AKT · Renal & urology/Urological cancer & LUTS

Bladder cancer

Transitional cell (urothelial) carcinoma usually — smoking & occupational amines the key risks

Overview

Malignancy of the bladder, in the UK usually transitional cell (urothelial) carcinoma. The cardinal presentation is PAINLESS VISIBLE HAEMATURIA, which mandates urgent (2-week-wait) referral for cystoscopy. Smoking and occupational aromatic-amine exposure (dye/rubber industry) are major risks; schistosomiasis causes squamous-cell bladder cancer in endemic areas.

Recognise

PAINLESS visible (macroscopic) haematuria — the classic presentation; also recurrent UTIs, storage LUTS, non-visible haematuria
Risk factors: SMOKING (the big one), occupational aromatic amines (dye, rubber, leather), chronic inflammation/catheters; schistosomiasis → squamous-cell carcinoma
Most are non-muscle-invasive at presentation; muscle-invasive disease is more aggressive

Red flags

Visible haematuria (any age) → urgent 2-week-wait referral; non-visible haematuria with risk factors/age → refer per NICE NG12
Muscle-invasive or metastatic disease → radical treatment

Differentials & how to tell them apart

UTI / stonesinfection (nitrites/dysuria) or colic — but always exclude cancer in unexplained haematuria

Renal cancerhaematuria + flank mass/pain ± paraneoplastic features — upper-tract

BPH / prostate cancerhaematuria with prostatic LUTS/nodule

Bladder tumour seen at cystoscopy (white-light and blue-light)
Jecontributes / CC BY-SA 4.0 — Wikimedia Commons

Investigations

Flexible CYSTOSCOPY (the key diagnostic test) + urine cytology; CT urogram for upper-tract assessment/staging; TURBT for histology and depth (muscle-invasive vs not); bloods/renal function. Urgent referral per NICE NG12 for haematuria.

Management

Cystoscopy + TURBT; non-muscle-invasive → intravesical BCG/mitomycin; muscle-invasive → cystectomy/radiotherapy

1Painless visible haematuria → urgent 2-week-wait referral for flexible cystoscopy (+ urine cytology, CT urogram). TURBT gives histology and depth.Gate: The depth at TURBT splits management: non-muscle-invasive → intravesical therapy + surveillance; muscle-invasive → radical cystectomy/radiotherapy.
2Non-muscle-invasive → TURBT + intravesical BCG/mitomycin and surveillance cystoscopy; muscle-invasive → radical treatment ± neoadjuvant chemo; metastatic → systemic therapy. Stop smoking.

Non-muscle-invasive: TURBT ± intravesical therapy (BCG or mitomycin) — transurethral resection then intravesical chemo/immunotherapy to reduce recurrence; surveillance cystoscopy

Muscle-invasive: radical cystectomy or radical radiotherapy ± neoadjuvant chemotherapy — for organ-confined invasive disease

Metastatic: systemic chemotherapy/immunotherapy — platinum-based; palliative care as needed

Smoking cessation + occupational review — risk-factor modification

Key points

PAINLESS visible haematuria = bladder cancer until proven otherwise → urgent 2-week-wait cystoscopy. Smoking + aromatic amines (dye/rubber) are the risks; schistosomiasis → squamous-cell. Depth at TURBT decides treatment: non-muscle-invasive (intravesical BCG/mitomycin) vs muscle-invasive (cystectomy/radiotherapy).

Monitor & prognosis

Surveillance cystoscopy (recurrence), treatment response, renal function.

Non-muscle-invasive: good but recurs (lifelong surveillance); muscle-invasive/metastatic: worse.

Source: NICE NG2 (bladder cancer); NG12 (haematuria referral)