Urothelial carcinoma: bladder and upper urinary tract cancer explained

The urinary tract is lined by a specialised tissue called the urothelium. Cancer Research UK explains that the cells, formerly called transitional cells, line the renal pelvis, the ureters, the bladder and the urethra, and that they can change shape and stretch, which allows these parts to expand to store urine or let urine flow through them. Cancer arising from them is urothelial carcinoma, previously called transitional cell cancer.

The same cancer can occur in different places. The charity says urothelial cancer of the bladder is the most common type of bladder cancer, whereas cancer of the upper urinary tract, meaning the renal pelvis in the middle of the kidney or the ureters that carry urine to the bladder, is rare, and of the ureter even less common.

Which part is affected matters for treatment. The NHS bladder cancer pages cover bladder disease, and Cancer Research UK covers the upper urinary tract disease separately, so this guide describes both.

The NHS says it is not always known what causes bladder cancer, and lists factors that may make it more likely. Cancer Research UK adds factors specific to the upper tract.

For bladder cancer, the NHS lists blood in the pee as the main symptom, which may be bright pink, red or dark brown. Other symptoms include pain, burning or stinging when you pee, repeated urinary tract infections, needing to pee more often or very suddenly, loss of appetite and weight, pain in the back and lower tummy, bone pain and unexplained tiredness.

For upper tract disease Cancer Research UK lists blood in the urine and pain in the side between the ribs and the hip (the flank), similar to kidney cancer, and says it is sometimes found on a scan done for another reason. The NHS says some of these symptoms are very common and can be caused by other conditions, but it is important to get checked, because finding cancer early may make it easier to treat.

• Blood in the urine, even once, even a small amount, and even without other symptoms.

• Pain or burning when passing urine, or frequent urinary infections.

• Needing to pass urine more often or very suddenly.

• Pain in the flank, back or lower tummy.

• Unexplained weight loss, loss of appetite or tiredness.

The NHS says a GP may do a blood test or ask for a urine sample and, depending on your symptoms, an examination. If a GP refers you to a urologist, the main test is cystoscopy, performed with painkilling medicine or under general anaesthetic, during which a small sample (biopsy) of the bladder lining may be taken. Further tests such as ultrasound, MRI or CT scans, blood tests and a bone scan help determine the size, type and stage.

For the upper tract, Cancer Research UK lists a CT urogram (a CT scan with contrast dye to look at the urinary system), a chest CT, looking inside the bladder with a cystoscope or inside the ureter and kidney with a ureteroscope with a biopsy if needed, and examination of urine under a microscope for cancer cells.

The NHS says bladder cancer can often be treated and that you will usually be offered surgery, with chemotherapy, radiotherapy and targeted medicines also used. Treatment depends on the type, size and position of the cancer, whether it has spread and your general health. Surgery may remove the cancer from the bladder lining, remove all or part of the bladder and make a new way to pee, or unblock the ureters or urethra.

For the upper urinary tract, Cancer Research UK says surgery is the most common treatment: usually a radical nephroureterectomy removing the kidney, ureter and part of the bladder, sometimes with nearby lymph nodes. Very small, low-risk cancers may be treated by laser or heat through a ureteroscope. Chemotherapy with gemcitabine and cisplatin or carboplatin after surgery may be recommended if the cancer has grown into the muscle layer or spread to nearby lymph nodes, and a single dose of chemotherapy may be put into the bladder after nephroureterectomy to reduce the risk of recurrence there.

For advanced disease, Cancer Research UK says cancer drugs are the main treatment, including the combination of enfortumab vedotin with pembrolizumab or chemotherapy combinations, with avelumab as maintenance treatment after chemotherapy in some cases. The NHS adds that if the cancer cannot be cured, the aim of treatment is to slow its growth and spread and help with symptoms, and a palliative care team supports you.

The NHS says you will have regular check-ups during and after treatment, and that a clinical nurse specialist is your main point of contact. Cancer Research UK says follow-up after endoscopic treatment is regular because the cancer may come back.

Practical steps to lower your own risk include stopping smoking and, for those working with chemicals, wearing protective clothing and masks, according to the NHS. Care is delivered through NHS cancer services, with urgent referral pathways for suspected cancer; private oncology and urology are available but follow the same investigative steps.