Bladder cancer

Ranks ninth in worldwide cancer incidence. Egypt, Western Europe, and North America have the highest incidence rates and Asian countries the lowest rates. More than 90% of new cases occur in people ≥55 years of age.

Gross or microscopic haematuria is the primary symptom of bladder cancer. Screening for haematuria appears to markedly improve the prognosis of bladder cancer.

Cystoscopy and urinary cytology are key to making the diagnosis. Low-grade tumours are papillary and easy to visualise, but often have negative cytology. High-grade tumours are often flat or in situ and difficult to visualise, but typically have a positive cytology.

Complete transurethral resection is the treatment of choice for tumours that have not invaded the detrusor muscle, but recurrence is high. Seeding after surgery is reduced by intravesical instillation of chemotherapy.

High-grade disease is potentially lethal and requires aggressive treatment and close follow-up. Treatment of choice for carcinoma in situ and high-grade tumours not invading muscle is immunotherapy using tuberculosis vaccine bacille Calmette-Guérin.

Muscle-invasive tumours are treated with neoadjuvant chemotherapy, cystoprostatectomy, and extended pelvic lymphadenectomy. Neoadjuvant chemotherapy and thorough pelvic node dissection both significantly increase 5-year survival. Precautions should be taken to prevent wound seeding during cystoprostatectomy.

Combination cisplatinum-based chemotherapy such as methotrexate, vinblastine, doxorubicin, and cisplatin produces response in ≥50% of cases. Less toxic combinations, such as cisplatin with either gemcitabine or taxol, have similar efficacy and less toxicity, and all 3 together appear to have better efficacy than cisplatin and gemcitabine. New immunotherapies have created great excitement with the promise to bring the benefit of immunotherapy to patients with advanced disease.

Over 90% of cancers of the urinary bladder are urothelial carcinoma (previously termed transitional cell carcinoma; UC). Non-muscle-invasive tumours are most common. Low-grade tumours are papillary and generally easy to visualise. High-grade tumours are often flat or in situ, and can be difficult to visualise. If muscle invasion occurs, transurethral resection is insufficient and radical cystoprostatectomy is usually advised.