repeat TURBT

Initial TURBT
    │
    ▼
Is any of the following present?
    │
    ├─ Incomplete initial resection
    ├─ T1 tumor
    ├─ High-grade Ta tumor
    ├─ No detrusor muscle in specimen
    └─ Doubt regarding stage or completeness
    │
    ▼
YES ─────────► Repeat TURBT in 2-6 weeks
                 │
                 ▼
         Restage and decide intravesical therapy
         versus early radical cystectomy
    │
NO ──────────► Risk-adapted adjuvant treatment and surveillance
Exception: Absence of muscle is less concerning in an unequivocal low-grade Ta tumor or primary CIS.

Flowchart 4: Muscle-invasive bladder carcinoma

Treatment pathway for cT2-T4a N0M0 bladder cancer, including diagnosis, neoadjuvant treatment, radical cystectomy, trimodality therapy, and adjuvant treatment
MIBC: cT2-T4a N0 M0
        │
        ▼
Multidisciplinary assessment
Fitness, renal function, performance status,
histology, imaging, patient preference
        │
        ├──────────────────────────────────────┐
        │                                      │
        ▼                                      ▼
Cisplatin-fit                         Cisplatin-unfit
        │                                      │
        ▼                                      ▼
Neoadjuvant cisplatin-based          Radical cystectomy or
systemic therapy                     selected trimodality therapy
        │                                      │
        └───────────────────┬──────────────────┘
                            ▼
       Radical cystectomy + bilateral pelvic lymph-node dissection
                            │
                            ▼
              Appropriate urinary diversion
          ┌─────────────────┼──────────────────┐
          ▼                 ▼                  ▼
     Ileal conduit   Orthotopic neobladder   Continent reservoir
                            │
                            ▼
   Final histopathology → consider adjuvant systemic treatment,
                 surveillance, rehabilitation
For selected patients, trimodality bladder preservation consists of maximal TURBT, concurrent chemoradiation, close cystoscopic follow-up, and salvage cystectomy for invasive recurrence. The 2026 EAU MIBC guideline provides current systemic-treatment recommendations.

Diagram 2: Radical cystectomy and diversion options

                  Radical cystectomy
                         │
        ┌────────────────┴─────────────────┐
        │                                  │
        ▼                                  ▼
 Male patient                         Female patient
 Bladder + prostate +                 Bladder + urethra +
 seminal vesicles +                   distal ureters + anterior
 distal ureters                       vaginal wall ± uterus/adnexa
        │                                  │
        └────────────────┬─────────────────┘
                         ▼
         Bilateral pelvic lymph-node dissection
                         │
                         ▼
                  Urinary diversion
     ┌───────────────────┼────────────────────┐
     │                   │                    │
     ▼                   ▼                    ▼
Ileal conduit      Orthotopic ileal      Continent cutaneous
(incontinent)      neobladder            reservoir
                   (voiding per urethra) (intermittent catheterization)

Diversion selection table

DiversionMain indicationImportant limitation
Ileal conduitMost patients, frail patients, simplest reliable diversionExternal stoma appliance
Orthotopic neobladderMotivated, fit patient with negative urethral marginContinence/retention issues; may require self-catheterization
Continent cutaneous pouchPatient unable to have neobladder but able to catheterizeRequires regular clean intermittent catheterization

Flowchart 5: Selection for bladder-preserving trimodality therapy

MIBC patient requests bladder preservation
                 │
                 ▼
Assess suitability
                 │
                 ├─ Solitary/unifocal tumor?
                 ├─ Complete or maximal TURBT feasible?
                 ├─ No extensive CIS?
                 ├─ No severe hydronephrosis?
                 ├─ Functional bladder with adequate capacity?
                 ├─ Suitable for chemotherapy and radiotherapy?
                 └─ Will comply with close surveillance?
                 │
        ┌────────┴─────────┐
        │                  │
        ▼                  ▼
 Suitable             Unsuitable
        │                  │
        ▼                  ▼
Maximal TURBT +       Radical cystectomy +
concurrent            pelvic lymph-node dissection +
chemoradiation        urinary diversion
        │
        ▼
Cystoscopy, cytology and imaging surveillance
        │
        ├─ Complete response → continue surveillance
        │
        └─ Persistent/recurrent invasive tumor → salvage cystectomy

