Bladder Cancer
NICE guideline [NG2] Bladder cancer: diagnosis and management. Published: Feb 2015.
NICE guideline [NG12] Suspected cancer: recognition and referral 1.6 Urological cancers. Last updated: May 2025.
Background information added accordingly.
Date: 06/12/25
Background Information
Histology
There are 2 main types of bladder cancers: [Ref]
- Transitional cell carcinoma (urothelial carcinoma) – 95% cases
- Squamous cell carcinoma
Risk Factors
Risk factors for bladder cancer: [Ref]
- Advanced age (esp. >55 y/o)
- Tobacco smoking – most important risk factor
- Occupational exposure to aromatic amines (primarily seen in industrial areas processing dye, paint, metal and petroleum products)
- Water pollution (exposure to arsenic in drinking water)
- Family history
- Pelvic radiation (e.g. external-beam radiotherapy for prostate cancer)
- Drugs
- Cyclophosphamide
- Pioglitazone
Notably, the following risk factors predispose patients to squamous cell carcinoma rather than transitional cell carcinoma: [Ref]
- Chronic mechanical irritation of the bladder
- Long-term indwelling catheters and intermittent self-catheterisation
- Bladder stones
- Chronic cystitis
- Schistosomiasis (seen in the Middle East, Southeast Asia, and South America)
- Recurrent UTIs
Clinical Features
Hallmark clinical feature: painless visible haematuria
Other features:
- Recurrent UTIs
- Abdominal / pelvic pain
- Urinary obstruction in advanced cases
Diagnosis
Bladder Cancer Red Flags and Referral
Refer with suspected bladder cancer pathway if:
- ≥45 y/o with unexplained visible haematuria in the absence of UTI / persisting or recurring after UTI treatment, OR
- ≥60 y/o with unexplained non-visible haematuria + dysuria / ↑ WCC
Consider non-urgent referral if: ≥60 y/o + recurrent / persistent unexplained UTI
Investigation and Diagnosis
Diagnostic
1st line and gold standard: cystoscopy
- Direct visualisation, then TURBT for histology (ensure to obtain detrusor muscle)
- If muscle-invasive bladder cancer is suspected at cystoscopy → consider delaying TURBT after CT / MRI staging
TURBT can, and is often performed at the initial diagnostic cystoscopy. TURBT is both diagnostic (biopsy for histology) and therapeutic (removal).
Staging
Staging is indicated in muscle-invasive bladder cancer and high-risk non-muscle invasive bladder cancer:
- 1st line: CT / MRI
- 2nd line: PET CT
Management
Classification of bladder cancer that is used to guide management (simplified from NICE):
- Non-muscle invasive bladder cancer, further categorised into:
- High risk – carcinoma in situ / lamina propria invasion / high grade (3)
- Non-high risk
- Muscle-invasive bladder cancer
- Metastatic disease
Exam-yield management of bladder cancer:
- Non-muscle-invasive bladder cancer → TURBT
- Muscle-invasive bladder cancer → neoadjuvant chemotherapy + radical cystectomy (or radiotherapy)
- Metastatic disease → chemotherapy (cisplatin-based combination)
Non-Muscle Invasive Disease
The key takeaway is that TURBT is the mainstay of management of non-muscle invasive bladder cancer. Further management typically involves intravesical therapy (e.g. BCG or mitomycin C), with the choice guided by the patient’s risk stratification (see below).
High-Risk
Offer:
- Initial: TURBT (can be done at initial diagnostic cystoscopy)
- Followed by: Repeat TURBT <6 weeks after 1st resection, and a choice of:
- Radial cystectomy (with urinary stoma / continent urinary diversion), or
- Intravesical BCG
Non-High Risk (Low / Intermediate)
Offer:
- TURBT, and
- Intravesical mitomycin C
Muscle-Invasive Disease
Offer:
- Neoadjuvant chemotherapy (cisplatin-based combination), and
- Radical cystectomy / radiotherapy
Metastatic Disease
Offer cisplatin-based chemotherapy
Other management:
- Palliative radiotherapy for bladder symptoms
- Percutaneous nephrostomy / retrograde stenting for ureteric obstruction
References