Bladder Cancer

Bladder cancer is a malignant tumour that develops in the cells lining the bladder. The most common type in the UK is urothelial carcinoma (also known as transitional cell carcinoma). Bladder cancer is broadly divided into two groups: non-muscle-invasive bladder cancer (NMIBC) — stages Ta, T1 and carcinoma in situ — which is contained within the inner layers of the bladder wall, and muscle-invasive bladder cancer (MIBC) — T2 and beyond — which has grown into the deeper muscle layer.

The classic warning sign is painless blood in the urine (haematuria), which occurs in around 80% of cases. Blood may be visible or detected only on a urine dipstick. Other symptoms include increased urinary frequency, urgency, burning when passing urine, and — less commonly — pelvic or lower back pain. Any episode of blood in the urine, even if it only happens once and goes away on its own, warrants specialist assessment.

The most important risk factor is smoking, which is responsible for around half of all bladder cancers. Other risk factors include occupational exposure to aromatic amines and industrial chemicals (historically in the rubber, dye, textile and leather industries), increasing age, male sex, chronic bladder inflammation, previous pelvic radiotherapy, and a family history of bladder cancer.

Assessment typically starts with a urine test (dipstick and cytology), a bladder ultrasound or CT urogram to image the whole urinary tract. Flexible cystoscopy — a quick, thin-camera examination of the bladder lining under local anaesthetic — is the key test to confirm or exclude bladder cancer. If a suspicious area is seen, a formal transurethral resection of bladder tumour (TURBT) is arranged under general anaesthetic to remove the tumour and provide tissue for staging and grading.

Non-muscle-invasive bladder cancer (NMIBC) — stages Ta, T1 and carcinoma in situ (CIS) — is confined to the inner layers of the bladder and can usually be treated by TURBT ± intravesical (into-the-bladder) therapy, with lifelong surveillance. Muscle-invasive bladder cancer (MIBC) — T2 and beyond — has grown into the deeper muscle wall and generally requires more radical treatment, most often radical cystectomy (bladder removal) with urinary diversion, sometimes preceded by neoadjuvant chemotherapy. Distinguishing between the two — through TURBT and staging imaging — is critical because the treatment differs fundamentally.

BCG (Bacillus Calmette-Guérin) is an intravesical immunotherapy used for higher-risk non-muscle-invasive bladder cancer. A live attenuated form of the tuberculosis vaccine is instilled into the bladder through a catheter, where it triggers a local immune response that helps eradicate residual cancer cells and reduce the risk of recurrence. A typical course involves weekly instillations for six weeks followed by maintenance treatment over one to three years. Common side effects include urinary frequency, mild bladder irritation and flu-like symptoms.

No. The majority of bladder cancers are non-muscle-invasive and can be effectively managed by TURBT plus intravesical therapy (Mitomycin or BCG) with regular cystoscopy surveillance, preserving the bladder. Radical cystectomy (bladder removal) is generally reserved for muscle-invasive disease, very high-risk non-muscle-invasive disease that has not responded to intravesical treatment, or recurrent high-grade disease. Where cystectomy is needed, it is typically performed robotically and combined with a urinary diversion (ileal conduit, neobladder or continent diversion).

Long-term surveillance is essential because bladder cancer has a high rate of recurrence, particularly for NMIBC. Follow-up typically includes regular flexible cystoscopy (every 3–6 months initially, extending as time passes) and periodic imaging of the upper tracts (CT urogram or ultrasound) to check the kidneys and ureters. After radical cystectomy, follow-up focuses on cross-sectional imaging (CT), blood tests including renal function, and monitoring for vitamin B12 and folate deficiency (as a segment of bowel is used for the urinary diversion).