Bladder cancer is among the 10 most common cancer types in the world and around three-quarters of new cases occur in men. Smoking is the most important causative factor.
Gross or microscopic hematuria is the primary symptom of bladder cancer. Cystoscopy and urinary cytology are key to making the diagnosis.
Complete transurethral resection is the treatment of choice for tumors that have not invaded the detrusor muscle, but recurrence is high. Seeding after surgery is reduced by intravesical instillation of chemotherapy.
High-grade disease requires aggressive treatment and close follow-up. Treatment of choice for carcinoma in situ and high-grade tumors not invading muscle is immunotherapy using tuberculosis vaccine bacille Calmette-Guérin.
Muscle-invasive tumors 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. New immunotherapies 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). Nonmuscle-invasive tumors are most common. Low-grade tumors are papillary and generally easy to visualize, but often have negative cytology. High-grade tumors are often flat or in situ and difficult to visualize, but typically have a positive cytology. If muscle invasion occurs, transurethral resection is insufficient and radical cystoprostatectomy is usually advised.
History and exam
Key diagnostic factors
- hematuria (gross or microscopic)
Other diagnostic factors
- urinary frequency
- tobacco exposure
- exposure to chemical carcinogens
- age >65 years
- pelvic radiation
- systemic chemotherapy
- diabetes mellitus
- Schistosoma infection
- male sex
- chronic bladder inflammation
- genetic predisposition
1st investigations to order
Investigations to consider
- urine cytology
- renal and bladder ultrasound
- CT urogram
- MR urogram
- intravenous urogram
- chemistry profile (including alkaline phosphatase)
- CT abdomen and pelvis
- MRI abdomen and pelvis
- bone scan
- urinary biomarkers
locally invasive tumors
- Benign prostatic hyperplasia (BPH)
- Hemorrhagic cystitis
- NCCN clinical practice guidelines in oncology: bladder cancer
- Guidelines on muscle-invasive and metastatic bladder cancer
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