One-page exam flowchart

HEMATURIA → CYSTOSCOPY → TURBT WITH MUSCLE → HISTOPATHOLOGY
                                      │
                ┌─────────────────────┴──────────────────────┐
                ▼                                            ▼
          NMIBC: Ta/T1/Tis                               MIBC: ≥T2
                │                                            │
     Risk stratify: low/intermediate/high                 Stage with CT
                │                                            │
  ┌─────────────┼──────────────┐                    ┌────────┴─────────┐
  ▼             ▼              ▼                    ▼                  ▼
Low risk   Intermediate      High risk         Fit for cystectomy    Selected candidate
TURBT +    TURBT + chemo     Repeat TURBT +    Neoadjuvant therapy   for trimodality
single     or BCG            BCG or early RC   + radical cystectomy  TURBT + CRT
instillation
                │                                            │
                └──────────────► Lifelong surveillance ◄─────┘
Abbreviations: TURBT, transurethral resection of bladder tumor; CIS, carcinoma in situ; NMIBC, non-muscle-invasive bladder cancer; MIBC, muscle-invasive bladder cancer; BCG, Bacillus Calmette-Guérin; RC, radical cystectomy; CRT, chemoradiotherapy.

Make a presentation on bladder carcinoma

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2026 EAU guidelines bladder cancer non-muscle invasive muscle invasive management TURBT BCG radical cystectomy

Running Command

mkdir -p "/tmp/workspace/bladder-carcinoma-presentation/assets" "/tmp/workspace/bladder-carcinoma-presentation/output" "/tmp/workspace/bladder-carcinoma-presentation/src" && python /tmp/skills/shared/scripts/fetch_images.py "https://cdn.orris.care/cdss_images/BAILY_1760535111430_feadb8b1-7e4e-49a2-a674-f52a30042c0f.png" "https://cdn.orris.care/cdss_images/GLGCA_4543173_1766512484420_69729039-1cef-4d77-bee7-5da78f530dbc_b93d4941-eb72-41b1-b45f-83d6032dbd64.png" > "/tmp/workspace/bladder-carcinoma-presentation/assets/images.json"

Writing File

~/bladder-carcinoma-presentation/src/create_presentation.py

import json, base64, os
from io import BytesIO
from pptx import Presentation
from pptx.util import Inches, Pt
from pptx.dml.color import RGBColor
from pptx.enum.shapes import MSO_SHAPE, MSO_CONNECTOR
from pptx.enum.text import PP_ALIGN, MSO_ANCHOR
from pptx.enum.dml import MSO_THEME_COLOR

OUT='/tmp/workspace/bladder-carcinoma-presentation/output/Bladder_Carcinoma_Surgery_Resident.pptx'
ASSETS='/tmp/workspace/bladder-carcinoma-presentation/assets'
W,H=13.333,7.5
NAVY=RGBColor(16,43,67); TEAL=RGBColor(0,122,130); CYAN=RGBColor(49,181,192); LIGHT=RGBColor(240,247,248)
DARK=RGBColor(28,40,51); GREY=RGBColor(100,116,130); RED=RGBColor(177,55,60); GREEN=RGBColor(52,137,95); GOLD=RGBColor(210,151,42); WHITE=RGBColor(255,255,255)
prs=Presentation(); prs.slide_width=Inches(W); prs.slide_height=Inches(H)
blank=prs.slide_layouts[6]

