Bladder cancer

Presentation

• Painless visible haematuria is the classic symptom and should prompt urgent urological assessment.
• Microscopic haematuria on urinalysis in an adult over 40 - investigated similarly.
• Irritative bladder symptoms (frequency, urgency, pelvic discomfort) in a smoker or someone with other risk factors.

Diagnosis and initial management

• Cystoscopy - direct visual examination of the bladder. The main diagnostic step.
• CT urogram - to examine the upper urinary tract, which can occasionally harbour synchronous disease.
• Urine cytology - an adjunct, particularly for high-grade or carcinoma in situ.
• Transurethral resection of bladder tumour (TURBT) - both diagnostic (obtains tissue and defines depth) and therapeutic for non-muscle-invasive disease. Detrusor muscle must be included in the specimen to accurately stage.

Non-muscle-invasive disease (Ta, T1, CIS)

Treated by repeated TURBT, typically with single-shot intravesical chemotherapy at resection, and with intravesical BCG or mitomycin for higher-risk disease. Close cystoscopic surveillance is required lifelong.

Muscle-invasive disease (T2 or higher)

Standard treatment is radical cystectomy with urinary diversion, often preceded by cisplatin-based neoadjuvant chemotherapy in fit patients. The operation is increasingly performed with robotic access - see robotic cystectomy. A bladder-sparing trimodal therapy pathway (maximal TURBT + concurrent chemo-radiotherapy) is an alternative in carefully selected patients.

Advanced disease

Metastatic bladder cancer is treated with systemic therapy, often starting with platinum-based chemotherapy, increasingly with immune checkpoint inhibitors and targeted agents as second-line or subsequent therapy.