Related Subjects: |Urothelial tumour s |Haematuria |Acute Urinary Retention |Anuria and Oliguria |Bladder cancer |Renal cell carcinoma |Benign Prostatic Hyperplasia |IgA nephropathy |Prostate Cancer |Henoch-Schonlein purpura |Glomerulonephritis

ℹ️ About

• 👴 Common tumour with increasing age in men and women.
• 👨 Four times more common in males.
• 💧 Most are bladder cancers, but can occur anywhere in the urinary tract — from calyces to urethra.

🧭 Anatomy

• Can affect renal calyces, renal pelvis, ureter, bladder, or urethra.
• 🚫 Tumours in ureters/renal pelvis → may cause hydronephrosis & renal colic.

🔬 Histology

• 🌸 Papillary Urothelial Carcinoma (Ta, low-grade): Superficial, non-invasive, good prognosis.
• 🟥 Carcinoma in situ (CIS): High-grade, flat lesion in epithelium, high risk of progression to invasive disease.
• 💪 Muscle-invasive Urothelial Carcinoma (T2+): Invades detrusor muscle → high risk of metastasis, worse prognosis.

🧬 Aetiology

• 95% Transitional cell (urothelial) carcinomas.
• 5% Squamous cell carcinomas (e.g. chronic schistosomiasis).
• 🩸 Usually localised; distant spread less common than in other tumours.

⚠️ Risk Factors

• 🚬 Cigarette smoking (biggest risk).
• 🌍 Schistosomiasis → squamous cell variant.
• 🎨 Industrial carcinogens: aromatic amines (e.g. β-naphthylamine, benzidine).
• 💊 Drugs: phenacetin (withdrawn), cyclophosphamide.
• 🧪 Exposure to certain dyes and chemicals.

🩺 Clinical Features

• 🔴 Painless haematuria (classic presentation).
• 🫙 Bladder mass.
• ⚡ Irritative voiding symptoms: frequency, urgency, dysuria.
• 🚱 Obstructed ureter → hydronephrosis.

🔍 Investigations

• 🧾 FBC: anaemia; U&E: renal function.
• 💧 Urine: haematuria + cytology (malignant cells).
• 🧪 Urinary tumour markers (adjunctive role).
• 🖥️ Imaging (USS/MRI/CT abdomen + pelvis) for spread.
• 🔎 Cystoscopy with biopsy = gold standard diagnosis.

🛠️ Management

• 🌸 Non-muscle-invasive tumours: • TURBT (transurethral resection). • ± Intravesical therapy: – BCG (best for high-risk). – Intravesical chemotherapy (e.g. mitomycin C, gemcitabine).
• 💪 Muscle-invasive tumours: • Radical cystectomy ± pelvic lymph node dissection. • Neoadjuvant cisplatin-based chemotherapy improves survival. • Bladder preservation strategy: TURBT + chemo + radiotherapy in select patients.
• 🌍 Metastatic disease: • Systemic chemotherapy (cisplatin-based). • Immunotherapy: PD-1/PD-L1 checkpoint inhibitors (e.g. pembrolizumab, atezolizumab). • Targeted therapy: FGFR inhibitors if mutation present.
• 🔄 Surveillance: • Lifelong cystoscopy due to high recurrence risk. • Cytology for CIS/high-grade disease. • Imaging of upper tract for high-risk patients.

💡 Key Teaching Pearl: Any episode of painless haematuria in an adult = urothelial carcinoma until proven otherwise. Always refer for cystoscopy.

🩺 Case 1 — Painless Haematuria

A 68-year-old man presents with painless visible haematuria for 1 week. He is a smoker with a 40-pack-year history. Flexible cystoscopy shows a papillary bladder lesion. Management: 🏥 Transurethral resection of bladder tumour (TURBT) with intravesical mitomycin C; surveillance cystoscopies. Avoid: ❌ Assuming haematuria is due to infection without full urological work-up; avoid delay in referral (2-week wait pathway).

🩺 Case 2 — Upper Tract Urothelial Carcinoma

A 72-year-old woman with flank pain and haematuria undergoes CT urogram showing a filling defect in the renal pelvis. Urine cytology is positive for malignant cells. Management: 💊 Nephroureterectomy with bladder cuff excision is standard for high-grade upper tract TCC; intravesical therapy may be considered for bladder involvement. Avoid: ❌ Simple nephrectomy without removing ureter cuff; avoid missing synchronous bladder lesions (check cystoscopy).

🩺 Case 3 — Muscle-Invasive Bladder Cancer

A 74-year-old man presents with recurrent haematuria, weight loss, and frequency. Cystoscopy and biopsy confirm muscle-invasive TCC. CT staging shows no metastasis. Management: 🚑 Radical cystectomy with urinary diversion or bladder-preserving chemoradiation; cisplatin-based neoadjuvant chemotherapy improves survival. Avoid: ❌ Using intravesical therapy alone in muscle-invasive disease; avoid cisplatin in patients with poor renal function without alternative plan.