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Bladder and urothelial cancer
The key rule in bladder cancer is muscle invasion: a non-muscle-invasive tumour is treated by transurethral resection and intravesical therapy (BCG), and a muscle-invasive tumour by cisplatin-based chemotherapy and cystectomy, or by bladder-sparing combined treatment in suitable patients.
Why it matters in the exam
Bladder cancer appears in the exam in questions on selecting candidates for bladder-sparing (trimodality) therapy, neoadjuvant treatment, FGFR3 mutations, cisplatin-gemcitabine versus MVAC and treatment of metastatic disease. The common scenario is an older smoker with painless haematuria.
Other questions test when a patient is unfit for cisplatin, what follows nephroureterectomy for an upper-tract urothelial tumour, and how to recognise side effects of enfortumab vedotin. Remember that upper-tract tumours are also linked to Lynch syndrome.
Key points
- The key distinction is between non-muscle-invasive and muscle-invasive tumours, set by a TURBT that includes muscle.
- High-risk non-muscle-invasive tumours are treated with intravesical BCG with maintenance.
- Muscle-invasive tumours are treated with neoadjuvant cisplatin-based chemotherapy and cystectomy, or with bladder-sparing therapy in a suitable patient.
- In metastatic disease first line today is enfortumab vedotin with pembrolizumab.
- FGFR3 mutations are common in low-grade tumours and are a target for erdafitinib in advanced disease.
Summary table
| Situation | Treatment | Exam detail |
|---|---|---|
| Non-muscle-invasive low risk (low-grade Ta) | Transurethral resection (TURBT) and a single dose of intravesical chemotherapy | FGFR3 mutations are very common in these tumours |
| Non-muscle-invasive high risk (T1, high grade, CIS) | Repeat resection in T1, then intravesical BCG with maintenance | BCG failure — cystectomy or newer intravesical treatments |
| Muscle-invasive (T2–T4a) | Neoadjuvant cisplatin-based chemotherapy, then radical cystectomy | Durvalumab may be added around surgery; adjuvant nivolumab in high risk |
| Bladder-sparing treatment | Maximal transurethral resection followed by chemoradiation | Good candidate: single tumour, complete resection, no hydronephrosis and no extensive CIS |
| Metastatic, first line | Enfortumab vedotin with pembrolizumab | Alternative: gemcitabine-cisplatin and avelumab maintenance; GC is as effective as MVAC and less toxic |
| Unfit for cisplatin | Carboplatin or platinum-free treatment | Creatinine clearance below 60, poor performance status, neuropathy, hearing loss or heart failure |
| Upper-tract urothelial tumour | Nephroureterectomy, and adjuvant platinum-based chemotherapy from pT2 or with positive nodes | Test for Lynch syndrome |
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
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Sources
- NCCN Clinical Practice Guidelines in Oncology: Bladder Cancer, 2026 — Non-muscle-invasive, muscle-invasive and metastatic disease
- EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer, 2025 — Treatment
- Gunderson and Tepper's Clinical Radiation Oncology, 5th ed. (2021) — Bladder cancer
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.