Bladder Cancer

At a glance

• What it is: Bladder cancer is a malignancy that arises from the lining of the bladder. The great majority of cases in Australia are urothelial (transitional cell) carcinoma; less common types include squamous cell carcinoma and adenocarcinoma.^1,4,11
• Most common presentation: Painless visible blood in the urine (macroscopic haematuria) is the classic warning sign and should always be investigated.^3,4,11,17
• How it is diagnosed: Cystoscopy (a thin telescope passed into the bladder), upper-tract imaging (most commonly a CT urogram), urine cytology in selected cases, and a transurethral resection of the bladder tumour (TURBT) for tissue and depth.^3,4,11,12,17
• Two broad treatment groups: Non-muscle-invasive disease (Ta, T1, CIS - confined to the inner lining or lamina propria) is managed with TURBT, intravesical therapy where appropriate (BCG or intravesical chemotherapy) and lifelong cystoscopic surveillance. Muscle-invasive disease (T2 or higher) is treated with radical cystectomy and urinary diversion, often with neoadjuvant chemotherapy, or in selected patients with bladder-sparing trimodal therapy.^{4,6,7,9,10,11,12,15}
• Smoking matters: Smoking is the single largest modifiable risk factor for bladder cancer. Stopping smoking after diagnosis is associated with a lower risk of recurrence and progression and is consistently recommended in international guidelines.^2,11,13,18
• Where Urology NSW sits: Dr Raji Kooner manages bladder cancer at Urology NSW alongside the wider urological-oncology service at St Vincent's Hospitals and the Mater Hospital, Sydney, including TURBT, intravesical therapy, radical cystectomy with urinary diversion and onward referral for systemic and radiation oncology where required.

What is bladder cancer?

The bladder is a muscular reservoir that stores urine produced by the kidneys before it passes out through the urethra. Its inner surface is lined by a thin sheet of cells called the urothelium. The same type of urothelium also lines the renal pelvis and the ureters.^4,11

Most bladder cancers (around 90% in Australia) start from the urothelium and are called urothelial carcinoma, also still widely referred to as transitional cell carcinoma.^1,4,11 Less common types include squamous cell carcinoma (more often associated with chronic infection or long-term catheter use) and adenocarcinoma. Very rare subtypes also exist.^3,4,11

How a bladder cancer behaves depends largely on how deep into the bladder wall it has grown by the time it is found:

• Non-muscle-invasive bladder cancer (NMIBC) - the cancer is confined to the inner lining (Ta) or has grown into the layer just beneath it (T1, the lamina propria). Carcinoma in situ (CIS, Tis) is a flat, high-grade form that also sits in the lining.^4,7,11
• Muscle-invasive bladder cancer (MIBC) - the cancer has grown into the muscular wall of the bladder (T2 or higher). This group needs more aggressive treatment.^10,12,15
• Advanced or metastatic disease - the cancer has spread beyond the bladder, to lymph nodes or to other organs.^11,16

How does bladder cancer present?

The classic presenting symptom is painless visible blood in the urine (macroscopic haematuria). It can be present once and then disappear, which sometimes leads to delay - but any episode of visible blood in the urine in an adult should be investigated.^3,4,11,17

Other ways bladder cancer can present include:

• Microscopic haematuria found on a routine urine test, particularly in adults over 40 with risk factors.¹⁷
• Recurrent or unexplained urinary tract infections, especially in someone who is not usually prone to them.¹¹
• New irritative bladder symptoms - urinary frequency, urgency or burning - in a smoker or someone with other risk factors.¹¹
• Pelvic pain or back pain in more advanced disease.^11,16

None of these symptoms is specific to cancer - they can come from infection, stones or other benign causes - but they all justify proper investigation.

