Bladder Cancer
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Direct answer
Painless gross haematuria in a smoker is bladder cancer until cystoscopy proves otherwise; urothelial carcinoma is the dominant histology and smoking its single largest risk factor, ahead of aromatic-amine occupational exposure. Transurethral resection of bladder tumour (TURBT) is both biopsy and treatment, and its quality decides everything: muscle in the specimen, and a repeat resection two to six weeks later whenever muscle is absent or the tumour is T1 or high grade. High-risk non-muscle-invasive disease gets bacillus Calmette-Guérin induction plus maintenance for up to three years; muscle-invasive disease gets neoadjuvant cisplatin-based chemotherapy followed by radical cystectomy with extended lymphadenectomy, or trimodal bladder-preserving therapy for carefully selected patients.
What you must remember
- Diagnosis: cystoscopy plus CT urogram for every episode of gross haematuria; urine cytology adds value in high-grade and carcinoma-in-situ suspicion.
- TURBT quality: detrusor muscle in the specimen (absent in up to half of first resections), obturator reflex blunted by adequate anaesthesia, and a single post-operative mitomycin C instillation within 24 hours — reducing recurrence by roughly a third — provided there is no perforation.
- Repeat TURBT is mandatory for T1 tumours, high-grade tumours except primary CIS, and any specimen without muscle; timing two to six weeks after the first resection.
- Risk stratification: low risk — single, small, low-grade tumour; high risk — T1, high grade, carcinoma in situ, or multiple, recurrent tumours over 3 cm; the middle everything else.
- BCG protocol: six weekly induction instillations, then maintenance three weekly instillations at months 3, 6, 12, 18, 24, 30 and 36 — maintenance is precisely what carries the benefit, and omitting it is the commonest programme error.
- BCG failure: high-grade recurrence within twelve months of adequate BCG defines BCG-unresponsive disease; the classical answer is early radical cystectomy, with pembrolizumab an option for CIS in cystectomy-refusing patients.
- Muscle-invasive disease: neoadjuvant cisplatin chemotherapy before cystectomy adds roughly five to eight per cent absolute five-year survival; radical cystectomy includes an extended pelvic lymph node dissection.
- Follow-up covers the upper tracts and urethra, because urothelial cancer is a field disease.
One resection, read like a consultant
A 66-year-old smoker passes clots painlessly; CT urogram shows a left lateral wall filling defect, cystoscopy a 3 cm papillary tumour. The TURBT is performed under general anaesthesia with muscle relaxation blunting the obturator reflex — which, unblocked, has thrown more than one resection loop through the pelvic sidewall. The specimen is mapped: exophytic portion, base with clear muscle, margins. Pathology: T1 high grade. That single line converts him to high-risk NMIBC: repeat TURBT at four weeks, then BCG induction with the full maintenance schedule, since maintenance — not induction alone — carried the long-term benefit. At month ten, cytology turns high-grade again with a reddened patch: BCG failure within twelve months. The defensible answer is neoadjuvant cisplatin chemotherapy followed by radical cystectomy with extended lymphadenectomy — ileal conduit for comorbidity and age, orthotopic neobladder for the selected patient with negative urethral margins and the discipline to self-catheterise if needed.
How the exam frames it
Stems cluster around four decisions. "No muscle in the TURBT specimen of a high-grade tumour" — repeat TURBT, never intravesical therapy on an unstageable specimen. "Single instillation after TURBT" — mitomycin C within 24 hours, contraindicated after perforation. "BCG-unresponsive carcinoma in situ in a cystectomy-refusing patient" — pembrolizumab, the option the KEYNOTE programme earned. And the neoadjuvant question: sending a fit cisplatin-eligible patient straight to cystectomy loses the mark that "three cycles of cisplatin-based chemotherapy first" earns — among the cheapest marks in oncology. A viva favourite asks why maintenance BCG matters; answering "induction is enough" repeats the error that three decades of data dismantled.
Frequently asked questions
Which patients need a repeat TURBT?
Those with T1 disease, high-grade tumours except primary carcinoma in situ, and any resection lacking detrusor muscle in the specimen. Timing is two to six weeks after the initial resection.
What is the BCG schedule and why is maintenance emphasised?
Induction comprises six weekly instillations, followed by maintenance of three weekly instillations at 3, 6, 12, 18, 24, 30 and 36 months. Long-term data show maintenance reduces recurrence and mortality, so the schedule is worth memorising exactly.
What defines BCG-unresponsive disease, and what follows?
High-grade recurrence or persistence within twelve months of adequate BCG (a full induction plus maintenance or a second induction), including CIS. Standard of care is early radical cystectomy; pembrolizumab is an alternative for CIS in patients unfit for or refusing surgery.
Why is neoadjuvant chemotherapy given before cystectomy?
Cisplatin-based chemotherapy before radical cystectomy delivers roughly five to eight per cent absolute improvement in five-year survival by treating micrometastases while the patient is fit. It is offered to all cisplatin-eligible patients with muscle-invasive disease.
Which patients qualify for bladder-preserving trimodal therapy?
Selected patients with a unifocal tumour under 5–7 cm, no hydronephrosis, no extensive carcinoma in situ, a functional bladder and the capacity for rigorous surveillance. Treatment is maximal TURBT followed by chemoradiotherapy, with prompt salvage cystectomy for incomplete response or recurrence.