Bladder cancer: diagnosis and management

Do not substitute urinary biomarkers for cystoscopy to investigate suspected bladder cancer or for follow‑up after treatment for bladder cancer, except in the context of a clinical research study.

Consider CT or MRI staging before transurethral resection of bladder tumour (TURBT) if muscle‑invasive bladder cancer is suspected at cystoscopy.

Offer white‑light‑guided TURBT with one of photodynamic diagnosis, narrow‑band imaging, cytology or a urinary biomarker test (such as UroVysion using fluorescence in‑situ hybridization [FISH], ImmunoCyt or a nuclear matrix protein 22 [NMP22] test) to adults with suspected bladder cancer. This should be carried out or supervised by a urologist experienced in TURBT.

Obtain detrusor muscle during TURBT.

Do not take random biopsies of normal‑looking urothelium during TURBT unless there is a specific clinical indication (for example, investigation of positive cytology not otherwise explained).

Record the size and number of tumours during TURBT.

Offer adults with suspected bladder cancer a single dose of intravesical mitomycin C given at the same time as the first TURBT.

Consider further TURBT within 6 weeks if the first specimen does not include detrusor muscle.

Offer CT or MRI staging to adults diagnosed with muscle‑invasive bladder cancer or high-risk non-muscle-invasive bladder cancer that is being assessed for radical treatment.

Consider CT urography, carried out with other planned CT imaging if possible, to detect upper tract involvement in adults with new or recurrent high‑risk non‑muscle‑invasive or muscle‑invasive bladder cancer.

Consider CT of the thorax, carried out with other planned CT imaging if possible, to detect thoracic malignancy in adults with muscle‑invasive bladder cancer.

Consider fluorodeoxyglucose positron emission tomography (FDG PET)‑CT for adults with muscle‑invasive bladder cancer or high‑risk non‑muscle‑invasive bladder cancer before radical treatment if:

• there are indeterminate findings on CT or MRI, or

• a high risk of metastatic disease (for example, T3b disease).

Ensure that for adults with non‑muscle‑invasive bladder cancer all of the following are recorded and used to guide discussions, both within multidisciplinary team meetings and with the person, about prognosis and treatment options:

• recurrence history

• size and number of cancers

• histological type, grade, stage and presence (or absence) of flat urothelium, detrusor muscle (muscularis propria), and carcinoma in situ

• the risk category of the person's cancer

• predicted risk of recurrence and progression, estimated using a risk prediction tool.

For the treatment of low-risk non-muscle-invasive bladder cancer, see also recommendations 1.2.3 to 1.2.8 on the use of white-light-guided TURBT and intravesical mitomycin C in the sections on diagnosing and staging bladder cancer.

Offer adults with newly diagnosed intermediate-risk non-muscle-invasive bladder cancer a course of at least 6 doses of intravesical mitomycin C.

If intermediate‑risk non‑muscle‑invasive bladder cancer recurs after a course of intravesical mitomycin C, refer the person's care to a specialist urology multidisciplinary team.

If the first TURBT shows high-risk non-muscle-invasive bladder cancer, offer another TURBT as soon as possible and no later than 6 weeks after the first resection.

Offer the choice of intravesical BCG (Bacille Calmette‑Guérin) or radical cystectomy to adults with high‑risk non‑muscle‑invasive bladder cancer.

Involve the clinical nurse specialist and a urologist who performs both intravesical BCG and radical cystectomy in discussions with the person about the choice of treatment.

Consider fulguration without biopsy for adults with recurrent non‑muscle‑invasive bladder cancer if they have all of the following:

• no previous bladder cancer that was intermediate or high risk

• a disease‑free interval of at least 6 months

• solitary papillary recurrence

• a tumour diameter of 3 mm or less.

Do not offer primary prophylaxis to prevent BCG‑related bladder toxicity except as part of a clinical trial.

Seek advice from a specialist urology multidisciplinary team if symptoms of bladder toxicity after BCG cannot be controlled with antispasmodics or non‑opiate analgesia and other causes have been excluded by cystoscopy.

Offer adults with low-risk non-muscle-invasive bladder cancer cystoscopic follow‑up 3 months and 12 months after diagnosis.

Do not use urinary biomarkers or cytology in addition to cystoscopy for follow‑up after treatment for low‑risk bladder cancer.

Discharge to primary care adults who have had low‑risk non‑muscle‑invasive bladder cancer and who have no recurrence of the bladder cancer within 12 months.

Do not offer routine urinary cytology or prolonged cystoscopic follow‑up after 12 months for adults with low‑risk non‑muscle‑invasive bladder cancer.

Offer adults with intermediate-risk non-muscle-invasive bladder cancer cystoscopic follow‑up at 3, 9 and 18 months, and once a year thereafter.

Consider discharging adults who have had intermediate‑risk non‑muscle‑invasive bladder cancer to primary care after 5 years of disease‑free follow‑up.

Offer adults with high-risk non-muscle-invasive bladder cancer cystoscopic follow‑up:

• every 3 months for the first 2 years then

• every 6 months for the next 2 years then

• once a year thereafter.

For adults who have had radical cystectomy for high‑risk non‑muscle‑invasive bladder cancer, follow recommendations 1.6.1 and 1.6.2 in the section on follow-up after treatment for muscle-invasive bladder cancer.

Offer neoadjuvant chemotherapy using a cisplatin combination regimen before radical cystectomy or radical radiotherapy to adults with newly diagnosed muscle‑invasive urothelial bladder cancer for whom cisplatin‑based chemotherapy is suitable.

