Urothelial carcinoma

Diagnosis

The tests used to diagnose urothelial carcinoma depend partly on where the cancer may be in the urinary tract. Evaluation may include urine tests, imaging, biopsy and procedures to look inside the urinary tract.

Blood in the urine is a common symptom of urothelial carcinoma of the bladder and upper urinary tract. Unexplained blood in the urine should be checked by a healthcare professional.

Cystoscopy

Cystoscopy is a procedure that lets a healthcare professional see inside the urethra and bladder. A small, narrow tube called a cystoscope is passed through the urethra. The cystoscope has a lens that lets the healthcare professional check the urethra and bladder for signs of disease.

Urine tests

A urine cytology test involves looking at a sample of urine with a microscope to check for cancer cells. Urine tests also can find blood that isn't visible. Urine tests are used along with other tests to check for urothelial carcinoma.

Imaging tests

Imaging tests make pictures of the urinary tract. They can help find cancer and show whether it may have spread. A computerized tomography (CT) urogram uses contrast material and CT images to show the kidneys, ureters and bladder. Retrograde pyelography is an X-ray test that uses contrast to show the upper urinary tract.

Biopsy

A biopsy is a procedure to remove a sample of tissue for testing in a lab. For a bladder tumor, your healthcare team may remove tissue during cystoscopy or a procedure called transurethral resection of bladder tumor (TURBT). The tissue can confirm cancer and help determine its type and grade.

Transurethral resection of bladder tumor

Transurethral resection of bladder tumor (TURBT) is a procedure used to diagnose bladder cancer and remove cancers from the inside of the bladder. During TURBT, a healthcare professional passes an instrument through the urethra and into the bladder to remove the tumor. TURBT can provide tissue for diagnosis and also treat many non-muscle invasive bladder cancers.

Diagnosing upper tract urothelial carcinoma

When your healthcare professional suspects that you may have upper tract urothelial carcinoma, you may have tests such as cystoscopy and imaging of the kidneys and ureters. A procedure called ureteroscopy also may be used to look inside the ureter and renal pelvis. During ureteroscopy, your healthcare professional may take a tissue sample, called a biopsy, and collect urine for testing.

The healthcare team also checks the bladder because urothelial cancer can be present there at the same time.

Diagnosing urethral urothelial carcinoma

Tests for suspected primary urethral cancer may include urethrocystoscopy, in which a thin tube with a camera is used to look inside the urethra and bladder. A tissue sample and urine sample also may be tested. Imaging, including MRI, may be used to find out how far the cancer has grown.

Stage and grade describe different things. Stage tells how far the cancer has grown or spread. Grade describes how the cancer cells look and gives clues about how they may behave.

Learn more about urothelial carcinoma stages.

Grades

Urothelial carcinomas are classified by grade. Grade describes how cancer cells look under a microscope. Grade can help show how quickly the cancer may grow or spread.

Urothelial carcinoma does not behave the same way in everyone. Low-grade cancers often grow more slowly, while high-grade cancers are more likely to grow into deeper tissues or spread.

Low-grade urothelial carcinoma

Low-grade urothelial carcinoma has cells that more closely resemble typical cells in appearance and organization. Low-grade bladder cancer tends to grow more slowly and is less likely to grow into the bladder muscle than is high-grade cancer.

High-grade urothelial carcinoma

High-grade urothelial carcinoma has cells that look very different from typical tissue. High-grade bladder cancer tends to grow faster and is more likely to invade the bladder muscle or spread to other tissues and organs. Carcinoma in situ of the bladder is high grade.

Grade also matters in upper tract urothelial carcinoma. Low-grade and high-grade UTUC are managed differently, and grade helps the healthcare team understand the cancer's risk.

Treatment

Treatment for urothelial carcinoma depends on where the cancer started, its grade and stage, whether it has spread, your overall health and your personal preferences. Treatment may include surgery or other procedures, chemotherapy, immunotherapy, antibody-drug conjugates, targeted therapy, or radiation therapy. Some of these treatments are used together.

Bladder urothelial carcinoma can sometimes be cured. Non-muscle invasive bladder cancer often can be managed with treatments directed at the bladder. Muscle-invasive bladder cancer generally needs more-intensive treatment. For metastatic urothelial carcinoma, treatment may shrink or slow the cancer, ease symptoms, and help people live longer.

TURBT

TURBT is both a diagnostic procedure and a treatment for many non-muscle invasive bladder cancers. A surgeon removes visible tumor through the urethra without making an incision in the abdomen. Medicine may be placed directly into the bladder after TURBT to kill cancer cells that may remain and lower the risk of recurrence.

Intravesical therapy

Intravesical therapy puts medicine directly into the bladder. The treatment may include chemotherapy or immunotherapy. Bacillus Calmette-Guerin (BCG) is an immunotherapy put directly into the bladder. It is used for some intermediate- and high-risk non-muscle invasive bladder cancers. BCG after TURBT can lower the risk that the cancer comes back.

Intravesical treatments can cause bladder irritation and urinary symptoms. BCG also can cause flu-like symptoms and, rarely, more-serious complications.

Cystectomy and urinary diversion

Cystectomy is surgery to remove all or part of the bladder. During a partial cystectomy, only the part of your bladder containing cancer is removed. During a radical cystectomy, the surgeon removes your entire bladder and nearby lymph nodes. The surgeon also may remove nearby reproductive organs.

After radical cystectomy, urinary diversion makes a new way for urine to leave the body. Options may include a neobladder, an ileal conduit that drains to a pouch outside the body or a continent urinary reservoir that is drained through an opening in your abdomen.