# image assets
with open(os.path.join(ASSETS,'images.json')) as f: imgdata=json.load(f)
imgs=[]
for i,x in enumerate(imgdata):
    if x.get('base64'):
        mime,b64=x['base64'].split(',',1)
        path=os.path.join(ASSETS,f'img_{i}.png')
        with open(path,'wb') as g:g.write(base64.b64decode(b64))
        imgs.append(path)
staging_img=imgs[0] if imgs else None
mibc_img=imgs[1] if len(imgs)>1 else None

def bg(slide, dark=False):
    fill=slide.background.fill; fill.solid(); fill.fore_color.rgb=NAVY if dark else WHITE
    # top bar
    sh=slide.shapes.add_shape(MSO_SHAPE.RECTANGLE,0,0,Inches(W),Inches(.14)); sh.fill.solid(); sh.fill.fore_color.rgb=CYAN; sh.line.fill.background()

def text(slide,x,y,w,h,s,size=18,color=DARK,bold=False,align=PP_ALIGN.LEFT, font='Aptos', valign=MSO_ANCHOR.TOP):
    tb=slide.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h)); tf=tb.text_frame; tf.clear(); tf.word_wrap=True; tf.margin_left=0; tf.margin_right=0; tf.margin_top=0; tf.margin_bottom=0; tf.vertical_anchor=valign
    for j,line in enumerate(s.split('\n')):
        p=tf.paragraphs[0] if j==0 else tf.add_paragraph(); p.text=line; p.alignment=align; p.space_after=Pt(4)
        for r in p.runs: r.font.name=font; r.font.size=Pt(size); r.font.bold=bold; r.font.color.rgb=color
    return tb

def title(slide,t,sub=None,dark=False):
    text(slide,.55,.35,12.1,.55,t,28,WHITE if dark else NAVY,True)
    if sub:text(slide,.57,.97,12,.3,sub,11,CYAN if dark else TEAL,False)

def footer(slide,n,dark=False):
    text(slide,.55,7.15,7,.18,'Bladder carcinoma | Surgery resident teaching deck',9,RGBColor(182,207,211) if dark else GREY)
    text(slide,12.2,7.15,.55,.18,str(n),9,RGBColor(182,207,211) if dark else GREY,True,PP_ALIGN.RIGHT)

def box(slide,x,y,w,h,label,fill=LIGHT,line=TEAL,fs=16,tc=DARK, radius=True):
    shape=slide.shapes.add_shape(MSO_SHAPE.ROUNDED_RECTANGLE if radius else MSO_SHAPE.RECTANGLE, Inches(x), Inches(y), Inches(w), Inches(h))
    shape.fill.solid(); shape.fill.fore_color.rgb=fill; shape.line.color.rgb=line; shape.line.width=Pt(1.25)
    text(slide,x+.14,y+.08,w-.28,h-.16,label,fs,tc,False,PP_ALIGN.CENTER,valign=MSO_ANCHOR.MIDDLE)
    return shape

def arrow(slide,x1,y1,x2,y2,color=TEAL):
    ln=slide.shapes.add_connector(MSO_CONNECTOR.STRAIGHT,Inches(x1), Inches(y1), Inches(x2), Inches(y2)); ln.line.color.rgb=color; ln.line.width=Pt(2); ln.line.end_arrowhead=True

def bullet_slide(t,sub,bullets,accent=TEAL):
    s=prs.slides.add_slide(blank); bg(s); title(s,t,sub); y=1.45
    for head,body in bullets:
        box(s,.65,y,11.95,.77,'',RGBColor(248,251,252),RGBColor(212,225,228),12)
        text(s,.9,y+.12,2.65,.24,head,16,accent,True)
        text(s,3.45,y+.1,8.8,.44,body,14,DARK)
        y+=.92
    return s

