The initial symptoms include haematuria, dysuria and frequency of micturition. These symptoms are, unfortunately, sometimes treated with antibiotics by GPs for a period of time, prior to referral to a specialist. New urinary tract infections in older women should always be investigated actively, and symptoms occurring in a man should always be considered to be pathological and a referral made. Treating haematuria in a man with antibiotics without further investigation is negligent. There is of course a differential diagnosis, but one should have a very high index of suspicion of malignancy. Referral should be promptly organized to a specialist urological surgeon. The patient will be seen in an outpatient clinic. A careful history should be taken and an examination made. The patient’s symptoms should be investigated further by performing a blood count, renal function tests, liver function tests and bacteriological and cytological examination of urine, to examine for the presence of infection and malignancy. An intravenous pyelogram (IVP) or increasingly a CT urogram may be ordered to examine the urothelial tract radiologically or an ultrasound investigation carried out.

These investigations should be organized promptly and the patient reviewed with the result within 2 weeks. A flexible cystoscopy is then generally organized and this takes place in the initial outpatient setting. If there is any suspicious appearance to the bladder, arrangements should then be made for a formal cystoscopy. The patient is anaesthetized for this procedure and the urethra and bladder carefully examined using a fibreoptic cystoscope. Any abnormal areas within the bladder should be biopsied together with areas of surrounding, apparently normal-looking bladder. The urologists at cystoscopy may describe a normal-looking bladder or the presence of a papilloma or solid tumour. The suspicious areas are treated by diathermy and the pelvis carefully examined in order to describe the clinical staging of the tumour.

The majority of transitional cell carcinoma of the bladder present as superficial tumours. The first step in the diagnosis and management of non-muscle invasive bladder cancer is cystoscopic transurethral resection of the bladder tumour (TURBT). After resection by diathermy at cystoscopy, approximately 60% of tumours will recur. The recurrence rate is greater where there are multiple tumours, associated carcinoma in situ or poorly differentiated tumours. For patients at low risk of recurrence, a single dose of intravesical mitomycin C may be administered following TURBT, whilst for those at high risk a course of intravesical bacillus Calmette–Guerin (BCG) is given to reduce the recurrence rate. Maintenance therapy with BCG, given for up to 2 years, has been shown to prevent recurrence, but the side effects mean that only 30% patients complete the course of maintenance therapy. Cystoscopic surveillance following TURBT is advocated. The recommendation for follow-up is slightly controversial, but in most practices cystoscopy is performed 3-monthly until the patient is tumour-free and thereafter 6-monthly for 2 years and yearly for 3 years. Practice varies throughout the United Kingdom. The requirement for lifelong routine monitoring and treatment in bladder cancer made it the most expensive cancer in terms of total medical care expenditure at least in 2001 when this cost was estimated at US$ 100,000 from diagnosis to death.

The authors of this book are impressed by the alacrity with which surgeons thrust out with knives advanced to excise bladders in patients with superficial bladder cancer. Many surgeons would view a recurrence-free survival of over 80% following cystectomy as a triumph of their surgical skills, but the truth (from several clinical trials) is that this recurrence-free survival is achieved by conservative treatment with intravesical BGC alone.

The treatment of muscle-invasive carcinoma of the bladder is by surgery or radiation in those unfit for surgery. Radical cystectomy with urinary diversion is the preferred treatment for localized muscle-invasive bladder cancer and may in some cases be performed laparoscopically. Neoadjuvant cisplatin-containing chemotherapy before surgery has been shown to improve overall survival in two randomized controlled trials, whilst the use of post-operative adjuvant chemotherapy remains controversial. After cystectomy, patients must be nursed either in intensive care or in high-dependency beds. Continent bladders may be fashioned by the surgeon so that the patient does not require an ileostomy. Men are invariably rendered impotent by cystectomy. Little is known of the effects of cystectomy on female sexual function. There are well-known electrolyte disorders associated with ileostomies (chiefly dehydration and loss of sodium and potassium).

Radical radiotherapy is generally given to a total dose of 6500 cGy over a 6-week period. Treatment should be given to the whole pelvis, focusing down upon the bladder towards the end of treatment, or may be given to the bladder alone. Some radiotherapists insist on treating pelvic nodes in addition to the bladder primary. This leads to added toxicity and is illogical. If there are metastases present in pelvic nodes, there is a very high chance that they will also be present in intra-abdominal nodes so irradiating pelvic nodes had no logical benefit. Radiotherapy can also be used to reduce haematuria in advanced disease if TURBT is unable to control this. During radiotherapy, the patient may get cystitis or proctitis. At the end of treatment, he or she may suffer from a small, shrunken bladder as a consequence of radiation fibrosis. Both cystitis and proctitis are common after radiotherapy to the bladder, occurring in up to 30% of patients.

Adenocarcinoma of the bladder is thought to be relatively resistant to chemotherapy and radiotherapy, and as a consequence surgery is the main treatment option. Small cell bladder cancer and bladder lymphoma are managed with treatment regimens for small cell lung cancer and disseminated lymphoma, respectively.