Bladder Cancer
Most bladder cancers are urothelial carcinomas.
The critical treatment distinction is:
Non muscle invasive bladder cancer
- Ta
- T1
- Carcinoma in situ, Tis
versus
Muscle invasive bladder cancer
- T2 or greater
Ta is confined to urothelium.
T1 invades lamina propria.
T2 invades detrusor muscle.
Carcinoma in situ is a flat high grade intraepithelial malignancy.
Smoking is the dominant preventable risk factor.
The classic presentation is:
Painless visible haematuria.
Other presentations include:
- Microscopic haematuria
- Frequency
- Urgency
- Dysuria
- Pelvic pain in advanced disease
- Hydronephrosis
Carcinoma in situ can cause severe irritative symptoms despite minimal visible tumour.
Visible haematuria in an adult requires appropriate malignancy investigation even when it resolves spontaneously.
Initial assessment includes:
- Cystoscopy
- Upper urinary tract imaging according to risk
- Urine cytology for high grade disease
Cystoscopy cannot be replaced by urine cytology or a noninvasive urinary marker.
TURBT provides diagnosis, staging and initial treatment.
A high quality TURBT should:
- Remove all visible tumour where safe
- Include detrusor muscle in the specimen for most lesions
- Submit tumour and deep components appropriately
Absence of detrusor muscle increases understaging risk.
Repeat TURBT within approximately 2 to 6 weeks when:
- Initial resection is incomplete
- T1 disease exists
- Detrusor muscle is absent from a relevant initial specimen.
Low risk NMIBC
Complete TURBT.
Give a single immediate postoperative intravesical chemotherapy instillation when there is no:
- Suspected perforation
- Significant bleeding requiring continuous irrigation
An example is:
Mitomycin C 40 mg intravesically once
according to local preparation and dwell protocol.
Intermediate risk NMIBC
Options include:
- Intravesical chemotherapy
- One year BCG according to recurrence and progression risk
High risk NMIBC
Use full dose intravesical BCG with induction followed by maintenance.
A typical induction course is:
BCG intravesically once weekly for 6 weeks
followed by maintenance courses.
High risk treatment can continue for 1 to 3 years.
Immediate radical cystectomy should also be discussed in patients with features indicating major progression risk.
Very high risk or BCG unresponsive NMIBC
Radical cystectomy provides the most reliable oncological control.
Further BCG is inappropriate for true BCG unresponsive disease.
Bladder preserving systemic or intravesical approaches can be considered when cystectomy is declined or medically unsuitable. The 2026 landscape now includes additional immunotherapy combinations in selected high risk BCG naïve patients.
Muscle invasive bladder cancer
For resectable T2 to T4a disease, definitive treatment usually includes:
- Perioperative systemic therapy
- Radical cystectomy with pelvic lymph node dissection
Standard male cystectomy removes:
- Bladder
- Prostate
- Seminal vesicles
with urinary diversion.
Current perioperative systemic treatment
For cisplatin eligible muscle invasive disease, a current standard option is:
Gemcitabine plus cisplatin with durvalumab perioperatively, followed by definitive cystectomy and postoperative durvalumab according to the established regimen. This treatment has demonstrated event free and overall survival benefit and is now incorporated into 2026 practice.
Patients who are ineligible for cisplatin can now be offered perioperative:
Enfortumab vedotin plus pembrolizumab
where available and appropriate.
Traditional neoadjuvant cisplatin combination chemotherapy remains appropriate when immunotherapy combinations are unavailable or unsuitable.
Do not substitute carboplatin for cisplatin as routine neoadjuvant curative therapy.
Bladder preserving trimodality therapy
Selected patients can undergo:
- Maximal TURBT
- Concurrent radiosensitising chemotherapy
- Definitive radiotherapy
Best candidates generally have:
- Solitary tumour
- Good bladder function
- Limited or no hydronephrosis
- Ability to achieve substantial TURBT
- No extensive CIS
Close lifelong cystoscopic surveillance is required.
Muscle invasive recurrence requires salvage cystectomy when feasible.