# 1
s=prs.slides.add_slide(blank); bg(s,True)
text(s,.7,1.1,7.8,1.15,'CARCINOMA OF\nTHE URINARY BLADDER',34,WHITE,True)
text(s,.74,2.45,6.9,.55,'Surgery resident teaching presentation',19,RGBColor(194,229,232))
text(s,.75,3.18,5.6,.55,'Diagnosis • TURBT • risk-adapted NMIBC • radical cystectomy • diversion',15,RGBColor(194,229,232))
# visual simplified bladder
shape=s.shapes.add_shape(MSO_SHAPE.OVAL,Inches(9.2),Inches(1.35),Inches(2.7),Inches(3.0));shape.fill.solid();shape.fill.fore_color.rgb=RGBColor(50,139,149);shape.line.color.rgb=CYAN;shape.line.width=Pt(2)
for x in [9.52,10.65]:
    l=s.shapes.add_connector(MSO_CONNECTOR.STRAIGHT,Inches(x),Inches(.72),Inches(x+.25),Inches(1.45));l.line.color.rgb=CYAN;l.line.width=Pt(4)
l=s.shapes.add_connector(MSO_CONNECTOR.STRAIGHT,Inches(10.55),Inches(4.25),Inches(10.55),Inches(5.18));l.line.color.rgb=CYAN;l.line.width=Pt(5)
text(s,.75,6.6,7,.22,'A practical, exam-oriented surgical approach',13,RGBColor(194,229,232))
footer(s,1,True)

# 2
s=bullet_slide('Learning objectives','By the end, the resident should be able to:',[
('Recognize','Identify risk factors, presentation, and red flags for advanced disease.'),
('Stage','Explain TURBT requirements and TNM depth of invasion.'),
('Treat NMIBC','Select repeat TURBT, intravesical chemotherapy/BCG, or early cystectomy.'),
('Treat MIBC','Plan staging, perioperative therapy, radical cystectomy, and urinary diversion.'),
('Follow up','Anticipate surveillance and diversion-specific postoperative issues.')]); footer(s,2)

# 3
s=bullet_slide('Epidemiology and risk factors','Urothelial carcinoma is the dominant histology in most regions.',[
('Most important','Cigarette smoking.'),('Occupational','Aromatic amines: dye, rubber, leather, paint, printing and chemical exposure.'),('Chronic irritation','Long-term catheter, calculi, chronic infection; schistosomiasis favors squamous carcinoma.'),('Iatrogenic','Cyclophosphamide and pelvic radiation.'),('Field change','Urothelial tumors can coexist in renal pelvis, ureters, bladder and urethra.')]); footer(s,3)

# 4
s=prs.slides.add_slide(blank); bg(s); title(s,'Clinical presentation and initial assessment','Painless visible hematuria is bladder carcinoma until proved otherwise.')
box(s,.7,1.55,3.5,1.1,'Painless visible hematuria\n± clots / anemia',RGBColor(253,241,241),RED,18,RED)
box(s,4.92,1.55,3.5,1.1,'Irritative LUTS\nconsider CIS',RGBColor(242,248,252),TEAL,18,TEAL)
box(s,9.13,1.55,3.5,1.1,'Flank pain, edema, bone pain\nthink advanced disease',RGBColor(253,248,239),GOLD,17,GOLD)
text(s,.75,3.15,3.5,.3,'Core assessment',18,NAVY,True)
for i,(h,b) in enumerate([('History','Smoking, exposure, radiation, cyclophosphamide, prior tumors.'),('Examination','Abdominal/pelvic mass, nodes, edema; bimanual exam under anesthesia.'),('Tests','Urinalysis/culture, CBC, renal function, cytology when high-grade/CIS suspected.')]):
    box(s,.75,3.7+i*.78,11.85,.58,h+'  |  '+b,RGBColor(248,251,252),RGBColor(210,226,229),14)
footer(s,4)

#5 staging
s=prs.slides.add_slide(blank); bg(s); title(s,'Pathology and T staging','Depth of invasion determines treatment.')
if staging_img: s.shapes.add_picture(staging_img,Inches(.6),Inches(1.35),width=Inches(6.4),height=Inches(5.35))
text(s,7.35,1.5,5.2,.35,'Key pathological categories',20,NAVY,True)
for i,(h,b,c) in enumerate([('Ta / Tis','Non-muscle-invasive papillary tumor / flat CIS',TEAL),('T1','Lamina propria invasion',GOLD),('T2','Muscularis propria invasion = MIBC',RED),('T3','Perivesical fat invasion',RED),('T4','Adjacent organ or pelvic/abdominal wall invasion',RED)]):
    box(s,7.35,2.0+i*.75,5.1,.57,h+'  |  '+b,RGBColor(249,251,252),c,13)
text(s,7.35,6.08,5.1,.4,'TURBT specimen should contain detrusor muscle whenever staging requires it.',14,RED,True)
footer(s,5)