Risk factors

The main known risk factors for bladder cancer are:^2,11,13,18

• Smoking. Cigarette smoking is by far the largest modifiable risk factor. Current smokers have approximately a three- to four-fold increase in risk compared with people who have never smoked, and the risk drops significantly with cessation, although it remains elevated for many years.^2,13
• Occupational exposure to aromatic amines and certain industrial chemicals (historically dye, rubber, leather, paint, printing and aluminium industries). Modern occupational protections have reduced this risk in Australia.^11,13
• Increasing age. Bladder cancer is uncommon below age 50 and most cases are diagnosed in people in their 60s, 70s and 80s.^1,11
• Male sex. Bladder cancer is approximately three times more common in men than women, although outcomes for women are often poorer because of delayed diagnosis.^1,11
• Chronic bladder irritation - long-term indwelling catheters, recurrent infection, bladder stones, and (in some parts of the world) schistosomiasis - which is more strongly associated with squamous cell bladder cancer.¹¹
• Previous pelvic radiotherapy or treatment with cyclophosphamide.¹¹
• Family history in a small minority of cases (Lynch syndrome and other rarer syndromes).¹¹

It is important to note that many people with bladder cancer have no obvious risk factor, and the absence of risk factors does not rule the diagnosis out.

How is bladder cancer diagnosed?

Investigating visible or unexplained haematuria usually involves a combination of the following.^3,4,11,12,17

Cystoscopy

A thin telescope (cystoscope) is passed through the urethra to look directly at the lining of the bladder. A flexible cystoscopy under local anaesthetic in the rooms is the usual first look; a rigid cystoscopy under anaesthetic in theatre is performed if a tumour is found and needs resection. See flexible cystoscopy for more on this test.^3,4

Imaging of the upper urinary tract

The kidneys, renal pelves and ureters are lined by the same urothelium as the bladder, and a small proportion of patients have additional tumours upstream. CT urography is the standard imaging test in patients fit to receive contrast; ultrasound and MRI urography are alternatives where CT is not appropriate.^11,12,17

Urine cytology and urine markers

A urine sample examined under the microscope can detect malignant cells shed by a tumour. Urine cytology is most useful for high-grade disease and CIS; it is less sensitive for low-grade tumours. Cytology supports - but does not replace - cystoscopy. Newer urine biomarker tests are available but are not yet a routine substitute for cystoscopy in published guidelines.^11,17

Transurethral resection of the bladder tumour (TURBT)

If a tumour is seen, the next step is a TURBT under general or spinal anaesthesia. A telescope is passed into the bladder and the tumour is removed in small chips with a resectoscope until the bladder wall beneath it is flat. A separate deeper bite is taken to confirm whether the cancer has invaded into the muscle layer. The detrusor muscle should be present in the specimen so the pathologist can stage the cancer accurately.^4,11,12

A repeat TURBT (commonly at around 4 to 6 weeks) is recommended in selected high-risk situations - for example T1 disease, high-grade tumours, large or multifocal tumours, or where the original specimen lacked detrusor muscle.^11,12

Staging and grading

Bladder cancer is described by both stage (how far it has grown) and grade (how aggressive the cells look under the microscope). Both shape the treatment plan.^4,11,12

• Ta - non-invasive papillary tumour, confined to the inner lining.
• Tis (CIS) - flat, high-grade carcinoma in situ in the inner lining.
• T1 - tumour invades the lamina propria (the supporting layer just beneath the lining), but not the muscle.
• T2 - tumour invades the muscular wall of the bladder.
• T3 - tumour extends through the muscle into the surrounding fat.
• T4 - tumour extends into adjacent organs (prostate, uterus, vagina, pelvic side wall, abdominal wall).

Cancers are also assigned a grade (low-grade vs high-grade in the WHO 2004/2016 system) and, where invasion is present, a CT or MRI of the chest, abdomen and pelvis is performed to look for lymph node or distant spread.^11,12

Non-muscle-invasive bladder cancer (NMIBC)

About 75% of newly diagnosed bladder cancers are non-muscle-invasive at the time they are found.^4,11 The aim of treatment is to clear the visible disease, reduce the chance of recurrence and progression, and detect new tumours early through surveillance.^7,11,12

Single-instillation intravesical chemotherapy at TURBT

For most patients with low- or intermediate-risk NMIBC, a single dose of an intravesical chemotherapy agent (usually mitomycin C or epirubicin) given inside the bladder soon after the TURBT reduces the risk of early recurrence. It is used selectively rather than universally, weighing benefit against the small risk of complications such as a chemical cystitis or, very rarely, perforation.^9,11,12

Risk-stratified surveillance

NMIBC is the original "recurring" cancer - across all groups, the risk of finding a new tumour somewhere on the bladder lining at follow-up is around 50% to 80% over five years, because the same urothelium has been exposed to the same risk.^5,7,11 Cystoscopic surveillance is therefore lifelong and is matched to the risk category. A typical schedule for higher-risk disease is:^11,12

• Every 3 to 4 months in the first year.
• Every 4 to 6 months in the second year.
• Yearly thereafter, often for life.

