Bladder Cancer - Diagnosis & Treatment

The most important early sign is haematuria - blood in the urine. This may be visible (frank haematuria - pink, red or brown urine) or microscopic (detected on a urine test when the urine looks normal). Painless visible haematuria is the presenting symptom in 80–85% of bladder cancer cases. It is always abnormal and must be investigated. Other symptoms include: frequent urination, burning sensation when passing urine (without infection), urgency, and in advanced disease - pelvic or bone pain, or inability to urinate. Because bladder cancer causes these symptoms early, it is often diagnosed while still curable.

No - most haematuria is not cancer. Common causes include kidney stones, urinary infection, benign prostatic enlargement (BPH), strenuous exercise, and trauma. However, bladder cancer and kidney cancer are important causes that must be excluded. The key principle is this: haematuria must be investigated every time, regardless of age, gender, or likelihood - even if there is an obvious alternative explanation like a UTI. Investigations include urine cytology, ultrasound KUB, and cystoscopy. A CT urogram may be added to assess the upper urinary tract. Do not wait for blood to reappear - investigate the first episode.

TURBT stands for Transurethral Resection of Bladder Tumour - it is both the initial diagnostic procedure and the first treatment for bladder cancer. A resectoscope (a thin telescope with an electrical loop) is passed through the urethra into the bladder under general or spinal anaesthesia. The tumour is resected (shaved away in layers) and the specimens are sent to pathology. TURBT tells us: (1) whether the lesion is cancer, (2) what type and grade, and (3) how deeply it has invaded the bladder wall. No skin incisions are made. Hospital stay is usually 1–2 nights. A urethral catheter is left for 1–2 days. Most patients return to work within 1–2 weeks.

This distinction determines whether the bladder can be saved. Superficial (non-muscle-invasive) bladder cancer: Stage Ta, T1, or CIS (carcinoma in situ). The tumour is limited to the inner lining or submucosa - it has not grown into the muscle wall. Treated by TURBT + intravesical therapy (BCG or chemotherapy instilled into the bladder). The bladder is preserved. Recurrence is common (50–70% over 5 years) so regular cystoscopy surveillance is essential. Muscle-invasive bladder cancer (MIBC): Stage T2 or beyond. The tumour has grown into the detrusor muscle. Standard treatment is radical cystectomy (removal of the bladder) with or without neoadjuvant chemotherapy. Bladder-sparing trimodality therapy (TURBT + radiotherapy + chemotherapy) is an alternative for selected patients.

BCG (Bacillus Calmette-Guérin) intravesical therapy is an immunotherapy instilled directly into the bladder after TURBT for high-risk non-muscle-invasive bladder cancer. BCG is a weakened form of the tuberculosis bacterium that triggers a local immune response in the bladder wall, destroying remaining tumour cells and preventing recurrence. The standard regimen is 6 weekly instillations (induction course) followed by 3-weekly maintenance courses at 3, 6, 12, 18, 24, 30, and 36 months. BCG significantly reduces recurrence and progression to muscle-invasive disease. Common side effects include urinary frequency, urgency, and mild flu-like symptoms after instillations.

Radical cystectomy is the surgical removal of the bladder (and prostate in men, or uterus and front wall of vagina in women). It is the standard treatment for muscle-invasive bladder cancer and for high-risk non-muscle-invasive disease that has failed BCG. When the bladder is removed, a new way to store and pass urine must be created - this is called urinary diversion. Options: (1) Ileal conduit - the most common - a short segment of bowel is used to create a stoma through which urine drains into an external bag. (2) Orthotopic neobladder - bowel is fashioned into a new bladder and connected to the urethra; the patient passes urine normally (with some technique adaptation). (3) Continent cutaneous diversion - an internal pouch emptied by catheterisation through the skin. The right option depends on cancer stage, patient fitness, and preference. Dr. Nitin performs robotic radical cystectomy at Apollo Hospital Gurugram.

Bladder cancer has a high recurrence rate - 50–70% of non-muscle-invasive tumours will recur within 5 years. Regular cystoscopy is therefore essential for life after treatment. The standard surveillance schedule: for low-risk disease - cystoscopy at 3 months, then annually for 5 years. For intermediate-risk - every 3 months for 2 years, then every 6 months for 3 years, then annually. For high-risk - every 3 months for 2 years, every 6 months for 3 years, then annually for life. CT urogram is added at intervals to check the upper tracts. Urine cytology at each visit detects microscopic cancer cells. Missing surveillance appointments significantly worsens outcomes - recurrence caught early is almost always treatable.