Diagnosis
- n/a
Investigation
If bladder cancer suspected:
- Transurethral resection of bladder tumour (TURBT), white light guided with photodynamic diagnosis, cytology or urinary biomarkers
- Do not substitute urinary biomarkers for cystoscopy to investigate suspected bladder cancer
Staging
- Consider CT or MRI staging before TURBT if muscle-invasive bladder cancer suspected at cystoscopy
- CT urography to detect upper tract involvement in new or high risk cancer
- Consider fluorodeoxyglucose PET if indeterminate findings on MRI / CT
| Low Risk | Solitary pTaG1 or G2 < 3 cm (Ta = innermost layer) |
|---|---|
| Intermediate Risk | Solitary pTaG1 or G2 > 3 cm or multifocal |
| High Risk | Any pTaG3; Any pT1G2 or G3 (T1 = grow into connective tissue, T2 into muscle); Any PTis or Cis (Very early high grade) |
Management
Non Muscle invasive Treatment
- Low Risk:
- Transurethral resection of bladder tumour (TURBT) white light guided with photodynamic diagnosis, cytology or urinary biomarkers
- Obtain detrusor muscle sample and note size and number of tumours
- Offer intravesical mitomycin C during TURBT (Chemotherapy agents via catheter to bladder)
- Intermediate Risk:
- Offer min 6 courses of intravesical mitomycin C, if recurs refer to specialist
- High Risk:
- Repeat TURBT in 6 weeks
- Offer the choice of intravesical BCG (Bacille Calmette-Guérin) or radical cystectomy
- Offer induction & maintenance intravesical BCG, if induction BCG fails (not tolerated, or bladder cancer persists) refer the person’s cancer to a specialist urology MDT
- Consider fulguration (destruction with diathermy) without biopsy for people with recurrent non-muscle-invasive bladder cancer if solitary papillary regrowth < 3 mm
- Follow up: Cystoscopy follow up every 3 mths for 2 years if high risk
Muscle Invasive Treatment
via Specialist urology MDT
- Neoadjuvant chemotherapy with Cisplatin before radical cystectomy / radiotherapy
- Radical cystectomy with urinary stoma or a continent urinary diversion
- Radiotherapy with radiosensitizer
- Consider adjuvant cisplatin combination chemotherapy after radical cystectomy for people with muscle-invasive or lymph-node-positive cancer not detected before cystectomy
- Side Effects: specialist urology MDT if symptoms of bladder toxicity after radiotherapy cannot be controlled with antispasmodics or non-opiate analgesia
- Follow up: monitoring of the upper tracts for hydronephrosis, stones and cancer using imaging and eGFR annually and monitoring for local and distant recurrence using CT abdomen, pelvis, chest
Locally Advanced:
- First Line Chemo: Cisplatin or Carboplatin in combo with Gemcitabine if performance status 0-2
- Second Line: Gemcitabine in combo with cisplatin, or high-dose MVAC in combination with G-CSF
Symptoms Management:
- Bladder symptoms: offer palliative hypofractionated radiotherapy if haematuria, dysuria, urinary frequency or nocturia caused by cancer unsuitable for curative treatment
- Loin pain: percutaneous nephrostomy or retrograde stenting for people with locally advanced or metastatic bladder cancer and ureteric obstruction