Bladder Cancer

What is bladder cancer?

Most bladder cancers arise from the lining of the bladder (the urothelium) and are called urothelial carcinoma (previously “transitional cell carcinoma”). These same lining cells are also present in the ureters and kidney drainage system, which is why evaluation sometimes includes the upper urinary tract as well.

Symptoms: blood in the urine matters

The most common presenting symptom is blood in the urine (haematuria), which often occurs suddenly and is not necessarily painful. Other symptoms can include urinary frequency, urgency, burning, and occasionally lower abdominal discomfort.

Not everyone with blood in the urine has cancer—but visible haematuria should always be assessed.

Risk factors (briefly)

Bladder cancer is more common in people with a history of smoking. Certain occupational exposures and chronic bladder irritation can also contribute. Risk factors help guide urgency and thoroughness of assessment, but the diagnosis is made by tests, not by risk factors alone.

A practical overview of the bladder cancer pathway in Australia

While every case is individual, most patients move through a fairly predictable sequence:

1) Initial assessment and urine tests

This often includes urine testing (for infection and blood) and sometimes urine cytology (looking for abnormal cells). Cytology can be helpful in higher-grade disease but does not replace direct inspection of the bladder.

2) Imaging of the urinary tract

Many patients will have imaging to assess the kidneys, ureters and bladder—particularly when haematuria is present or if there is concern for tumour burden or upper tract involvement.

3) Cystoscopy (camera inspection of the bladder)

Cystoscopy is central. It allows direct visual assessment and is the most reliable way to identify a bladder tumour.

4) TURBT: the key diagnostic and staging procedure

If a tumour is seen, the next key step is usually TURBT (transurethral resection of bladder tumour). TURBT is not just “a biopsy”—it is the procedure that removes visible tumour and provides tissue needed to determine:

• tumour type and grade

• depth of invasion (the critical staging element)

• whether there is carcinoma in situ (CIS)

• and whether further treatment is needed

A second “re-resection” TURBT is sometimes recommended in selected cases (for example, high-risk features) to confirm staging and completeness.

The distinction that drives management: non-muscle invasive vs muscle-invasive

Non-muscle invasive bladder cancer (NMIBC)

This includes tumours confined to the lining or just beneath it (commonly labelled Ta, T1, and CIS). Many NMIBCs are treatable with bladder-sparing strategies, but they often require structured surveillance because recurrence is common.

Treatment typically involves:

• TURBT (removal and staging)

• sometimes a single immediate intravesical chemotherapy instillation (case-dependent)

• and, for higher-risk disease, intravesical therapy such as BCG

For high-risk NMIBC, BCG is commonly given as an induction course (often weekly for 6 weeks) with maintenance schedules used in appropriate patients.

Follow-up for NMIBC is not optional. Surveillance cystoscopy timing depends on risk category; as a reference point, low-risk disease often involves cystoscopy at 3 months, then spaced follow-up if clear.

Muscle-invasive bladder cancer (MIBC)

When cancer invades the bladder muscle (typically stage T2 or higher), the treatment intent is still often curative, but the pathway becomes more intensive and commonly multidisciplinary.

Management options may include:

• radical cystectomy (removal of the bladder with urinary diversion), often combined with perioperative chemotherapy in suitable patients

• or bladder-preserving “trimodality therapy” in selected cases (maximal TURBT + chemoradiation), which can be a definitive treatment option for appropriately selected patients

Not every patient is suitable for bladder-preserving therapy, and not every patient is suited to major surgery. The decision is individualized.

Treatment options: how decisions are usually made

TURBT alone vs additional therapy

Some small, low-risk NMIBC tumours can be managed with TURBT plus surveillance. Higher-risk NMIBC often needs intravesical therapy (commonly BCG) to reduce recurrence and progression risk.

Intravesical therapy (BCG and other agents)

BCG is placed into the bladder via catheter (it is not intravenous chemotherapy). It is commonly used for high-risk NMIBC. Side effects can include bladder irritation symptoms and flu-like symptoms; serious complications are uncommon but important to recognise early.

Radical cystectomy (bladder removal)

Cystectomy is major cancer surgery. It involves removal of the bladder and construction of a urinary diversion. The two most common diversion pathways discussed are:

• ileal conduit (stoma/bag), and

• neobladder (selected patients, and not appropriate for everyone)

The “best” diversion is the one that fits the cancer, anatomy, kidney function, and the person’s priorities and capacity for rehabilitation.

Bladder-preserving treatment (trimodality therapy)

For selected patients with muscle-invasive bladder cancer, a bladder-preserving approach may be appropriate. This typically involves maximal TURBT followed by chemoradiation. This pathway requires careful selection and structured follow-up.

The multidisciplinary reality

For muscle-invasive disease and higher-risk situations, bladder cancer care commonly involves urology, medical oncology and radiation oncology. A good plan is usually the product of accurate staging, clear explanation, and time to weigh trade-offs—not urgency-driven decisions.

Where robotic surgery fits (and what it does not change)

Robotic surgery is one approach to performing cystectomy and other complex pelvic operations through small incisions. In many settings, minimally invasive approaches are associated with less blood loss and shorter hospital stay on average—but cystectomy remains major surgery regardless of platform.

The platform does not replace judgement. The key determinants of outcomes are:

• accurate staging and appropriate pathway selection

• the quality and safety of the operation and reconstruction

• perioperative planning and recovery support

• and the biology of the cancer itself

For a broader overview of robotics across prostate, kidney and bladder cancer surgery, see Robotic Urologic Cancer Surgery.

After treatment: follow-up and surveillance

Follow-up depends on tumour stage, grade, treatment type, and recurrence risk. NMIBC often requires scheduled cystoscopies over years because recurrence can occur even after successful initial treatment. Muscle-invasive disease follow-up may include imaging and multidisciplinary review depending on the pathway chosen.