Bladder Cancer

The 7th most common malignancy; ~90% transitional cell (urothelial) carcinoma.

Smoking is a significant risk factor.

Presentation

Haematuria/microhaematuria, irritative symptoms (frequency, urgency, nocturia), dysuria, smoking history.

Examination

Abdominal examination, urine dipstick.

Investigations

• Urine cytology — three specimens
• Cystoscopy and biopsy
• Gold standard imaging: CT IVU (urography/KUB with contrast)

See haematuria.md for the broader haematuria assessment algorithm and urothelial- malignancy risk stratification tools.

Management

Any patient with unexplained microhaematuria should be referred to a urologist for further investigation including cystoscopy. Encourage smoking cessation.

Treatment depends on stage/grade:

• Carcinoma in situ / non-muscle-invasive disease: intravesical BCG immunotherapy (other intravesical agents include cytotoxics) — remains standard
• Surgery: tumour resection, partial or total cystectomy
• Radio-chemotherapy
• Locally advanced/metastatic disease: enfortumab vedotin + pembrolizumab is now the new first-line standard of care, replacing platinum-based chemotherapy — the EV-302 trial showed nearly double median overall survival (31.5 vs 16.9 months) versus chemotherapy, a substantial practice change

Lifelong surveillance is often required given high recurrence rates.