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🫧 BLADDER CANCER — Complete Guide

Based on Campbell's Urology & Harrison's Principles of Internal Medicine

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🧠 MEMORY FRAMEWORK: "STEP-UP"

Symptoms → Types → Etiology/Risk Factors → Pathology & Staging → Urology Workup (Diagnosis) → Plan (Management)

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1️⃣ SYMPTOMS — "Blood in urine = Bladder Cancer until proven otherwise"

🔴 Cardinal Symptom: Painless Gross Hematuria

• Present in ~85% of cases
• PAINLESS = key distinguishing feature (painful hematuria = stones/infection)
• Intermittent in nature — patient may ignore it!
• Can be microscopic (found incidentally on urinalysis)

🟡 Other Symptoms (LUTS — Lower Urinary Tract Symptoms):

💡 Memory Tip: Any adult >40 with "UTI that doesn't resolve" or "recurrent UTI in a man" → think bladder cancer!

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2️⃣ TYPES — "Who causes most trouble?"

🏆 Urothelial (Transitional Cell) Carcinoma — 90–95%

• Arises from the urothelium (transitional epithelium lining bladder)
• Most common in developed countries

Other Types (less common):

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3️⃣ ETIOLOGY / RISK FACTORS — "SMOKING SCAB"

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4️⃣ PATHOLOGY & STAGING — "How deep does it go?"

Bladder Wall Layers (inside → outside):

Urothelium → Lamina Propria → Muscularis Propria → Perivesical Fat → Adjacent Organs

TNM Staging:

💡 The Big Split:

• NMIBC (Non-Muscle Invasive) = Ta, T1, Tis → ~75% of cases → Treated conservatively
• MIBC (Muscle Invasive) = T2–T4 → ~18% of cases → Treated aggressively
• Metastatic = only ~3% at presentation (Harrison's, p. 2614)

Lymph Node (N) Staging:

• N0 = no nodes
• N1 = single pelvic node
• N2 = multiple pelvic nodes
• N3 = common iliac nodes

Grade (also critical!):

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5️⃣ DIAGNOSIS / WORKUP — "See it, Sample it, Stage it"

Step 1: SEE IT — Cystoscopy

• Gold standard for diagnosis
• Directly visualizes the tumor; guides biopsy
• Describes: size, number, location, appearance (papillary vs. sessile/flat)

Step 2: TEST THE URINE

Step 3: SAMPLE IT — TURBT (Transurethral Resection of Bladder Tumor)

• Diagnostic AND therapeutic procedure
• Resects visible tumor, sends for histopathology
• Must include muscularis propria in the specimen to assess depth of invasion
• Re-TURBT at 4–6 weeks for high-grade T1 or incomplete initial resection

Step 4: STAGE IT — Imaging

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6️⃣ MANAGEMENT — "Match the treatment to the stage"

🟢 A. NON-MUSCLE INVASIVE BLADDER CANCER (NMIBC) — Ta, T1, Tis

Step 1: TURBT (always first)

Step 2: Risk-Stratify

🧫 Intravesical BCG (Bacillus Calmette-Guérin):

• Immunotherapy — stimulates local immune response against tumor cells
• Best treatment for CIS and high-grade NMIBC
• Protocol: 6-week induction + 3-week maintenance courses
• Side effects: cystitis symptoms, BCG sepsis (rare but life-threatening)

⚠️ BCG Failure → Radical Cystectomy (or intravesical Valrubicin/Pembrolizumab in BCG-unresponsive cases)

Step 3: Surveillance

• Cystoscopy + cytology every 3 months × 2 years, then every 6 months × 2 years, then annually
• Upper tract imaging annually

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🔴 B. MUSCLE-INVASIVE BLADDER CANCER (MIBC) — T2–T4, N0–N2, M0

🏆 Gold Standard: Radical Cystectomy + Neoadjuvant Chemotherapy

• Given BEFORE surgery
• Improves overall survival by ~5–8%
• Targets micrometastatic disease
• Must have adequate renal function (GFR >50–60)

• Males: Remove bladder, prostate, seminal vesicles, proximal urethra, pelvic lymph nodes
• Females: Remove bladder, uterus, ovaries, anterior vaginal wall, urethra, pelvic lymph nodes

🔵 Bladder-Sparing Trimodality Therapy (TMT):

1. Maximal TURBT (debulk as much as possible)
2. Concurrent chemoradiation (Cisplatin + RT)
3. Outcomes comparable to cystectomy in selected patients

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🟣 C. METASTATIC BLADDER CANCER

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7️⃣ PROGNOSIS — "Stage is everything"

⚠️ NMIBC has a high recurrence rate (~70%) but low mortality if properly surveilled. CIS has the highest risk of progression to invasive disease.

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🗂️ MASTER SUMMARY TABLE

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🔑 HIGH-YIELD EXAM PEARLS

1. Painless gross hematuria = bladder cancer until proven otherwise
2. Smoking is the #1 risk factor (50% of cases)
3. TURBT = both diagnosis AND treatment for NMIBC
4. CIS = flat, high-grade, aggressive — always needs BCG
5. Muscularis propria in TURBT specimen is essential — without it, staging is incomplete
6. BCG failure in NMIBC = radical cystectomy (don't delay)
7. Neoadjuvant cisplatin before cystectomy improves survival
8. Schistosoma haematobium → squamous cell carcinoma (not transitional!)
9. Upper tract surveillance mandatory — same urothelium, same risk
10. Ileal conduit = simplest diversion; Neobladder = best quality of life

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