Surgery chapters
Bladder tumours
Types of bladder tumour, risk factors (smoking, aromatic amines, schistosomiasis), presentation with painless haematuria, investigation by cystoscopy and TURBT, TNM staging, and management of non-muscle-invasive disease, carcinoma in situ and muscle-invasive cancer.
- Over 90% of bladder cancers are urothelial (transitional cell); squamous cancer is linked to schistosomiasis, chronic stones and long-term catheters; adenocarcinoma arises in the urachal remnant at the dome.
- Smoking and aromatic amines (aniline dyes, rubber, leather) are the main causes; the usual presentation is painless visible haematuria.
- Diagnose by cystoscopy and TURBT (including muscle); non-muscle-invasive tumours get resection, mitomycin C and BCG, while muscle-invasive tumours need radical cystectomy (or radical radiotherapy) with neoadjuvant cisplatin chemotherapy.
On this page
Overview
Bladder cancer is a common urological cancer of older men, strongly tied to smoking and industrial chemicals. In Pakistan and other areas where schistosomiasis occurs, squamous bladder cancer is also seen.
The decisive question for treatment is whether the tumour has invaded the detrusor muscle. Non-muscle-invasive tumours are managed endoscopically with intravesical drugs; muscle-invasive tumours need radical treatment.
Types of bladder tumour
- About 95% of primary bladder tumours arise from the transitional epithelium (urothelium).
- The rest come from connective tissue (angioma, leiomyoma, sarcoma) or are rare paragangliomas (attacks of headache and palpitations on voiding).
- Secondary tumours are common: by direct spread from the sigmoid colon and rectum, prostate, cervix and uterus, ovary; rarely blood-borne (e.g. lung).
| Type | Share | Key associations |
|---|---|---|
| Urothelial (transitional cell) carcinoma | Over 90% | Smoking, aromatic amines; often papillary and multifocal |
| Squamous cell carcinoma | About 5% (much more where bilharzia is endemic) | Schistosoma haematobium, chronic stones, long-term catheters, chronic irritation; usually solid and muscle-invasive |
| Adenocarcinoma | About 1–2% | Urachal remnant at the dome (mucus in urine, mass towards the umbilicus), glandular metaplasia, bladder exstrophy |
Risk factors (urothelial carcinoma)
- Cigarette smoking: the main cause (about 40% of cases).
- Occupational aromatic amines: 2-naphthylamine, benzidine, 4-aminobiphenyl, o-toluidine. The link was first noticed in aniline dye workers.
- High-risk jobs: dye, rubber and tyre, cable, leather and shoe, textile, chemical and petrol workers, painters, hairdressers, lorry drivers.
- Drugs: cyclophosphamide (via acrolein), phenacetin, aristolochic acid (in some herbal remedies).
- Pelvic radiotherapy.
- Chronic inflammation: schistosomiasis, stones, catheters (mainly squamous).
- Balkan nephropathy (upper tract tumours).
- Male sex (male:female about 3:1), older age (median about 73 years at diagnosis).
Bladder cancer from an industrial carcinogen can appear many years after exposure. It is a recognised occupational disease, and workers may be entitled to compensation.
Pathology and behaviour
- Urothelial tumours show a field change: the whole urothelium (renal pelvis to urethra) is at risk, so tumours are often multifocal and recurrent.
- Grade: low grade versus high grade (WHO), or G1–G3.
- Three behavioural groups at diagnosis:
| Group | Share of new cases | Behaviour |
|---|---|---|
| Non-muscle-invasive (Ta, T1) | About 70% | Papillary; frequent recurrence; some progress |
| Muscle-invasive (T2 and above) | About 25% | Solid; spreads to nodes and blood; poor prognosis |
| Primary carcinoma in situ (CIS) | About 5% | Flat, high-grade; aggressive if untreated |
TNM staging (T stage)
| Stage | Extent |
|---|---|
| Ta | Non-invasive papillary tumour |
| Tis | Carcinoma in situ (flat, high grade) |
| T1 | Invades lamina propria |
| T2 | Invades detrusor muscle |
| T3 | Invades perivesical fat (a mass felt bimanually after resection) |
| T4a | Invades prostate, uterus or vagina |
| T4b | Fixed to pelvic or abdominal wall |
Spread: lymphatic to pelvic (obturator, internal and external iliac) then para-aortic nodes; blood-borne to lung, liver and bone.
"Ta = Top, T1 = Tissue under lining, T2 = muscle Too, T3 = Through to fat, T4 = To neighbours."
