Bladder cancer

Last reviewed: June 2019

Last updated: June 2018

Summary

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.

Definition

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.

History and exam

Key diagnostic factors

presence of risk factors
haematuria (gross or microscopic)
dysuria

Full details

Other diagnostic factors

urinary frequency

Full details

Risk factors

tobacco exposure
exposure to chemical carcinogens
age >55 years
pelvic radiation
systemic chemotherapy
diabetes mellitus, type 2
Schistosoma infection
male sex
chronic bladder inflammation
positive FHx

Full details

Diagnostic investigations

1st investigations to order

urinalysis

Full details

Investigations to consider

urine cytology
renal and bladder ultrasound
CT urogram
cystoscopy
intravenous urogram
FBC
chemistry profile (including alkaline phosphatase)
CXR
CT abdomen and pelvis
MRI abdomen and pelvis
MR urogram
bone scan
urinary markers

Full details

Treatment algorithm

ACUTE

Contributors

Authors VIEW ALL 

Donald Lamm, MD, FACS

Director

BCG Oncology

Clinical Professor

University of Arizona

Phoenix

Disclosures

DL is an author of a number of references cited in this monograph.

Acknowledgements

Dr Donald Lamm would like to gratefully acknowledge Dr Mary Heeley, the previous contributor to this monograph. MH declares that she has no competing interests.

Peer reviewers VIEW ALL 

Junaid Masood, MBBS, FRCS (Eng), MSc (Urol), FRCS (Urol)

Consultant Urological Surgeon

Homerton University Hospital NHS Foundation Trust

London

Disclosures

JM declares that he has no competing interests.

Hugh Mostafid, MD

Consultant Urologist

North Hampshire Hospital

Basingstoke

Disclosures

HM has received honoraria from GE Healthcare and Kyowa Kirin UK.

Thomas Guzzo, MD

Clinical Instructor of Urology

The James Buchanan Brady Urologic Institute

The Johns Hopkins Medical Institutions

Baltimore

Disclosures

TG declares that he has no competing interests.

Amir Kaisary, MD, MA, ChM, FRCS

Consultant Urological Surgeon

Honorary Senior Lecturer

Department of Urology

The Royal Free & University College Medical School

London

Disclosures

AK declares that he has no competing interests.

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Bladder cancer

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

non-muscle-invasive tumours

locally invasive tumours

metastatic disease

Contributors

Authors VIEW ALL 

Donald Lamm, MD, FACS

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Junaid Masood, MBBS, FRCS (Eng), MSc (Urol), FRCS (Urol)

Disclosures

Hugh Mostafid, MD

Disclosures

Thomas Guzzo, MD

Disclosures

Amir Kaisary, MD, MA, ChM, FRCS

Disclosures

Differentials

Guidelines

Patient leaflets

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