Radical cystectomy and urinary diversion can have long-lasting effects on urinary control, sexual function, fertility, bowel function and your body's chemical balance.

Chemotherapy

Chemotherapy uses medicines to kill cancer cells. Chemotherapy may be used for urothelial carcinoma depending on where the cancer started and how advanced it is. For some people who have muscle-invasive bladder cancer and can receive cisplatin, the chemotherapy medicines gemcitabine and cisplatin may be combined with the immunotherapy medicine durvalumab before radical cystectomy. Treatment with durvalumab may continue after surgery. Chemotherapy also can be used with radiation therapy to preserve the bladder or to treat advanced cancer.

Chemotherapy side effects depend on the medicines used. Side effects may include low blood cell counts, infection, mouth sores, hair loss, fatigue and digestive symptoms. Cisplatin also can affect your kidneys, hearing and nerves.

Immunotherapy

Immunotherapy is medicine that helps your immune system fight cancer. It is now an important part of treatment for urothelial cancer, including muscle-invasive bladder cancer. For muscle-invasive bladder cancer, immunotherapy may be combined with chemotherapy or with an antibody-drug conjugate before surgery. The combination treatment may continue after surgery. It also may be used to treat advanced disease. Side effects can affect healthy organs, including your skin, intestines, liver, lungs and hormone-producing glands.

Antibody-drug conjugates

An antibody-drug conjugate combines a cancer-killing medicine with an antibody that attaches to a specific target on cancer cells. Enfortumab vedotin is an antibody-drug conjugate used to treat urothelial cancer, including advanced disease.

For some people with muscle-invasive bladder cancer, enfortumab vedotin may be combined with the immunotherapy medicine pembrolizumab before radical cystectomy and continued after surgery.

Targeted therapy

Targeted therapy uses medicines that target specific features of cancer cells. For advanced urothelial carcinoma, tests may look for gene changes or other tumor features. The results can help show whether targeted therapy may be an option for you.

Radiation therapy and bladder preservation

Radiation therapy treats cancer with powerful energy beams. For selected people with muscle-invasive bladder cancer, bladder-preserving treatment may combine TURBT, chemotherapy and radiation therapy. This approach is sometimes called trimodality therapy. If cancer remains or comes back, radical cystectomy may be needed.

Treatment for upper tract urothelial carcinoma

Treatment for upper tract urothelial carcinoma (UTUC) depends on the cancer's grade and stage, where it is, how large it is, how likely it is to grow or spread, and how well your kidneys are working. Your overall health also affects your treatment choices.

For some low-risk UTUC, treatment may be able to preserve your kidney. A surgeon may use ureteroscopy or another procedure that reaches the tumor through your urinary tract to remove or destroy the cancer. Some low-grade cancers also may be treated with medicine placed directly into your upper urinary tract. These treatments require close follow-up because the cancer can come back.

For some high-risk UTUC, a surgeon may remove the kidney, the entire ureter and a small cuff of bladder where the ureter enters the bladder. This operation is called radical nephroureterectomy. Some people also receive chemotherapy before or after surgery. If UTUC has spread to other parts of your body, treatment usually uses medicines that work throughout your body, similar to treatment for advanced urothelial carcinoma of the bladder.

Treatment for urethral urothelial carcinoma

Treatment of urothelial carcinoma that starts in the urethra depends on its location and how far it has grown. Options may include endoscopic treatment, surgery, chemotherapy, radiation therapy or combinations of treatments. Because primary urethral cancer is rare, treatment is individualized.

After treatment

Urothelial carcinoma may come back even after successful treatment. Follow-up depends on where the cancer started, how likely the cancer is to come back or spread, and the treatment you received. For bladder cancer, follow-up may include cystoscopy, urine tests and imaging. After UTUC, follow-up may include cystoscopy, imaging or a procedure to look inside your remaining upper urinary tract.

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Coping and support

Knowing that urothelial carcinoma can come back may cause worry or anxiety. One way to feel more at ease is to ask your healthcare team for a schedule of the tests you will likely need and why you need them. Planning how you may cope with anxiety before follow-up visits also may help. Some tips include:

• Keep your follow-up appointments. Ask what tests you will likely need and how often.
• Talk about your concerns with someone you trust or with your healthcare team.
• Consider connecting with other people who have been treated for bladder or urothelial cancer.

Preparing for your appointment

Make an appointment with a healthcare professional if you have symptoms that worry you. You may start with your primary healthcare professional and then be referred to a specialist called a urologist. Depending on your diagnosis and the treatment you need, you also may see specialists in cancer treatment, radiation therapy, medical imaging and lab testing.

What you can do

When you make the appointment, ask whether there is anything you need to do beforehand. Make a list of:

• Your symptoms, including when they started and whether they come and go.
• Personal and family medical history, including cancer history.
• All medicines, vitamins and supplements you take, including doses.
• Questions you want to ask your healthcare professional.

If possible, take a family member, friend or another trusted person with you to help remember the information you get.

Questions to ask

• Where did my urothelial carcinoma start?
• Is the cancer limited to the bladder or another part of the urinary tract?
• What is the grade of my cancer?
• What is the stage?
• If the cancer is in the bladder, is it non-muscle invasive or muscle invasive?
• What treatment options do I have?
• Could treatment cure the cancer?
• What are the possible risks and side effects of treatment?
• What is the chance the cancer will come back?
• Will I need ongoing testing of my bladder or upper urinary tract?
• Should I see a specialist?