Clinical features
- Painless visible haematuria: the commonest presentation; may cause clot retention.
- Storage symptoms (frequency, urgency, dysuria) with sterile urine: think of CIS (once called "malignant cystitis").
- Recurrent UTIs.
- Loin pain or renal failure: tumour blocking a ureteric orifice (hydronephrosis).
- Pelvic pain and leg oedema: extravesical spread and nodes; bone pain from metastases.
- Paraganglioma: palpitations and headache on voiding.
- Examination is usually normal; bimanual examination under anaesthesia assesses fixity.
Investigations
| Test | Purpose |
|---|---|
| Urine cytology | Specific; good for high-grade tumours and CIS; poor for low-grade |
| Urine culture | Exclude infection |
| FBC, U&E | Anaemia, renal function (hydronephrosis) |
| Flexible cystoscopy (local anaesthetic) | Mainstay of diagnosis; papillary "frond-like" tumours; velvety red patches suggest CIS |
| Blue light (photodynamic) cystoscopy | Better detection of CIS and small tumours |
| CT urography | Upper tracts (synchronous urothelial tumours) and kidney |
| TURBT (transurethral resection of bladder tumour) | Diagnosis, grading, local staging and treatment in one step |
| Bimanual examination under anaesthesia | Before and after TURBT; a mass felt after resection = T3; fixed = T4b |
| Contrast CT chest/abdomen/pelvis or MRI pelvis | Staging of high-risk and muscle-invasive disease; ideally before TURBT |
| Bone scan | If bone symptoms or raised alkaline phosphatase |
TURBT technique points
- Resect the tumour in layers; send the base separately.
- The specimen must contain detrusor muscle; without it, muscle invasion cannot be judged.
- Biopsy suspicious red areas for CIS.
- Pale yellow glistening fat in the resection bed means perforation.
- Leave an irrigating catheter to prevent clot retention.
A TURBT report with no muscle in the specimen is not adequate staging. A repeat resection within about 6 weeks is needed, especially for T1 tumours, about 30% of which are under-staged at the first resection.
Storage symptoms with sterile urine in an older smoker are not "recurrent cystitis" until CIS has been excluded by cytology and cystoscopy with biopsy.
Management of non-muscle-invasive bladder cancer (NMIBC)
Natural history after TURBT
- Recurrence: about 50–70%.
- Progression to muscle invasion: about 15% overall, higher with high grade, T1, CIS, multiple tumours, large size and recurrence at the first 3-month check.
Treatment by risk
| Risk group | Typical tumour | Treatment |
|---|---|---|
| Low | Single, small, low-grade Ta | TURBT + single post-operative instillation of mitomycin C, then surveillance cystoscopy |
| Intermediate | Multiple or recurrent low-grade Ta | TURBT + a 6-week course of intravesical chemotherapy (mitomycin C, epirubicin) or BCG |
| High | High-grade T1, CIS, multiple high-grade | Re-resection, then intravesical BCG (induction + maintenance); early radical cystectomy for very high-risk or BCG-failure disease (progression risk 30–50% for high-grade T1) |
- BCG (bacillus Calmette–Guérin) is a live attenuated mycobacterium. It provokes a local immune reaction that destroys tumour cells. It is the most effective intravesical agent for CIS and high-grade disease. Side effects: cystitis, fever; rarely systemic BCG infection (BCGosis), treated with anti-TB drugs.
- Mitomycin C is a chemotherapeutic agent; a single dose given within hours of TURBT lowers recurrence of low-risk tumours. Intravesical chemotherapy reduces recurrence but not clearly progression.
Intravesical chemotherapy (mitomycin C) mainly cuts recurrence; BCG is the agent that also reduces progression in high-risk disease.
Carcinoma in situ (CIS)
- Flat, red, velvety patches; cytology positive, storage symptoms.
- Without treatment, about half of patients die of invasive cancer.
- First-line: intravesical BCG. Failure → cystectomy.
- External beam radiotherapy is not effective for CIS.
Surveillance
- Cystoscopy every 3 months in the first year, then less often according to risk.
- About 30% of patients never have another tumour; if the bladder is clear at 2 years, yearly checks may be enough in low-risk cases.
- The upper tracts are imaged periodically in high-risk disease.
