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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
Key points
- Commonest urological malignancy. ~90% are transitional cell carcinoma (TCC/urothelial). Smoking is the strongest risk factor
- Cardinal presentation: painless visible haematuria (any episode = 2WW referral to urology, NICE NG12)
- Non-visible haematuria in ≥45 years also requires investigation
- Initial management: TURBT (transurethral resection of bladder tumour) — diagnostic and therapeutic
- Non-muscle-invasive: intravesical BCG or mitomycin C. Muscle-invasive: radical cystectomy ± neoadjuvant chemotherapy
Overview
Bladder cancer arises from the urothelium (transitional epithelium) lining the urinary bladder. Transitional cell carcinoma (TCC) accounts for ~90% of cases. Squamous cell carcinoma (~5%) is associated with chronic irritation (schistosomiasis, long-term catheterisation). Adenocarcinoma (~2%) may arise from urachal remnants. The disease is classified as non-muscle-invasive (NMIBC — stages Ta, T1, CIS) or muscle-invasive (MIBC — stage ≥T2). Smoking is the single biggest risk factor (~50% attributable risk). Occupational exposure to aromatic amines (2-naphthylamine — rubber, dye, and textile industries) is a classic association.
Epidemiology
Approximately 10,000 new cases per year in the UK — the eleventh most common cancer. Male:female ratio ~3:1. Median age at diagnosis is ~73 years. Approximately 75% present with non-muscle-invasive disease. Five-year survival is ~75% for non-muscle-invasive disease but <50% for muscle-invasive disease and <10% for metastatic disease. Recurrence rates are high for NMIBC (~50–70%), requiring long-term cystoscopic surveillance.
Clinical Features
Symptoms
Painless visible (macroscopic) haematuria — the cardinal symptom (present in ~80%)
Non-visible (microscopic) haematuria found on dipstick
Recurrent UTIs (especially in elderly)
Irritative LUTS: frequency, urgency, dysuria (especially with CIS)
Pelvic pain (advanced disease)
Weight loss, bone pain (metastatic disease)
Signs
Usually no abnormal findings on examination
Palpable suprapubic mass (very advanced disease)
Palpable pelvic mass on bimanual examination (muscle-invasive disease fixed to pelvic wall)
Lower limb lymphoedema (pelvic lymph node involvement)
Investigations
First-line
Flexible cystoscopyGold standard for diagnosis — direct visualisation of bladder mucosa. Any visible haematuria in ≥45 years → 2WW referral for cystoscopy (NICE NG12)
CT urogramAssess upper tracts (urothelial tumours can occur anywhere in the urinary tract). Combined with cystoscopy for complete evaluation
Urine cytologyHigh sensitivity for high-grade TCC and CIS. Lower sensitivity for low-grade disease
Second-line
TURBT (transurethral resection of bladder tumour)Diagnostic (histology, stage, grade) AND therapeutic for NMIBC. Must include detrusor muscle in sample for accurate staging
CT chest/abdomen/pelvisStaging for muscle-invasive disease — lymph nodes, liver, lung, bone metastases
MRI pelvisT-staging of muscle-invasive disease (local extent assessment)
Specialist
Examination under anaesthesia (EUA)Bimanual palpation at time of TURBT — assess mobility and local invasion
PET-CTFor lymph node staging in muscle-invasive disease being considered for radical treatment
1
Non-muscle-invasive (NMIBC)
- TURBT: complete resection of visible tumour. Re-TURBT at 6 weeks for high-grade T1 tumours
- Immediate post-TURBT single-dose intravesical mitomycin C (within 24 hours) — reduces recurrence
- Intermediate/high-risk NMIBC: intravesical BCG (Bacillus Calmette-Guérin) course — induction (6 weekly) + maintenance (up to 3 years)
- CIS (carcinoma in situ): BCG is primary treatment — flat high-grade lesion with high progression risk
- Cystoscopic surveillance: every 3 months for 2 years, then 6-monthly, then annually. Lifelong for high-risk
2
Muscle-invasive (MIBC)
- Neoadjuvant cisplatin-based chemotherapy (e.g. gemcitabine + cisplatin) before surgery — improves survival
- Radical cystectomy with pelvic lymph node dissection: gold standard curative treatment. Urinary diversion (ileal conduit or neobladder)
- Radical radiotherapy: alternative to cystectomy in patients unfit for surgery or who wish to preserve their bladder
- Trimodal therapy: maximal TURBT + concurrent chemoradiotherapy (bladder-preserving option)
3
Metastatic/advanced
- Cisplatin-based chemotherapy (gemcitabine + cisplatin): first-line if fit
- Immune checkpoint inhibitors: pembrolizumab/atezolizumab for cisplatin-ineligible or second-line after progression
- Palliative radiotherapy for symptomatic control (bleeding, pain)
- Best supportive care for advanced disease
Complications
- Recurrence: NMIBC recurs in 50–70% — requires lifelong cystoscopic surveillance
- Progression: ~10–20% of high-risk NMIBC progresses to muscle-invasive disease
- Post-cystectomy: Urinary diversion complications (stomal issues, metabolic acidosis from ileal conduit, UTIs, sexual dysfunction)
- Ureteric obstruction: Tumour at VUJ → hydronephrosis → AKI
UKMLA Exam Tips
- 1Any episode of painless visible haematuria in ≥45 years = 2WW referral to urology (NICE NG12)
- 2Smoking is the single biggest risk factor for bladder cancer (~50% attributable risk)
- 32-naphthylamine: classic occupational carcinogen (rubber/dye industry) — historical exam favourite
- 4Schistosoma haematobium → chronic bladder irritation → SQUAMOUS cell carcinoma (not TCC)
- 5BCG = intravesical immunotherapy for high-risk NMIBC. Side effects: BCG-itis (cystitis, granulomatous reaction, rarely BCG sepsis)
- 6CIS = flat high-grade urothelial neoplasia. Very aggressive despite being non-muscle-invasive. BCG is primary treatment
- 7TURBT must include detrusor muscle in the specimen — without it, you cannot stage the tumour
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