Bladder Cancer

Overview

Bladder cancer is the fifth most common cancer in the United Kingdom and one of the most frequently encountered urological malignancies worldwide. The most common type, accounting for more than 90% of cases, is urothelial carcinoma (previously called transitional cell carcinoma), which arises from the cells lining the bladder.

The single most important risk factor is cigarette smoking, which is responsible for approximately half of all cases. Other risk factors include occupational exposure to certain chemicals (aromatic amines in the dye and rubber industries), prior pelvic radiotherapy, and chronic bladder irritation.

Bladder cancer is broadly divided into:

• Non-muscle-invasive bladder cancer (NMIBC) — confined to the inner lining of the bladder; can often be managed endoscopically with regular surveillance
• Muscle-invasive bladder cancer (MIBC) — has grown into the muscular wall of the bladder; requires more radical treatment involving other specialists

Symptoms

The most common and important presenting symptom is painless visible haematuria — blood in the urine without pain. This should always be investigated promptly, even if it occurs only once and resolves spontaneously.

Other symptoms may include:

• Non-visible (microscopic) haematuria, detected on a dipstick or urine test
• Urinary frequency and urgency, particularly if the tumour is near the bladder outlet or if there is carcinoma in situ (CIS) — a flat, high-grade tumour
• Dysuria (discomfort on urinating)
• Recurrent urinary tract infections

Advanced disease may cause pelvic or bone pain, and lower limb swelling from lymph node involvement.

Diagnosis

When bladder cancer is suspected, investigations typically include:

• Flexible cystoscopy — a thin, flexible telescope is passed through the urethra under local anaesthetic to directly visualise the bladder lining; this is the key investigation for haematuria
• CT urogram (CTU) — a CT scan with contrast that images the kidneys, ureters, and bladder to identify upper urinary tract tumours, stones, or other causes of haematuria
• Urine cytology — examination of cells shed in the urine; most useful for detecting high-grade tumours
• Urine dipstick and culture — to exclude infection as a cause of symptoms

If a tumour is identified at cystoscopy, the patient is listed for TURBT (transurethral resection of bladder tumour) under anaesthesia. The resected tissue is sent for histopathological examination to determine tumour grade and depth of invasion.

Treatment

Non-muscle-invasive bladder cancer (NMIBC)

TURBT is the primary treatment — it removes the visible tumour and provides tissue for staging. Following TURBT:

• Low-risk tumours: a single instillation of chemotherapy (mitomycin C) into the bladder at the time of TURBT, followed by surveillance cystoscopy
• Intermediate-risk tumours: a course of intravesical chemotherapy (mitomycin C)
• High-risk tumours (including CIS): a course of intravesical BCG (Bacillus Calmette-Guérin) immunotherapy, followed by maintenance instillations

Regular cystoscopy surveillance is essential after treatment of NMIBC because recurrence is common.

Muscle-invasive bladder cancer (MIBC)

Muscle-invasive disease requires radical treatment, which is managed in conjunction with other specialists:

• Radical cystectomy — surgical removal of the bladder, with urinary diversion (ileal conduit or neobladder)
• Radical radiotherapy with concurrent chemotherapy — bladder-preserving approach for selected patients

Dr Hadjipavlou performs TURBT and administers intravesical therapies (BCG and mitomycin C) for bladder cancer management. Muscle-invasive disease is managed through a multidisciplinary oncology team.