Management of muscle-invasive bladder cancer (MIBC)
| Treatment | Key points |
|---|---|
| Neoadjuvant chemotherapy | Cisplatin-based (gemcitabine + cisplatin, or MVAC) before surgery improves survival by about 5–7% |
| Radical cystectomy + pelvic lymphadenectomy | Standard for organ-confined T2–T3 disease and BCG-failure CIS. In men: cystoprostatectomy; in women: anterior exenteration (bladder, uterus, anterior vaginal wall). Urethrectomy if CIS or prostatic stromal involvement |
| Radical radiotherapy | For those unfit for surgery or choosing bladder preservation; often with chemotherapy (chemoradiation); salvage cystectomy if it fails |
| Partial cystectomy | Small urachal adenocarcinoma at the dome; rarely for urothelial cancer |
| Palliative | Radiotherapy for bleeding, embolisation, palliative TURBT, systemic chemotherapy or immune checkpoint inhibitors for metastases |
Even with treatment, 5-year survival for MIBC is often no better than about half.
Urinary diversion after cystectomy
| Method | Features |
|---|---|
| Ileal conduit (Bricker) | Standard; ureters joined to an isolated ileal segment brought out as a stoma (urostomy) in the right iliac fossa; needs a bag |
| Orthotopic neobladder | Pouch of detubularised bowel joined to the urethra; voids by straining; may need CISC; not if urethra involved |
| Continent cutaneous pouch | Catheterised through a small stoma (e.g. Mitrofanoff appendix channel) |
| Ureterosigmoidostomy | Ureters into the sigmoid colon; now rare |
Metabolic effects of bowel in the urinary tract: bowel absorbs urinary chloride and ammonium, causing hyperchloraemic metabolic acidosis with hypokalaemia. This is most marked with ureterosigmoidostomy (large area and long contact time). Others: recurrent pyelonephritis, stones, vitamin B12 deficiency (terminal ileum used), and, after ureterosigmoidostomy, a raised risk of colonic cancer at the anastomosis.
Ureterosigmoidostomy → hyperchloraemic, hypokalaemic metabolic acidosis. Treat with oral potassium citrate and sodium bicarbonate, and IV saline if severe.
Squamous cell carcinoma and schistosomiasis
- Schistosoma haematobium eggs in the bladder wall cause chronic inflammation, fibrosis, calcification and squamous metaplasia.
- Squamous tumours are usually solid and muscle-invasive at diagnosis and treated by radical cystectomy.
- Other causes: long-term indwelling catheters (e.g. paraplegics), chronic bladder stones.
Expect: urothelial carcinoma as the commonest type, smoking and aromatic amines (aniline dyes, rubber, leather), cyclophosphamide, schistosomiasis and catheters causing squamous cancer, urachal adenocarcinoma at the dome, painless haematuria as the commonest symptom, cystoscopy and TURBT with muscle in the specimen, TNM T stages, CIS with positive cytology and storage symptoms, single-dose mitomycin and BCG for high-risk NMIBC, radical cystectomy with neoadjuvant cisplatin for MIBC, ileal conduit, and hyperchloraemic acidosis after ureterosigmoidostomy.
Quick revision
- Over 90% urothelial; squamous ~5% (bilharzia, stones, catheters); adeno 1–2% (urachus, dome).
- Smoking ~40%; aromatic amines (2-naphthylamine, benzidine) in dye, rubber, leather workers.
- Male:female ~3:1; painless visible haematuria commonest.
- CIS: storage symptoms, sterile urine, positive cytology; treat with BCG.
- TURBT must include detrusor; re-resect T1 within ~6 weeks.
- NMIBC: 50–70% recur, ~15% progress; single mitomycin; BCG for high risk.
- MIBC: neoadjuvant cisplatin + radical cystectomy (or radical radiotherapy).
- Ileal conduit standard; ureterosigmoidostomy → hyperchloraemic acidosis.
Written by The House Job from standard references (Bailey & Love; Kumar and Clark's Clinical Medicine).
FAQ
What is the most common symptom of bladder cancer?
Painless visible haematuria. Any adult with this symptom should have cystoscopy and upper tract imaging.
Why is detrusor muscle needed in a TURBT specimen?
Treatment depends on whether the tumour invades muscle. Without muscle in the sample, the pathologist cannot exclude invasion and the tumour may be under-staged.
What is BCG used for in bladder cancer?
It is placed inside the bladder to trigger a local immune response. It is the main treatment for carcinoma in situ and high-risk non-muscle-invasive tumours, reducing both recurrence and progression.
Why does ureterosigmoidostomy cause acidosis?
The colon absorbs chloride and ammonium from the urine and loses bicarbonate and potassium, giving a hyperchloraemic, hypokalaemic metabolic acidosis.