Urinary tract cancer

Last updated: September 13, 2023

Summarytoggle arrow icon

Urinary tract cancer most commonly involves the bladder, although it may also occur in the renal pelvis, ureters, and, rarely, the urethra. The most common histological type of urinary tract cancer is urothelial carcinoma, followed by squamous cell carcinoma and adenocarcinoma. Symptomatic patients often present with painless gross hematuria and/or irritative voiding symptoms. Urinary tract cancer may also be diagnosed in patients with an incidental finding of microhematuria. All patients with unexplained gross hematuria should be evaluated for urinary tract carcinoma, while patients with microhematuria should undergo risk stratification to determine the need for further evaluation. Diagnostic evaluation includes laboratory studies, imaging, and direct visualization with collection of biopsy samples. Treatment selection is guided by histology, location, and tumor grade and stage. Upper urinary tract carcinomas (i.e., in the renal pelvis and/or ureters) and urethral carcinomas are rare, and there are no standardized treatment protocols. For bladder cancer, nonmuscle invasive disease is treated with transurethral resection of the bladder tumor (TURBT) and either intravesical chemotherapy or bacillus Calmette-Guérin (BCG). Muscle invasive bladder cancer is usually treated more aggressively with neoadjuvant chemotherapy followed by radical cystectomy. Metastatic bladder cancer is managed with palliative chemotherapy. Disease recurrence is common; therefore, close follow-up surveillance is required.

Renal cancer is covered separately in “Renal cell carcinoma.”

Epidemiologytoggle arrow icon


Epidemiological data refers to the US, unless otherwise specified.

Risk factorstoggle arrow icon

Transitional cell urothelial carcinoma [4][8][9][10]

Squamous cell carcinoma [3][9][10]


A carcinogen ACTS on the bladder: Aniline dye, Cyclophosphamide, Tobacco, Schistosomiasis

Clinical featurestoggle arrow icon

Clinical features of urinary tract cancer
Location Symptoms Features of advanced/metastatic disease
Bladder carcinoma

Carcinoma of the renal pelvis and ureteral carcinoma

Urethral carcinoma


Diagnosticstoggle arrow icon

Approach [21][22][23]

Evaluate the entire urinary tract if malignancy is suspected. Use imaging to assess the renal pelvis and ureters and perform cystoscopy to assess the bladder and urethra.

Initial laboratory studies

Urinalysis with microscopy [21]

Identification of dysmorphic RBCs, RBC casts, and/or significant proteinuria on urine microscopy indicates a glomerular cause of hematuria. [25]

Assessment of urine tumor markers is not recommended, as their diagnostic value is uncertain. [21][23]

Blood tests [21]

Imaging [22][23][26]

Perform urinary tract imaging prior to direct visualization as inflammation from instrumentation/biopsy can make radiological interpretation challenging. [21]

Direct visualization (cystoscopy/ureteroscopy) [22][23][29]

TURBT may be performed during cystoscopy if lesions are detected.

Direct visualization is the gold standard for diagnosing urinary tract cancer. [23][33]

During cystoscopy, TURBT can allow for simultaneous diagnosis and treatment.

Pathology studies

Biopsy [23][33]

Urine cytology [23]

  • Indication: an adjunct study for patients with gross hematuria [21][22][23]
  • Findings: can detect sloughed malignant cells, especially from high-grade urothelial tumors [22]

Staging studies for urinary tract cancer [34][35][36]

Examination under anesthesia may be used to determine locoregional extension. [34]

Assessment of microhematuriatoggle arrow icon

Overview [22][23]

Risk stratification for microhematuria

Risk of malignancy in patients with microhematuria [23]

Low risk

(all criteria must be fulfilled)

Intermediate risk

(if any of the following are present)

High risk

(if any of the following are present)

Age (years)
  • Women < 50
  • Men < 40
  • Women 50–59
  • Men 40–59
  • Patients ≥ 60
Smoking history (pack-years)
  • < 10
  • 10–30
  • > 30
RBCs per HPF on urine microscopy
  • 3–10 on single analysis
  • 11–25 on single analysis
  • 3–10 on more than one sample
  • > 25

Additional features

  • None

Risk-based assessment of microhematuria [23]

Pathologytoggle arrow icon

Differential diagnosestoggle arrow icon

Other causes of hematuria and flank pain


The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

This article primarily discusses treatment options for urothelial carcinoma, as squamous cell carcinoma and adenocarcinoma of the urinary tract are less common and protocols are less established.

General principles

Treatment of bladder cancer

Bladder cancer is the most common urothelial cancer; treatment differs based on the presence of muscular invasion and/or metastases.

Nonmuscle invasive [39]

Nonmetastatic muscle invasive [34]

Metastatic disease [42]

Treatment of carcinoma of the renal pelvis and ureters [29]

Treatment of urethral carcinoma [5][43][44]

Monitoring [29][34][39]

Prognosistoggle arrow icon

  • 5-year survival of bladder, ureteral, and pelvic cancer is 90–95% for noninvasive disease and ∼ 12% for metastatic disease.
  • Prognosis of urethral cancer is poorer (5-year survival of ∼ 45%).


Preventiontoggle arrow icon

Routine screening for bladder cancer in asymptomatic adults is not recommended


Referencestoggle arrow icon

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