#6 diagnostic
s=prs.slides.add_slide(blank); bg(s); title(s,'Diagnostic pathway','Cystoscopy and TURBT establish the diagnosis. Cross-sectional imaging stages disease.')
steps=[('Hematuria / symptoms','History, urinalysis, CBC, renal function'),('CT urography','Upper tracts, renal parenchyma, nodes'),('Cystoscopy','Map tumor, assess urethra and bladder'),('TURBT','Complete resection + separate deep specimen'),('Histology + imaging','Grade, stage, CIS, variants, LVI; chest CT for MIBC')]
for i,(a,b) in enumerate(steps):
 x=.7+i*2.5; box(s,x,2.3,2.0,1.35,a+'\n'+b,RGBColor(243,250,251),TEAL,13)
 if i<4: arrow(s,x+2.0,2.97,x+2.45,2.97)
text(s,.78,5.15,11.5,.7,'Bimanual examination under anesthesia before and after TURBT helps assess fixation and local extension. Positive cytology is most useful for high-grade disease and CIS.',17,DARK)
footer(s,6)

#7 turbt
s=bullet_slide('TURBT: the pivotal surgical procedure','Diagnostic, staging and therapeutic for non-muscle-invasive disease.',[
('Objectives','Complete visible resection, obtain detrusor muscle, define grade/stage and control bleeding.'),
('Technique','Inspect systematically; resect exophytic tumor then deep base separately; label specimens.'),
('Lateral wall','Anticipate obturator reflex. Use meticulous technique and consider obturator nerve block.'),
('Complications','Hematuria, clot retention, bladder perforation, ureteric injury and infection.'),
('Repeat TURBT','Incomplete resection, T1, high-grade Ta, absent detrusor muscle, or uncertain staging.')],GOLD); footer(s,7)

#8 NMIBC
s=prs.slides.add_slide(blank); bg(s); title(s,'NMIBC: risk-adapted management','Ta, T1 and CIS require risk stratification after adequate TURBT.')
box(s,.6,1.45,2.35,.85,'TURBT\nwith muscle when indicated',LIGHT,TEAL,15); arrow(s,2.96,1.87,3.45,1.87)
box(s,3.5,1.45,2.35,.85,'Risk group\nlow / intermediate / high',LIGHT,TEAL,15); arrow(s,5.86,1.87,6.35,1.87)
box(s,6.4,1.45,2.35,.85,'Repeat TURBT?\nT1 / incomplete / no muscle',LIGHT,GOLD,14); arrow(s,8.76,1.87,9.25,1.87)
box(s,9.3,1.45,3.3,.85,'Adjuvant intravesical strategy',LIGHT,TEAL,15)
for i,(a,b,c) in enumerate([('LOW RISK','Single immediate intravesical chemotherapy when safe; cystoscopic follow-up.',GREEN),('INTERMEDIATE','Intravesical chemotherapy or 1 year BCG based on recurrence/progression risk.',GOLD),('HIGH / VERY HIGH','BCG maintenance 1-3 years; discuss immediate RC. BCG-unresponsive disease: early RC.',RED)]):
 box(s,.72,3.05+i*1.05,11.85,.78,a+'  |  '+b,RGBColor(250,252,252),c,14)
text(s,.75,6.42,11.5,.3,'Do not give immediate intravesical chemotherapy if perforation, extensive resection, or significant bleeding is suspected.',13,RED,True)
footer(s,8)