Intravesical BCG immunotherapy

For higher-risk NMIBC (high-grade Ta, T1 and CIS), intravesical Bacillus Calmette-Guerin (BCG) reduces recurrence and progression. BCG is a live attenuated strain of Mycobacterium bovis; an immune reaction in the bladder wall also targets cancer cells.^6,7,11,12

For full information on how BCG is given, what to expect at each instillation, household precautions, side effects and red flags, and what happens if BCG does not control the cancer, see the dedicated BCG Treatment for Bladder Cancer page.

BCG is given as an "induction" course of six weekly instillations through a catheter, followed by maintenance dosing for at least one year (and commonly up to three years for high-risk disease) in line with the published SWOG schedule.^7,11,12 Side effects and risks include:^6,7,8

• Urinary frequency, urgency and a burning feeling on passing urine, usually starting within hours of an instillation and settling over a day or two.⁷
• Flu-like symptoms - low-grade fever, malaise, occasional joint pains (arthralgia).^7,8
• Visible blood in the urine after an instillation.
• BCG cystitis, prostatitis or epididymo-orchitis (rare).
• BCG sepsis - a rare but serious systemic infection where the organism enters the bloodstream. It typically presents with high fever, rigors and feeling very unwell, and needs urgent assessment with anti-tuberculous therapy.⁸

Because of this profile, BCG is reserved for selected patients and is not a small treatment. Intravenous global supply of BCG has also been intermittently constrained in recent years, which can affect scheduling. Intravesical chemotherapy (mitomycin C, gemcitabine, or in selected patients gemcitabine plus docetaxel) is the alternative when BCG is unsuitable, unavailable or has failed; it lowers recurrence but the evidence for an effect on progression is less strong than for BCG.^9,11,12

For BCG-unresponsive high-risk NMIBC where the patient is fit, early radical cystectomy is recommended in the EAU and AUA guidelines because it offers the highest cancer-control. Newer bladder-preserving systemic options (for example pembrolizumab, and more recently nadofaragene firadenovec and nogapendekin alfa inbakicept-pmln in the United States) are emerging in international guidelines for selected patients who decline or are unfit for cystectomy.^11,12

Muscle-invasive bladder cancer (MIBC)

About 25% of bladder cancers are muscle-invasive at diagnosis (T2 or higher).^4,11 Treatment decisions in MIBC are made by a multidisciplinary team including urology, medical oncology and radiation oncology, and depend on stage, grade, kidney function, performance status and patient preference.^10,11,12,15

Neoadjuvant chemotherapy

Cisplatin-based combination chemotherapy given before radical cystectomy improves overall survival in patients fit enough to receive it. This is the international standard of care for cisplatin-eligible patients with MIBC.^11,12,15

Radical cystectomy with urinary diversion

Radical cystectomy remains the standard surgical treatment for MIBC and for selected very high-risk NMIBC that has failed conservative treatment. It involves removal of the bladder; in men the prostate and seminal vesicles are usually also removed, and in women the procedure may include the uterus, ovaries and a portion of the anterior vagina. A pelvic lymph node dissection is performed at the same operation.^10,11,12

Because the natural reservoir is removed, a new way for urine to drain has to be created. The two options most often discussed at consultation are:^10,11,12

