Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
Definitions for the grade of recommendation (A-B) are provided at the end of the "Major Recommendations" field.
Recommendations for Primary Assessment of TaT1 Bladder Tumours
- Renal and bladder ultrasonography, intravenous urography (IVU) or computed tomography (CT) in selected cases (tumours located in the trigone). (Grade of recommendation: B)
- Cystoscopy with description of the tumour (site, size, number and appearance) and mucosal abnormalities. A bladder diagram is recommended. (Grade of recommendation: C)
- Urine analysis
- Urine cytology
- Transurethral resection (TUR) in one piece for small tumours (less than 1 cm), including a part from the underlying bladder wall. (Grade of recommendation: B)
- TUR infractions (including muscle tissue) for larger tumours. (Grade of recommendation: B)
- Biopsies of abnormal-looking urothelium, biopsies from normal-looking mucosa when cytology is positive or when exophytic tumour is of non-papillary appearance. (Grade of recommendation: C)
- Biopsy of the prostatic urethra in the case of bladder neck tumour, when bladder CIS is present or suspected or when abnormalities of prostatic urethra are visible. (Grade of recommendation: C)
- A second TUR at 2-6 weeks after the initial resection when it was incomplete or when a high-grade or T1 tumour was detected. (Grade of recommendation: B)
- The pathological report should specify the grade, the depth of tumour invasion and whether the lamina propria and muscle are present in the specimen. (Grade of recommendation: C)
Predicting Recurrence and Progression in TaT1 Tumours
The tables below provide a patient's risk of recurrence and progression based on their most important clinical and tumour characteristics. Using these tables, the urologist can discuss with a patient his prognosis and offer different treatment options.
For providing treatment recommendations, the European Association of Urology (EAU) working group suggests using a three-tier system reflecting the European Organization for Research and Treatment of Cancer (EORTC) risk tables, which define low-, intermediate-, and high-risk groups for both recurrence and progression (see Tables below).
Table: Weighting Used to Calculate Recurrence and Progression Scores
Factor |
Recurrence |
Progression |
Number of tumours |
Single |
0 |
0 |
2-7 |
3 |
3 |
> 8 |
6 |
3 |
Tumour diameter |
< 3 cm |
0 |
0 |
> 3 cm |
3 |
3 |
Prior recurrence rate |
Primary |
0 |
0 |
< 1 recurrence/year |
2 |
2 |
> 1 recurrence/year |
4 |
2 |
Category |
Ta |
0 |
0 |
T1 |
1 |
4 |
Concomitant CIS |
No |
0 |
0 |
Yes |
1 |
6 |
Grade (1973 WHO) |
G1 |
0 |
0 |
G2 |
1 |
0 |
G3 |
2 |
5 |
Total score |
0-17 |
0-23 |
CIS = carcinoma in situ
Table: Probability of Recurrence and Progression According to Total Score
Recurrence Score |
Probability of Recurrence at 1 Year |
Probability of Recurrence at 5 Years |
Recurrence Risk Group |
|
% |
(95% CI) |
% |
(95% CI) |
|
0 |
15 |
(10-19) |
31 |
(24-37) |
Low risk |
1-4 |
24 |
(21-26) |
46 |
(42-49) |
Intermediate risk |
5-9 |
38 |
(35-41) |
62 |
(58-65) |
10-17 |
61 |
(55-67) |
78 |
(73-84) |
High risk |
Progression Score |
Probability of Progression at 1 Year |
Probability of Progression at 5 Years |
Progression Risk Group |
|
% |
(95% CI) |
% |
(95% CI) |
|
0 |
0.2 |
(0-0.7) |
0.8 |
(0-1.7) |
Low risk |
2-6 |
1 |
(0.4-1.6) |
6 |
(5-8) |
Intermediate risk |
7-13 |
5 |
(4-7) |
17 |
(14-20) |
High risk |
14-23 |
17 |
(10-24) |
45 |
(35-55) |
Note: Electronic calculators for these Tables are available at http://www.eortc.be/tools/bladdercalculator/.
Recommendations for Intravesical Therapy
- The type of intravesical therapy is based on the risk groups as shown in the table above.
- In patients at low risk of tumour recurrence and progression, one immediate instillation of chemotherapy is strongly recommended as the complete adjuvant treatment. (Grade of recommendation: A)
- In patients at an intermediate or high risk of recurrence and an intermediate risk of progression, one immediate instillation of chemotherapy should be followed by further instillations of chemotherapy or a minimum of 1 year of Bacillus Calmette-Guérin (BCG). (Grade of recommendation: A)
- If chemotherapy is given, it is advised to use the drug at its optimal pH and to maintain the concentration of the drug during instillation by reducing fluid intake. The optimal schedule and the duration of the chemotherapy instillations remain unclear, but it should probably be given for 6 to 12 months. (Grade of recommendation: B)
- In patients at high risk of tumour progression, intravesical BCG for at least 1 year. Immediate radical cystectomy may be offered to the highest risk patients. (Grade of recommendation: A)
- The absolute risks of recurrence and of progression do not always indicate the risk at which a certain therapy is optimal. The choice of therapy may be considered differently according to what risk is acceptable for the individual patient and the urologist.
Recommendations for Follow-Up Cystoscopy
- Patients with tumours at low risk of recurrence and progression should have a cystoscopy at 3 months. If negative, the following cystoscopy is advised at 9 months and consequently yearly for 5 years. (Grade of recommendation: B)
- Patients with tumours at high risk of progression should have a cystoscopy at 3 months. If negative, the following cystoscopies should be repeated every 3 months for a period of 2 years, every 4 months in the third year, every 6 months thereafter until 5 years, and yearly thereafter. A yearly exploration of the upper tract is recommended. (Grade of recommendation: B)
- Patients with intermediate-risk of progression (about one-third of all patients) should have an in-between follow-up scheme, adapted according to personal and subjective factors. (Grade of recommendation: B)
Definitions:
Grades of Recommendation
- Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
- Based on well-conducted clinical studies, but without randomized clinical trials
- Made despite the absence of directly applicable clinical studies of good quality