Involve an oncologist who treats bladder cancer in discussions with the person about the risks and benefits of neoadjuvant chemotherapy using a cisplatin combination regimen before radical cystectomy, or radical radiotherapy.

Offer a choice of radical cystectomy or radiotherapy with a radiosensitiser to adults with muscle‑invasive urothelial bladder cancer for whom radical therapy is suitable.

Involve a urologist who performs radical cystectomy, a clinical oncologist and a clinical nurse specialist in discussions with the person about the choice of treatment.

When discussing the choice of treatment, cover the:

• prognosis with or without treatment

• limited evidence about whether surgery or radiotherapy with a radiosensitiser is the most effective cancer treatment

• benefits and risks of surgery and radiotherapy with a radiosensitiser, including the impact on sexual and bowel function and the risk of death as a result of the treatment.

Seek advice from a specialist urology multidisciplinary team if symptoms of bladder toxicity after radiotherapy cannot be controlled with antispasmodics or non‑opiate analgesia and other causes have been excluded by cystoscopy.

Offer a cisplatin‑based chemotherapy regimen (such as cisplatin in combination with gemcitabine, or accelerated [high‑dose] methotrexate, vinblastine, doxorubicin and cisplatin [MVAC] in combination with granulocyte‑colony stimulating factor [G‑CSF]) to adults with locally advanced or metastatic urothelial bladder cancer who are:

• otherwise physically fit (have an Eastern Cooperative Oncology Group [ECOG] performance status of 0 or 1) and

• have adequate renal function (typically defined as a glomerular filtration rate [GFR] of 60 ml/min/1.73 m² or more).

Offer carboplatin in combination with gemcitabine to adults with locally advanced or metastatic urothelial bladder cancer with an ECOG performance status of 0 to 2 if a cisplatin‑based chemotherapy regimen is unsuitable, for example, because of ECOG performance status, inadequate renal function (typically defined as a GFR of less than 60 ml/min/1.73 m²) or comorbidity.

In September 2025 this was an off-label use of carboplatin in combination with gemcitabine. See NICE's information on prescribing medicines.

Enfortumab vedotin with pembrolizumab is recommended as an option in NICE technology appraisal guidance for untreated unresectable or metastatic urothelial cancer in adults when platinum-based chemotherapy is suitable. For full details, see the guidance on enfortumab (TA1097, 2025).

Atezolizumab is recommended as an option in NICE technology appraisal guidance for adults with untreated locally advanced or metastatic urothelial cancer whose tumours express PD-L1 at a level of 5% or more and for whom cisplatin-containing chemotherapy is unsuitable. For full details, see the guidance on atezolizumab (TA739, 2021).

For adults having first‑line systemic anticancer therapy for locally advanced or metastatic bladder cancer:

• carry out regular clinical and radiological monitoring and

• actively manage symptoms of disease and treatment‑related toxicity and

• stop first‑line systemic anticancer therapy if there is excessive toxicity or disease progression.

Avelumab is recommended as an option in NICE technology appraisal guidance for maintenance treatment of locally advanced or metastatic urothelial cancer in adults that has not progressed after platinum-based chemotherapy, only if avelumab is stopped at 5 years of uninterrupted treatment or earlier if the disease progresses. For full details, see the guidance on avelumab (TA788, 2022).

Consider second‑line chemotherapy with gemcitabine in combination with cisplatin, or accelerated (high‑dose) MVAC in combination with G‑CSF for adults with incurable locally advanced or metastatic urothelial bladder cancer whose condition has progressed after first‑line systemic anticancer therapy if:

• their renal function is adequate (typically defined as a GFR of 60 ml/min/1.73 m² or more) and

• they are otherwise physically fit (have an ECOG performance status of 0 or 1).

Consider second‑line chemotherapy with carboplatin in combination with paclitaxel or gemcitabine in combination with paclitaxel for adults with incurable locally advanced or metastatic urothelial bladder cancer for whom cisplatin‑based chemotherapy is not suitable, or who choose not to have it.

In September 2025 this was an off-label use of carboplatin in combination with gemcitabine and gemcitabine in combination with paclitaxel. See NICE's information on prescribing medicines.

Atezolizumab is recommended as an option in NICE technology appraisal guidance for treating locally advanced or metastatic urothelial cancer in adults after platinum-containing chemotherapy, only if atezolizumab is stopped at 2 years of uninterrupted treatment or earlier if the disease progresses. For full details, see the guidance on atezolizumab (TA525, 2018).

Erdafitinib is recommended as an option in NICE technology appraisal guidance for treating unresectable or metastatic urothelial cancer with susceptible FGFR3 genetic alterations in adults after at least 1 line of treatment for unresectable or metastatic cancer that included a PD-1 or PD-L1 inhibitor. For full details, see the guidance on erdafitinib (TA1062, 2025).

For adults having second-line systemic anticancer therapy for locally advanced or metastatic bladder cancer:

• carry out regular clinical and radiological monitoring and

• actively manage symptoms of disease and treatment-related toxicity and

• stop second-line systemic anticancer therapy if there is excessive toxicity or disease progression.

For medicines not recommended in NICE technology appraisal guidance for treating locally advanced or metastatic urothelial cancer after platinum-containing chemotherapy, see the guidance on:

• pembrolizumab (TA692, 2021)

• nivolumab (TA530, 2018)

• vinflunine (TA272, 2013).

For NTRK inhibitors recommended as options in NICE technology appraisal guidance through the Cancer Drugs Fund for treating locally advanced or metastatic NTRK fusion-positive solid tumours when there are no other satisfactory treatment options, see the guidance on:

• entrectinib (TA644, August 2020)

• larotrectinib (TA630, May 2020).