Bladder Cancer

Who May Benefit

A consultation may be appropriate if you:

• Have visible or microscopic blood in the urine that has not been fully investigated
• Have been diagnosed with a bladder tumour and want to understand the stage and what it means
• Have recurrent non-muscle-invasive bladder cancer despite BCG or chemotherapy instillations
• Have muscle-invasive bladder cancer and are weighing radical cystectomy against bladder preservation
• Are considering urinary diversion and want to understand neobladder versus ileal conduit
• Have an upper tract urothelial cancer of the ureter or renal pelvis
• Have persistent irritative urinary symptoms with no infection found

When This Page May Not Apply

• Metastatic bladder cancer where systemic chemotherapy or immunotherapy is the primary treatment — led by a medical oncologist
• Blood in the urine clearly due to stones or proven infection, though investigation is still usually warranted

Available Treatment Alternatives

Non-Muscle-Invasive Disease

Managed by transurethral resection followed by intravesical therapy — BCG immunotherapy or chemotherapy instilled into the bladder — and a structured cystoscopic surveillance programme. The intensity of treatment and surveillance is matched to the recurrence and progression risk.

Radical Cystectomy with Urinary Diversion

Removal of the bladder with pelvic lymph node dissection, performed robotically or open. Reconstruction options include an ileal conduit with a stoma, or an orthotopic neobladder constructed from bowel that allows voiding through the urethra. The choice depends on tumour location, kidney function, and your own priorities.

Bladder-Preserving Trimodal Therapy

Maximal transurethral resection combined with chemotherapy and radiotherapy, for selected patients with favourable muscle-invasive tumours or those unfit for major surgery. Requires close surveillance and a willingness to proceed to cystectomy if the cancer returns.

Neoadjuvant Chemotherapy

Chemotherapy before radical surgery for muscle-invasive disease, which improves survival in appropriately selected patients.

Nephroureterectomy

For upper tract urothelial cancers, removal of the kidney, ureter and bladder cuff, performed laparoscopically or robotically.

Investigations Usually Required

• Urine analysis and culture — to exclude infection as a cause of bleeding
• Urine cytology — examination of urine for cancer cells; most useful for high-grade disease
• Flexible cystoscopy — direct inspection of the bladder lining under local anaesthesia; the definitive test
• CT urography — images the kidneys, ureters and bladder to assess the whole urinary tract and exclude upper tract tumours
• Transurethral resection of bladder tumour (TURBT) — both diagnostic and therapeutic; the specimen must include bladder muscle for accurate staging
• Re-resection — a second TURBT within a few weeks for high-grade or incompletely resected tumours
• Staging CT or MRI, and bone scan — where muscle-invasive disease is confirmed

Important Limitations and Risks

• Non-muscle-invasive bladder cancer recurs frequently. Even with correct treatment, recurrence is common, and lifelong cystoscopic surveillance is required. This is the single most important thing for patients to understand.
• BCG therapy causes urinary symptoms in most patients, and occasionally systemic reactions. Supply of BCG has been intermittent worldwide.
• Radical cystectomy is major surgery with a meaningful complication rate. Risks include bowel-related complications, infection, and effects on sexual function.
• A neobladder is not a normal bladder. Continence takes months to develop, night-time leakage is common, and some patients need to self-catheterise. It is not suitable for everyone.
• Trimodal therapy is not appropriate for all tumours — it requires complete initial resection, good bladder capacity, and no widespread carcinoma in situ. Salvage cystectomy after radiotherapy is more difficult.
• Smoking is the dominant risk factor. Continuing to smoke after diagnosis increases the risk of recurrence and progression.

What a Consultation Involves

A first consultation usually takes 30 to 45 minutes and covers:

• Your history — symptoms, smoking history, occupational exposures, and previous urological treatment
• Review of investigations — cystoscopy findings, imaging, and pathology reports including grade, stage, and whether muscle was present in the specimen
• An explanation of your risk category — and what it means for treatment intensity and surveillance
• Treatment options — including, where relevant, a frank discussion of diversion choices and how each affects daily life
• Surveillance planning — what follow-up will look like and why it matters
• Your questions

Please bring all pathology reports and imaging. Where a neobladder is being considered, we encourage you to bring your partner or a family member to that discussion.