• Ileal conduit (urostomy). The ureters are joined to a short segment of small bowel that is brought out through the abdominal wall as a small spout (stoma). Urine drains continuously into a bag worn on the skin. It is the most established and most reliable diversion, with a shorter operation, fewer late complications and no need for self-catheterisation.^10,11
• Neobladder (orthotopic neobladder). A pouch is constructed from a longer segment of small bowel and joined to the urethra, so urine is passed out through the natural outlet. It avoids an external stoma but requires a longer operation, careful patient selection (good kidney function, intact urethra and sphincter, suitable disease pattern, motivation to learn timed voiding and intermittent self-catheterisation if required), and a defined recovery period.^10,11

Other reservoirs (continent cutaneous diversion, ureterosigmoidostomy) are less commonly used in current practice.¹¹ Cystectomy is increasingly performed with robotic-assisted access in centres with that experience; this is a technical refinement of the same operation rather than a different procedure, and the choice between open and robotic access is made between surgeon and patient.^11,12

Robotic cystectomy and ileal conduit

Robotic cystectomy means the bladder, pelvic lymph nodes and surrounding organs that must be removed for cancer control are dissected using the robotic platform rather than through a large open abdominal incision. The cancer operation is the same in intent: complete removal of the bladder cancer, appropriate lymph node dissection, and reconstruction of a safe urinary drainage pathway.^11,12,19,20

For many patients who need cystectomy, the urinary diversion chosen is an ileal conduit (correct spelling: ileal, from the ileum or small bowel). A short segment of ileum is separated from the bowel stream, the ureters are joined into it, and the end of the segment is brought out through the abdominal wall as a small stoma. Urine then drains continuously into a flat appliance worn on the skin.^10,11,12

In an intracorporeal ileal conduit, the bowel segment and ureteric joins are created inside the abdomen using the robot. In an extracorporeal diversion, the cancer dissection is robotic but the bowel segment is brought out through a small incision so the conduit can be made outside the body. Both are valid approaches; the choice depends on anatomy, prior surgery, operating-room logistics and surgeon judgement.

Randomised trials comparing robot-assisted radical cystectomy with open radical cystectomy show broadly similar cancer-control outcomes at current follow-up. Robotic access is associated with lower blood loss and transfusion rates, and the iROC trial of robotic cystectomy with intracorporeal diversion reported fewer thromboembolic and wound complications and improved early recovery scores. It remains a major operation, usually taking longer than open surgery, and it does not remove the need for careful counselling about bowel, stoma, sexual, kidney-function and general surgical risks.^19,20

Before an ileal conduit operation, patients usually meet a stomal therapy nurse to plan the stoma site, learn how the appliance works, and understand skin care, bag emptying, night drainage and travel planning. The goal is not just to remove the cancer safely, but to leave the patient with a urinary diversion they can manage confidently over the long term.

Bladder-preserving trimodal therapy

For carefully selected patients - typically smaller, solitary T2 tumours without extensive CIS, with good bladder function - trimodal therapy (a maximal TURBT followed by concurrent chemotherapy and radiotherapy) is an evidence-based bladder-preserving alternative. Long-term outcomes in suitable patients are comparable in observational data to cystectomy. Lifelong cystoscopic surveillance and the possibility of salvage cystectomy are part of the plan.^11,12,15

Adjuvant systemic therapy

Patients with adverse pathology after cystectomy who did not receive neoadjuvant chemotherapy may be offered adjuvant cisplatin-based chemotherapy. Adjuvant immune checkpoint inhibitor therapy (nivolumab) has also been added to international guidelines for selected patients with high-risk pathology.^11,12,15

Advanced (metastatic) disease

If bladder cancer has spread beyond the bladder to lymph nodes or distant sites, treatment is led by medical oncology and is increasingly multimodal:^11,16

• First-line treatment now most commonly combines an antibody-drug conjugate (enfortumab vedotin) with an immune checkpoint inhibitor (pembrolizumab) in eligible patients, based on phase III trial evidence (EV-302). Cisplatin-based chemotherapy followed by maintenance avelumab remains an alternative.¹⁶
• Later-line options include further immune checkpoint inhibitors, FGFR-targeted therapy (erdafitinib) for tumours with FGFR alterations, and other antibody-drug conjugates.¹⁶
• Surgery and radiotherapy are used for symptom control where appropriate.

Because the systemic-therapy landscape changes rapidly, every patient with advanced disease should have access to a specialist medical oncologist and consideration for clinical trials.

