PassFinals
Renal & Urology

Bladder Cancer

Bladder cancer most often presents with painless haematuria; cystoscopy and TURBT establish the diagnosis and depth of invasion, separating non-muscle-invasive disease from muscle-invasive disease that needs specialist radical-treatment planning.

In a nutshell

Think bladder cancer when an older adult has painless visible haematuria. Refer on the NICE suspected-cancer pathway, then use cystoscopy and TURBT to confirm histology and whether detrusor muscle is invaded. Non-muscle-invasive disease is risk-stratified for repeat TURBT, intravesical therapy and cystoscopic surveillance; muscle-invasive disease needs specialist MDT discussion of neoadjuvant therapy plus radical cystectomy or radiosensitised radiotherapy.

Classic presentation

Painless visible haematuria, often without dysuria or systemic symptoms, in an older person with smoking or occupational-exposure risk.

Key points

  • NICE suspected-cancer referral: visible haematuria aged 45 or over if unexplained or persistent/recurring after successful UTI treatment.
  • Cystoscopy is central; urinary biomarkers must not replace it outside research.
  • TURBT must obtain detrusor muscle and report stage, grade, size, number and carcinoma in situ.
  • Intermediate-risk non-muscle-invasive disease: at least 6 doses of intravesical mitomycin C.
  • High-risk non-muscle-invasive disease: repeat TURBT within 6 weeks, then discuss BCG or radical cystectomy with the specialist MDT.
  • Muscle-invasive disease: specialist MDT, cisplatin-based neoadjuvant therapy if suitable, then radical cystectomy or radiosensitised radiotherapy.
  • Surveillance is risk-adapted; do not assume a single negative cystoscopy ends follow-up.

First-line investigation

Urgent specialist assessment with flexible cystoscopy; TURBT provides histology and detrusor-muscle staging, with CT or MRI according to suspected or confirmed muscle invasion.

Management

Recognise and refer

  • Refer on the suspected cancer pathway for unexplained visible haematuria in adults aged 45 and over, or for qualifying non-visible haematuria in adults aged 60 and over.3

Cystoscopy and TURBT

  • Cystoscopy is central; TURBT confirms histology and should include detrusor muscle, tumour size/number, grade, stage and carcinoma in situ status.1,6

Risk-stratify non-muscle-invasive disease

  • Use recurrence history, tumour features, grade, stage, carcinoma in situ and validated risk prediction to choose surveillance, mitomycin C, repeat TURBT, BCG or radical cystectomy.1,5

Treat muscle-invasive disease radically

  • Refer every muscle-invasive case to the specialist urology MDT for cisplatin-based neoadjuvant treatment when suitable and a choice of radical cystectomy or radiosensitised radiotherapy.1,5

Surveil and manage progression

  • Follow NICE risk-adapted cystoscopy schedules, investigate new haematuria urgently, and use current NICE systemic-therapy and palliative recommendations for advanced disease or obstruction.1,2

Exam traps

  • Painless haematuria is not reassuring; it is the classic early clue.
  • A positive urine culture does not end the cancer pathway if visible haematuria persists or recurs after successful treatment.
  • Urinary biomarkers do not replace cystoscopy for diagnosis or follow-up outside research.
  • The presence of detrusor muscle in the TURBT specimen matters: absence may require repeat TURBT.
  • High-risk non-muscle-invasive disease is not managed with indefinite intravesical treatment without specialist review; radical cystectomy is part of the treatment choice.
  • Do not treat muscle-invasive disease as if it were simply recurrent superficial disease.

Illustrations

Depth of invasion and the muscularis propria thresholdCross-sectional diagram of the bladder wall showing non-muscle-invasive versus muscle-invasive tumour depth and its prognostic significance.PassFinals · original
Blue-light (photodynamic) cystoscopy: bladder carcinoma in situ fluoresces bright red under blue light (lower panel) yet is inconspicuous under white light (upper panel).Cystoscopy image showing a papillary urothelial tumour on the bladder mucosa.B Geavlete, R MulÅ£escu, D Georgescu, M Jecu, and P Geavlete, Wikimedia Commons · CC-BY-4.0

Key sources

  1. NICE NG2: Bladder cancer: diagnosis and management (Current NICE recommendations on diagnosis, TURBT, risk classification, non-muscle-invasive and muscle-invasive treatment, surveillance, advanced disease and palliation; last reviewed 6 May 2026.)Updated 6 May 2026
  2. NHS: Treatment for bladder cancer (NHS information on surgery, intravesical and systemic chemotherapy, immunotherapy, radiotherapy and palliative support; page last reviewed 15 April 2025.)Updated 15 Apr 2025
  3. NICE NG12: Suspected cancer: recognition and referral (Current NICE suspected-cancer referral criteria for visible and non-visible haematuria and recurrent unexplained UTI.)Updated 1 Jul 2026
  4. NHS: Symptoms of bladder cancer (NHS information on haematuria, urinary symptoms and when to seek assessment; page last reviewed 15 April 2025.)Updated 15 Apr 2025
  5. BNF online (Current UK prescribing information for intravesical mitomycin, BCG, systemic anticancer therapy and radiosensitiser safety checks.)
  6. NHS: Tests and next steps for bladder cancer (NHS information on cystoscopy, biopsy and staging tests; page last reviewed 15 April 2025.)Updated 15 Apr 2025

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.