Bladder cancer is the 11th most common cancer in the UK, with almost 11,000 new cases diagnosed every year.
Here, we will explore who is most at risk, symptoms to look out for, and how it is diagnosed and treated. However, first, it helps to understand the different types and stages of bladder cancer.
Bladder cancer types
Most, around 9 in 10, bladder cancers are urothelial carcinomas, previously called transitional cell carcinomas. These cancers develop from cells that line the inside of the bladder.
Less common types of bladder cancer include squamous cell carcinoma, adenocarcinoma and neuroendocrine tumours.
Squamous cell carcinoma develops from flat cells in the bladder lining. In a healthy bladder, these flat cells are not normally present. They appear in bladders that have long-term irritation and inflammation. This could be caused by using a catheter for a long time, having persistent bladder stones or, in some parts of the world, having a parasitic infection called schistosomiasis.
Adenocarcinoma develops from cells in the bladder lining that form glands. They make up a small proportion of bladder cancers. Some cases are linked to long-term inflammation of the bladder or developmental abnormalities of the bladder.
Stages of bladder cancer
Bladder cancer can be broadly grouped into 2 categories: non-muscle invasive bladder cancer (NMIBC) and muscle-invasive bladder cancer (MIBC).
NMIBC has not grown into the bladder muscle. Around three-quarters of individuals with bladder cancer are diagnosed at this stage.
Muscle-invasive bladder cancer has grown into the muscle of the bladder wall. It may also extend through the bladder wall or spread to nearby lymph nodes or other parts of the body.
Risk factors for bladder cancer
The biggest risk factor for bladder cancer is smoking.
Other risk factors include increasing age, being male, and previous exposure to certain industrial chemicals historically used in the dye, rubber, paint, textile and leather industries.
Previous pelvic radiotherapy, treatment with certain medicines such as cyclophosphamide, and longstanding bladder inflammation may also increase the risk.
Bladder cancer symptoms
The most common symptom of bladder cancer is blood in the urine, which is often painless. It may come and go, and should be investigated even if it occurs only once.
Other symptoms can include passing urine more often, sudden urges to urinate, discomfort or burning when passing urine, and repeated urinary infections.
Although these symptoms are more commonly caused by conditions such as urinary infections, an overactive bladder, kidney stones or an enlarged prostate, they should be checked, particularly if they are persistent or if blood is visible in the urine.
Getting a diagnosis of bladder cancer
If you are concerned that you have symptoms of bladder cancer, see your GP. They will ask you about your symptoms and medical history, and may recommend that you have a urine test, blood test and/or imaging test, such as an ultrasound scan or CT scan.
You may also need to have a flexible cystoscopy, which is the main test used to examine the bladder. A thin, flexible camera is passed through the urethra (the tube through which urine leaves your body) into the bladder after a local anaesthetic gel has been applied. The examination usually takes only a few minutes and allows your doctor to inspect your bladder lining for abnormal areas.
Bladder cancer treatment: TURBT and cystectomy
Treatment for bladder cancer depends on the stage it’s at when it’s detected.
If a bladder tumour is found, it will usually be removed or sampled via a minimally invasive surgery performed under general or spinal anaesthesia. This is called transurethral resection of a bladder tumour (TURBT).
During a TURBT, no cuts are made in the skin. A rigid telescope-like instrument called a resectoscope is passed through the urethra into the bladder. The surgeon uses a wire loop or other specialised instruments passed through the resectoscope to remove the visible tumour and collect tissue for analysis in a lab.
Analysis of the tissue in a lab confirms the type and grade of cancer and whether it has invaded the bladder muscle.
TURBT is often performed as a day case procedure or with an overnight stay. Occasionally, a longer stay may be needed, depending on the size of the tumour, bleeding and how recovery goes.
A urinary catheter may be temporarily left in after the operation. Blood in the urine, urinary frequency and discomfort when passing urine are common for several days. Recovery usually takes around 1–2 weeks, although this varies.
After you have recovered from surgery, your bladder will be monitored via regular flexible cystoscopies. Further treatment depends on the tumour’s grade, stage and risk of recurring or progressing.
Some individuals have a dose or course of chemotherapy directly into the bladder. Others with higher-risk disease may have intravesical immunotherapy using Bacillus Calmette–Guérin, commonly called BCG. Some low-risk tumours may need continued surveillance with regular flexible cystoscopies, without a longer course of further treatment.
If the cancer has spread into the bladder muscle, but has not spread to distant parts of the body, the main treatments are a radical cystectomy or, in certain patients, bladder-preserving treatment combining a thorough TURBT, chemotherapy and radiotherapy.
Chemotherapy is often given before a radical cystectomy if it is appropriate for the type of cancer and the individual is fit enough. Treatment after surgery depends on the final findings and may involve chemotherapy or immunotherapy.
Risks and complications of TURBT
TURBT is generally considered to be a low-risk procedure. However, every type of surgery comes with risks.
For TURBT, risks include temporary bleeding, blood in your urine, urinary infections and finding it difficult to pass urine at first.
A less common complication is bladder perforation, where an opening is made in the bladder wall. Most perforations heal with monitoring and the temporary use of a catheter, although in rare cases, further treatment or surgery may be needed.
In some cases, after the initial TURBT, a second TURBT is needed to ensure complete removal of the cancer and/or to collect more tissue for examination in a lab for staging of the cancer.
Radical cystectomy: living without a bladder
A radical cystectomy removes the bladder and nearby lymph nodes. In men, it usually also involves removing the prostate and seminal vesicles. In women, the operation may involve removing nearby reproductive organs, depending on the tumour’s location and the surgical approach.
After a radical cystectomy, the surgeon must create a new way for urine to leave the body. The most common option is an ileal conduit, where a short segment of bowel is used to direct urine through a surgically created opening (stoma) on the abdomen into an external bag.
For certain individuals, a new internal reservoir called a neobladder can be made from the bowel and connected to the urethra. It takes time to learn how to empty it, and you may have some leakage, particularly at night. Some people need to use a catheter to empty it fully.
A neobladder is not suitable for everyone. The choice of a neobladder or an ileal conduit depends on the cancer, general health, kidney function, previous treatment and personal preferences of the individual, as well as their ability to manage the solution provided.