Surveillance after treatment

Surveillance is part of the treatment plan, not an optional extra:^11,12

• NMIBC. Lifelong cystoscopic checks at intervals matched to risk category, sometimes with urine cytology, and periodic upper-tract imaging in higher-risk disease.
• After cystectomy. Periodic CT imaging of the chest, abdomen and pelvis, blood tests and clinical review on a defined schedule, with surveillance of the urethra and the upper urinary tracts as those areas remain at risk of new urothelial cancers.
• After trimodal therapy. Cystoscopic surveillance of the preserved bladder and imaging on a defined schedule, with cystectomy held in reserve if local disease returns.

Risks and complications

Each treatment for bladder cancer has its own profile of risks. The following is not exhaustive - every patient is counselled on the specific risks for their proposed operation or treatment.

Risks of TURBT

• Visible blood in the urine for up to two weeks; occasional clots that need irrigation or a short re-admission.^11,14
• Burning or urgency on passing urine.
• Urinary tract infection.
• Bladder perforation - usually a small extraperitoneal injury that settles with a catheter; rarely a larger intraperitoneal injury that needs repair.¹⁴
• Anaesthetic risks and a small risk of venous thromboembolism (DVT or PE).
• Stricture (narrowing) of the urethra over time.

Risks of intravesical BCG

• Urinary frequency, urgency and burning, with flu-like symptoms after instillations.⁷
• Visible blood in the urine.
• BCG cystitis, prostatitis or epididymo-orchitis (uncommon).
• BCG sepsis (rare but serious).⁸

Risks of radical cystectomy

Radical cystectomy is a major operation with a defined morbidity. Reported 30- to 90-day complication rates from large contemporary series are in the order of 30-60%, and 30- to 90-day mortality in centres with experience in the procedure is approximately 1-3%.^10,11,12 Specific risks include:^10,11,12

• Bleeding and the need for transfusion.
• Wound infection or wound dehiscence.
• Bowel-related complications - prolonged ileus, anastomotic leak from the bowel reconstruction, small bowel obstruction.
• Stomal complications (parastomal hernia, stomal stenosis, skin problems) for an ileal conduit; mucus, urinary leakage, neobladder rupture and the need to learn intermittent self-catheterisation for a neobladder.
• Urinary leak from the ureteric anastomoses, with a small risk of long-term ureteric stricture.
• Sexual dysfunction (erectile dysfunction in men, vaginal and sexual changes in women).
• Changes in kidney function over time.
• Vitamin B12 deficiency (long term, related to use of bowel in the urinary tract).
• Venous thromboembolism (DVT or PE), mitigated by early mobilisation and prophylactic anticoagulation per hospital protocol.
• Anaesthetic and general medical risks of major abdominal surgery.

Risks of trimodal therapy

• Acute and late urinary side effects (frequency, urgency, haematuria, contracted bladder).^11,15
• Bowel side effects from pelvic radiotherapy.¹⁵
• Local recurrence requiring salvage cystectomy in a defined proportion of patients.^11,15

Stopping smoking

The evidence is consistent: stopping smoking is one of the most useful things any patient with bladder cancer can do. Continued smoking is associated with a higher risk of recurrence and progression in NMIBC, and with poorer outcomes around major surgery and systemic treatment for MIBC.^2,11,13,18 Quitline (13 78 48 in NSW) and your GP can support a structured cessation plan; nicotine replacement therapy and prescribed cessation medications are commonly used adjuncts.

Bladder cancer at Urology NSW

Dr Raji Kooner manages bladder cancer at Urology NSW alongside the wider urological-oncology service at St Vincent's Private and Public Hospitals and the Mater Hospital, Sydney. Care typically includes:

• Investigation of haematuria with cystoscopy and CT urography.
• TURBT with full pathological staging, and repeat TURBT where indicated.
• Risk-stratified intravesical therapy with BCG or intravesical chemotherapy.
• Risk-matched cystoscopic surveillance.
• Radical cystectomy with urinary diversion (ileal conduit or neobladder), discussed in detail and tailored to the patient.
• Multidisciplinary referral to medical oncology and radiation oncology where neoadjuvant chemotherapy, adjuvant therapy, trimodal therapy or systemic therapy for advanced disease is planned.
• Onward referral to dedicated bladder cancer support services where needed.

