Purpose: To evaluate the pathological correlation and prognostic significance of tissue stiffness measured by shear wave elastography (SWE) in bladder cancer. Materials and Methods: Patients with microscopic or macroscopic hematuria diagnosed with bladder tumors were included. SWE measurements were performed using a Samsung Medison RS80A Prestige ultrasonography device, with ten valid measurements taken for each tumor. Tumor specimens were collected via transurethral resection (transurethral resection of the bladder tumor) for histopathological analysis. Microvessel density (MVD) was assessed by immunohistochemical staining with anti-CD34 antibody using the hot-spot method. Correlations between tissue stiffness, MVD and tumor stage and grade were analyzed, and receiver operating characteristic (ROC) analysis determined the optimal SWE cutoff for differentiating tumor characteristics. Results: A total of 65 bladder urothelial carcinoma patients were included in the study (43 high-grade, 22 low-grade). SWE and MVD were significantly higher in the high-grade group (p=0.001, p=0.002, respectively). ROC analysis showed SWE could differentiate tumor grades (area under ROC curve=0.837, p<0.001), with a cut-off of 4.25 kPa (74% sensitivity, 86% specificity). Stiffness was also higher in recurrence (p=0.007). A strong positive correlation between SWE and MVD was found (rho=0.767, p<0.001).SWE may be a reliable, non-invasive tool for assessing tumor grade and recurrence risk. Conclusions SWE may be a reliable, non-invasive preoperative marker for bladder cancer, aiding in tumor characterization and clinical decision-making.