Bladder Cancer

What Is Bladder Cancer?

Bladder cancer occurs when the cells lining the inside of the bladder (the urinary mucosa) undergo genetic mutations that cause them to grow and multiply uncontrollably, forming a tumor.

The vast majority of these tumors (around 90%) originate from transitional cell carcinoma (or urothelial carcinoma), which affects the tissue that directly lines the inside of the organ. Clinically, bladder cancer is divided into two major diagnostic groups, which call for completely different treatment approaches:

  • Non-Muscle-Invasive Bladder Cancer (superficial): The tumor is confined to the innermost layers of the bladder lining. It accounts for most initial diagnoses and has a favorable prognosis, although it requires close monitoring due to the risk of recurrence.
  • Muscle-Invasive Bladder Cancer: The tumor has progressed and invaded the deep muscular layer of the bladder wall. This is a more serious situation, with an increased risk of spreading (metastasis) to the lymph nodes or other organs, requiring more aggressive treatment.

Main Risk Factors

The development of this condition is strongly linked to prolonged exposure to harmful chemical substances which, after being filtered by the kidneys, become concentrated in the urine stored in the bladder. The main risk factors include:

  • Smoking: On its own, this is the leading risk factor. Smokers are 3 to 4 times more likely to develop bladder cancer than non-smokers. Chemicals from tobacco smoke enter the bloodstream, are filtered by the kidneys, and severely damage the urothelium.
  • Occupational / Industrial Exposure: Workers in industries that use dyes, paints, rubber, leather, plastics, and certain chemical solvents (aromatic amines) face an increased risk.
  • Age and Gender: It is significantly more common in people over 60-65 years of age and affects men about 3 to 4 times more often than women.
  • Chronic Bladder Irritation: Recurrent urinary tract infections, prolonged catheter use, or a history of bladder stones may slightly increase the risk.
Symptoms of Bladder Cancer

Unlike prostate cancer, bladder cancer often becomes apparent in its early stages through visible changes in the urine.

The most common and characteristic warning sign is:

  • Hematuria (Blood in the Urine): This occurs in around 80-90% of cases. It is typically painless and intermittent — the urine may appear visibly red or pink on one day and return to its normal color the next, which often leads patients to mistakenly delay seeking medical attention.

As the tumor grows or spreads, other symptoms related to irritation of the organ may appear, often mistaken for a simple urinary tract infection:

  • Urgent need to urinate (urinary urgency);
  • Increased frequency of urination (needing to go to the bathroom more often);
  • Pain or a burning sensation when urinating (dysuria);
  • Pain in the pelvic or lower back region (common in more advanced stages).
Diagnosis of Bladder Cancer

When there is clinical suspicion or the appearance of blood in the urine, urological investigation should be prompt and structured in order to rule out or confirm the presence of malignancy.

Initial Tests

  1. Urine Tests: A urinalysis (urine test) detects the presence of microscopic hematuria (blood visible only under a microscope) and helps rule out active infections. Urinary Cytology examines the cells present in the urine to identify tumor cells that may have shed from the bladder wall.
  2. Bladder and Kidney Ultrasound: A non-invasive imaging test that allows visualization of the anatomy of the urinary tract, mapping of the kidneys, and detection of any masses or polyps inside the bladder.

Confirmation and Staging Tests

  • Cystoscopy: This is the definitive diagnostic test. It involves inserting a thin, flexible tube with an optical camera at the tip (cystoscope) through the urethra. It allows the urologist to directly view the entire inside of the bladder in real time, identify the location, size, and appearance of any lesion, and, if necessary, perform small biopsies.
  • Uro-CT (Computed Tomography of the Urinary Tract): Used to assess the upper urinary tract (kidneys and ureters) and check whether the tumor has invaded nearby tissue or whether there are affected lymph nodes.
  • Bladder MRI: a more sensitive test for assessing the local extent of the disease
Bladder Cancer Treatments and Surgeries

The treatment strategy depends entirely on the degree of tumor invasion into the bladder wall, as determined after testing and the initial surgical procedure.

1. Transurethral Resection of the Bladder (TURBT)

TURBT is both the first step in treatment and an essential diagnostic tool.

  • The Procedure: This is a minimally invasive endoscopic surgery performed in the operating room under anesthesia. The urologist inserts a surgical instrument through the urethra into the bladder to scrape away (resect) and completely remove the visible tumor tissue.
  • Post-Operative Care: The removed tissue is sent for pathological analysis to determine the tumor’s aggressiveness and depth. The patient usually remains hospitalized with a urinary catheter for 1 to 3 days to allow the bladder to be irrigated and to heal.
  • Intravesical Instillations (Complementary Treatment): If the tumor is non-muscle-invasive but carries a risk of recurrence, TURBT is complemented with local treatments applied directly inside the bladder through a temporary catheter. This may involve intravesical chemotherapy (such as Mitomycin C) or BCG immunotherapy (Bacillus Calmette-Guérin), which stimulates the local immune system to destroy any remaining cancer cells.

2. Radical Cystectomy (Bladder Removal)

In cases where the tumor has already invaded the muscle layer (muscle-invasive cancer) or when high-risk superficial tumors do not respond to intravesical treatments, the recommended surgery is complete removal of the bladder.

  • The Surgery: In men, this involves removal of the bladder, prostate, and seminal vesicles. In women, it usually involves removal of the bladder, uterus, ovaries, and part of the vaginal wall. A lymphadenectomy (removal of the pelvic lymph nodes) is also performed. This procedure can be carried out using classic open surgery or minimally invasive techniques (laparoscopy or robotic surgery).
  • Urinary Diversion: Once the organ that stores urine has been removed, the surgeon must create a new way for the body to eliminate the urine produced by the kidneys. The two main options are:
    1. Urostomy (Non-Continent Diversion or Ileal Conduit): A small segment of the intestine is used to connect the ureters to the skin of the abdomen, where an external adhesive pouch is attached to continuously collect urine.
    2. Ileal Neobladder (Continent Diversion): This is a complex reconstruction in which a new reservoir for urine is created from a segment of the patient’s own intestine, connecting it directly to the urethra. This allows the patient to continue urinating independently and naturally, without the need for external pouches.

3. Multimodal Approaches (Bladder Preservation)

For patients who refuse removal surgery or who are not clinically fit to tolerate such a demanding procedure, a bladder preservation strategy may be chosen, based on combining as complete a TURBT as possible with simultaneous sessions of radiotherapy and chemotherapy (trimodal therapy). While this offers the advantage of preserving the organ, it requires extremely rigorous follow-up monitoring to detect early recurrences.

4. Treatment of Advanced or Metastatic Disease

In cases where the disease has spread beyond the pelvic region, treatment relies on systemic therapies that act throughout the entire body:

  • Systemic Chemotherapy: Cisplatin-based protocols remain the standard first-line treatment to control tumor growth.
  • Immunotherapy: Modern drugs (such as immune checkpoint inhibitors) that help the patient’s own immune system recognize and attack malignant cells, offering new prospects for long-term survival and quality of life.
Have you had an episode of blood in your urine? Don’t delay. Schedule an urgent evaluation appointment.
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