#9 MIBC
s=prs.slides.add_slide(blank); bg(s); title(s,'Muscle-invasive disease: cT2-T4a N0M0','Management should be decided in a multidisciplinary team.')
if mibc_img: s.shapes.add_picture(mibc_img,Inches(.62),Inches(1.3),width=Inches(5.65),height=Inches(5.55))
for i,(h,b,c) in enumerate([('1. Stage','CT chest, abdomen and pelvis; assess local extent and renal function.',TEAL),('2. Systemic treatment','Cisplatin-based neoadjuvant therapy when fit; current perioperative regimens evolve.',GOLD),('3. Local control','Radical cystectomy + bilateral pelvic lymph-node dissection is standard.',RED),('Alternative','Trimodality therapy for selected, compliant candidates.',GREEN)]):
 box(s,6.65,1.42+i*1.15,5.9,.88,h+'\n'+b,RGBColor(249,252,252),c,14)
footer(s,9)

#10 RC
s=prs.slides.add_slide(blank); bg(s); title(s,'Radical cystectomy: oncological principles','Complete extirpation, pelvic lymph-node dissection and reconstruction in one planned pathway.')
box(s,.7,1.45,3.45,1.05,'Male extirpation\nBladder + prostate + seminal vesicles + distal ureters',RGBColor(242,249,251),TEAL,15)
box(s,4.95,1.45,3.45,1.05,'Female extirpation\nBladder + urethra + distal ureters ± anterior vaginal wall/gynecologic organs',RGBColor(242,249,251),TEAL,14)
box(s,9.2,1.45,3.45,1.05,'Both\nBilateral pelvic lymph-node dissection',RGBColor(253,247,239),GOLD,15)
text(s,.75,3.1,11.5,.35,'Operative sequence',20,NAVY,True)
for i,t in enumerate(['Exploration and resectability','Ureteric mobilization and division','Lymph-node dissection','Vascular pedicle control','Posterior and anterior dissection','Urethral division, specimen removal','Urinary diversion and drains']):
 x=.7+(i%4)*3.1; y=3.75+(i//4)*1.05; box(s,x,y,2.75,.68,str(i+1)+'. '+t,RGBColor(248,251,252),RGBColor(199,220,224),13)
footer(s,10)

#11 diversion
s=prs.slides.add_slide(blank); bg(s); title(s,'Urinary diversion after cystectomy','Choice is individualized and must be discussed before surgery.')
items=[('Ileal conduit','Reliable, shorter reconstruction; external stoma appliance. Suitable for many patients.',TEAL),('Orthotopic neobladder','Negative urethral margin, fit and motivated patient; may have nocturnal leakage or retention.',GREEN),('Continent cutaneous pouch','Catheterizable reservoir; requires reliable intermittent self-catheterization.',GOLD)]
for i,(h,b,c) in enumerate(items):
 x=.65+i*4.2; box(s,x,1.55,3.85,2.45,h+'\n\n'+b,RGBColor(248,251,252),c,17)
text(s,.75,4.65,11.6,.3,'Selection factors',20,NAVY,True)
for i,t in enumerate(['Renal and hepatic function','Bowel disease / prior irradiation','Urethral involvement and margin','Dexterity, cognition and preference','Performance status and oncological prognosis']):
 box(s,.75+(i%3)*4.0,5.15+(i//3)*.72,3.55,.48,t,RGBColor(243,250,251),TEAL,13)
footer(s,11)

#12 TMT
s=prs.slides.add_slide(blank); bg(s); title(s,'Bladder preservation: trimodality therapy','Not simply radiotherapy instead of surgery: selection and surveillance determine success.')
box(s,.7,1.55,2.5,.9,'Maximal TURBT',LIGHT,TEAL,20); arrow(s,3.2,2.0,3.72,2.0)
box(s,3.78,1.55,2.7,.9,'Concurrent\nchemoradiation',LIGHT,TEAL,19); arrow(s,6.48,2.0,7.0,2.0)
box(s,7.06,1.55,2.6,.9,'Intensive\nsurveillance',LIGHT,TEAL,19); arrow(s,9.67,2.0,10.18,2.0)
box(s,10.23,1.55,2.4,.9,'Salvage RC\nif invasive recurrence',RGBColor(253,242,242),RED,16,RED)
text(s,.75,3.15,5.7,.35,'Favorable candidate',19,NAVY,True)
for i,t in enumerate(['Solitary or unifocal tumor','Complete/near-complete TURBT feasible','No extensive CIS','No severe hydronephrosis','Functional bladder and adherence to follow-up']): box(s,.75,3.65+i*.52,5.65,.4,'• '+t,RGBColor(248,251,252),RGBColor(210,225,228),13)
text(s,7.0,3.15,5,.35,'Not appropriate when',19,NAVY,True)
for i,t in enumerate(['Bulky unresectable disease','Poor bladder function','Extensive CIS or multifocal disease','Unable to tolerate chemoradiation','Cannot comply with surveillance']): box(s,7.0,3.65+i*.52,5.55,.4,'• '+t,RGBColor(253,249,249),RGBColor(237,209,211),13)
footer(s,12)

