The hemostatic system as a therapeutic target in urothelial carcinoma.

Bladder neoplasms are associated with a high frequency of painless hematuria; however, when compared with the bleeding tendencies of other solid tumors, it is arguable that this comparatively high bleeding frequency is in part the result of an ascertainment bias, given that bladder neoplasms occupy the interior of a contractile organ that is bathed with urine and whose voided contents are amenable to daily inspection and microscopic examination. The pathophysiology of hematuria in this setting likely includes organand tumor-specific factors, ranging from the more prosaic (eg, the vulnerability of exophytic and invasive tumors with delicate associated neoplastic vasculature to repetitive trauma from physiologic detrusor contraction during bladder emptying), to localized impairment of hemostasis, such as that caused by tumor-related fibrinolytic activity. The risk of perioperative thromboembolism associated with urothelial cancer is also probably multifactorial, with causative factors including older age, extended surgical times, venous microtrauma, and cancer-related hypercoagulability; however, the perioperative thromboembolism seen in patients with bladder cancer is not readily distinguishable from that associated with other abdominopelvic and gynecologic surgeries, including those performed for nonmalignant indications.