Liquid Biopsy: Current advancements in clinical practice for bladder cancer

Bladder cancer is the ninth most common malignancy worldwide, with two clinically distinct forms: non-muscle-invasive disease, characterized by high recurrence and excellent long-term survival, and muscle-invasive disease, associated with poorer outcomes. Current surveillance—cystoscopy and urine cytology—offers high specificity but is invasive, costly, and insensitive to low-grade tumors, underscoring the need for reliable, non-invasive biomarkers. Liquid biopsy approaches in urine and blood have demonstrated promise for real-time assessment of tumor burden, molecular heterogeneity, and early recurrence. Circulating tumor DNA (ctDNA) assays detect tumor-derived genetic and epigenetic alterations, enabling dynamic monitoring of minimal residual disease and treatment response. Methylation-based tests and CpG-targeted sequencing in urine achieve high diagnostic accuracy, potentially reducing dependence on cystoscopy. Molecular classification of bladder tumors into luminal and basal subtypes has refined therapeutic strategies: FGFR inhibitors for luminal-papillary tumors, EGFR-targeted and chemotherapy approaches for basal/squamous cases, and immune-checkpoint inhibitors guided by immune-infiltration profiles. Integration of artificial intelligence with multi-omic liquid biopsy data further enhances predictive modeling for recurrence, treatment response, and minimal residual disease detection. Despite these advances, clinical implementation faces challenges including pre-analytical variability, lack of standardized assays, limited prospective validation, and unclear cost-effectiveness. Harmonized protocols, large multicenter trials, and health-economic evaluations are essential to translate liquid biopsy technologies into routine practice. Future integration with advanced imaging, tissue biopsy, and digital pathology—supported by multidisciplinary collaboration and formal guideline endorsement—holds the potential to personalize bladder cancer management, reduce invasive procedures, and improve patient outcomes.