#13 f/u
s=bullet_slide('Follow-up and postoperative priorities','Recurrence and treatment complications demand long-term surveillance.',[
('NMIBC','Cystoscopy at 3 months; interval thereafter is risk-adapted. Use cytology in high-risk disease.'),
('After cystectomy','Cross-sectional imaging for recurrence, renal function, hydronephrosis and upper tract surveillance.'),
('Diversion issues','Stoma care, ureteroenteric stricture, renal decline, electrolytes/acidosis and vitamin B12 deficiency.'),
('Functional outcomes','Continence, sexual function, body image, self-catheterization and rehabilitation.'),
('Metastatic disease','Systemic therapy is primary; TURBT, radiation, diversion and nephrostomy may palliate symptoms.')]); footer(s,13)

#14 summary
s=prs.slides.add_slide(blank); bg(s,True); title(s,'Take-home messages',None,True)
messages=['Painless visible hematuria needs prompt cystoscopy and upper-tract evaluation.','TURBT must be complete and include detrusor muscle when staging requires it.','NMIBC treatment is risk-adapted: repeat TURBT, intravesical therapy, or early cystectomy.','MIBC standard local therapy is radical cystectomy with bilateral pelvic lymph-node dissection.','Cisplatin-based perioperative therapy and trimodality treatment require multidisciplinary selection.','Diversion and surveillance planning are part of cancer surgery, not an afterthought.']
for i,m in enumerate(messages):
 box(s,.82,1.33+i*.84,11.7,.58,str(i+1)+'.  '+m,RGBColor(28,66,90),CYAN,16,WHITE)
text(s,.82,6.6,11.5,.25,'Teaching sources: Bailey & Love’s Short Practice of Surgery, 28e; Campbell-Walsh-Wein Urology; EAU NMIBC and MIBC Guidelines, 2026.',11,RGBColor(191,218,222))
footer(s,14,True)

prs.save(OUT)
print(OUT)
Running Command

python "/tmp/workspace/bladder-carcinoma-presentation/src/create_presentation.py" && python -c "from pptx import Presentation; p=Presentation('/tmp/workspace/bladder-carcinoma-presentation/output/Bladder_Carcinoma_Surgery_Resident.pptx'); print('slides',len(p.slides)); print([(i+1, sum(1 for sh in s.shapes if getattr(sh,'has_text_frame',False) and sh.text.strip())) for i,s in enumerate(p.slides)])"

Running Command

python - <<'PY' from pptx import Presentation p=Presentation('/tmp/workspace/bladder-carcinoma-presentation/output/Bladder_Carcinoma_Surgery_Resident.pptx') issues=[] for si,s in enumerate(p.slides,1): for sh in s.shapes: if sh.has_text_frame: # basic bounds validation if sh.left+sh.width > p.slide_width or sh.top+sh.height > p.slide_height: issues.append((si,sh.name,'out of bounds')) print('slides=',len(p.slides),'issues=',issues) PY

Created a 14-slide surgery-resident presentation with staging diagrams, diagnostic and management flowcharts, TURBT principles, NMIBC/MIBC treatment, radical cystectomy, urinary diversion, and trimodality therapy.
Download the PowerPoint presentation
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