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For further information, see CMDT Part 39-18: Bladder Cancer

Key Features

Essentials of Diagnosis

  • Gross or microscopic hematuria

  • Irritative voiding symptoms

  • Positive urinary cytology in most patients

  • Filling defect noted within bladder on imaging

General Considerations

  • Second most common urologic cancer

  • More common in men than women (3.1:1)

  • Mean age at diagnosis is 73 years

  • Risk factors: cigarette smoking, exposure to industrial dyes and solvents


  • Urothelial cell carcinomas: ~90%

  • Squamous cell cancers: ~7%

  • Adenocarcinomas: ~2%

  • Bladder cancer staging is based on the extent (depth) of bladder wall penetration and the presence of either regional or distant metastases

  • Both cancer grade and stage influence the natural history of bladder cancer including local recurrence within the bladder and progression to higher-stage disease

Clinical Findings

Symptoms and Signs

  • Hematuria is the presenting symptom in 85–90%

  • Irritative voiding symptoms in a small percent

  • Masses detected on bimanual examination with large-volume or deeply infiltrating cancers

  • Lymphedema of the lower extremities with locally advanced cancers or metastases to pelvic lymph nodes

  • Hepatomegaly or palpable lymphadenopathy with metastatic disease


Laboratory Tests

  • Urinalysis—hematuria; on occasion, pyuria

  • Azotemia

  • Anemia

Imaging Studies

  • Ultrasound, CT, MRI show masses within the bladder

Diagnostic Procedures

  • Urine cytology useful in detecting disease at initial presentation or recurrence

  • Cytology very sensitive (80–90%) in detecting cancers of higher grade and stage

  • Imaging is done primarily for evaluating the upper urinary tract and for staging

  • Diagnosis and staging are by cystourethroscopy and tumor biopsy, as well as random bladder and, on occasion, transurethral prostate biopsies

  • Transurethral resection of bladder tumor (TURBT)

  • TURBT can be done under general or regional anesthesia

  • Resection is done down to muscular elements of the bladder



  • Patients with superficial non–muscle invasive cancers (Tis, Ta, T1) are treated with complete transurethral resection with selective use of a single dose intravesical chemotherapy immediately following resection

  • The subset of patients with carcinoma in situ (Tis) and those undergoing resection of large, high-grade, recurrent Ta lesions and/or T1 cancers are good candidates for additional intravesical therapy

  • Patients with muscle invasive (T2+) but still localized cancers

    • Are at risk for both nodal metastases and progression

    • Require more aggressive treatment

    • Gold standard treatment is neoadjuvant chemotherapy followed by radical cystectomy, which confers a survival advantage versus cystectomy alone

    • This is particularly important for higher-stage or bulky tumors to improve their surgical resectability

    • Trimodal bladder preservation therapy can offer similar outcomes in optimally selected patients and consists of

      • Complete TURBT

      • Sensitizing systemic chemotherapy

      • External beam radiotherapy

      • Intravesical chemotherapy

    • Immunotherapeutic ...

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