Bladder cancer

Transitional cell carcinoma (TCC) accounts for 90–95% of malignant tumours of the bladder in the UK. It is usually seen in elderly men and is particularly associated with smoking and exposure to industrial carcinogens. Most TCCs present with frank haematuria, although a minority are associated with urinary frequency and urgency. Diagnosis is made by direct visualization of the bladder by rigid or flexible cystoscopy, with other imaging methods (CT, ultrasound, intravenous urogram) to assess the extent of disease. At presentation, 75% of bladder cancers do not invade the bladder detrusor muscle (Ta/T1). Most of these tumours recur, although <20% progress to muscle-invasive disease. Tumour volume, stage, grade and behaviour have been used to stratify these tumours into risk groups for recurrence and progression. These tumours are usually resected using a rigid endoscope, using a cutting loop within a monopolar diathermy circuit. Chemotherapy (e.g. mitomycin C) applied directly to the bladder reduces recurrence rates, while BCG immunotherapy may also reduce the rate of progression. After initial surgery, periodic endoscopic surveillance is undertaken to identify and treat recurrences. Muscle-invasive tumours may be treated by radical radiotherapy or surgery. Radical cystectomy is associated with a mortality of 2%, it is usually combined with urinary diversion or formation of a neobladder from bowel. The outlook for metastatic TCC is bleak, although chemotherapy improves survival for a minority. New advances in the treatment of bladder cancer include neoadjavant chemotherapy before radical cystectomy and continuing efforts to identify and prevent the progression of Ta/T1 tumours.