Other related pages on this site: BCG treatment for bladder cancer, flexible cystoscopy, robotic surgery, single-port robotic surgery, kidney cancer, and request a second opinion.

Frequently asked questions

I had blood in my urine but it stopped on its own. Do I still need to see someone?

Yes. Visible blood in the urine in any adult should be investigated even if it goes away. Bladder cancer can bleed once and then settle for weeks or months before bleeding again, and early diagnosis matters.^3,11,17

Does a bladder cancer diagnosis mean I will lose my bladder?

For most patients, no. About three-quarters of bladder cancers are non-muscle-invasive at diagnosis and are managed with TURBT, intravesical therapy where appropriate and lifelong cystoscopic surveillance, keeping the bladder in place.^4,11 Cystectomy is reserved for muscle-invasive disease and for very high-risk non-muscle-invasive disease that has not responded to bladder-sparing treatment.^10,11,12

What is the difference between BCG and intravesical chemotherapy?

BCG is an immunotherapy - it triggers an immune reaction inside the bladder that also targets cancer cells. Intravesical chemotherapy uses a chemotherapy drug delivered directly into the bladder. BCG has the strongest evidence for reducing both recurrence and progression in higher-risk NMIBC; intravesical chemotherapy reduces recurrence and is the alternative when BCG is unsuitable, unavailable or has failed.^6,7,9,11,12

Is BCG safe?

BCG is a well-established treatment with a long track record, but it is not a small treatment. Most patients have a few days of urinary irritation and some flu-like symptoms after each instillation. Less common but more important risks include BCG cystitis or prostatitis, and the rare but serious risk of BCG sepsis. Significant side effects must be reported to the team promptly so the schedule can be paused or modified.^6,7,8

Can I drive after a TURBT?

Most patients are not safe to drive on the day of any general or spinal anaesthetic. The catheter is often removed before discharge or the next day; light activity is usually possible within a few days. Heavy lifting, cycling and strenuous exercise are typically deferred for about two weeks. Visible blood in the urine for up to two weeks afterwards is expected and not a reason for alarm unless heavy clots prevent passing urine.^11,14

Neobladder or ileal conduit - which is better?

Neither is automatically "better"; the right choice depends on the cancer, the anatomy, kidney function, the patient's preferences, and a careful conversation about lifestyle. A neobladder avoids an external stoma and bag but is a longer operation, requires a defined recovery period, and a proportion of patients learn intermittent self-catheterisation. An ileal conduit is the most reliable and reproducible diversion, with a shorter operation and well-understood long-term care, but uses an external stoma and bag.^10,11

Why do I need cystoscopies forever?

The whole inner lining of the bladder has been exposed to the same risk factors as the cancer that was removed, so new tumours can appear elsewhere on that lining over time - in published series the chance is around 50-80% over five years, depending on risk category.^5,7,11 Surveillance is the only reliable way to find new tumours early, when they are still treatable with bladder-sparing options.

What about my kidneys and ureters?

The renal pelves and ureters are lined by the same urothelium as the bladder, so a small but real proportion of patients with a bladder tumour will develop a similar tumour upstream over time. Periodic upper-tract imaging is built into surveillance for higher-risk groups, and any new visible haematuria after treatment should always be reported.^11,12

Will I need chemotherapy or radiotherapy?

It depends on the stage. Most patients with non-muscle-invasive disease do not need systemic chemotherapy or radiotherapy. Patients with muscle-invasive disease often have neoadjuvant chemotherapy before cystectomy, may have adjuvant systemic therapy after surgery, or may choose bladder-preserving trimodal therapy with concurrent chemotherapy and radiotherapy. Patients with metastatic disease are managed by medical oncology with combination immunotherapy and antibody-drug conjugate regimens.^11,12,15,16

Can I get a second opinion?

Yes. Bladder cancer treatment plans benefit from being clearly understood, and a structured second opinion is welcome. See Request a Second Opinion or telephone 02 8382 6980.