Non Muscle Invasive Bladder Cancer Plan
(based on AUA)

LOW RISK
Low Grade solitary Ta < or = 3cm
PUNLMP





Offer blue light, consider NBI
Cysto and document tumor size, location, configuration, number, and mucosal abnormalities
Upper tract imaging
Restaging TURBT within 6 weeks (unless completely resected low grade Ta)
intravesical chemo w/in 24 hrs (if no perforation or extensive resection)
No induction therapy
Not routinely use urinary biomarkers or cytology during surveillance
1st surveillance cystoscopy within three to four months
If negative, next cysto 6-9 mo later, then annually for 5 years, possibly longer depending on shared decision making
If h/o LG Ta and < 1cm lesion, can fulgurate in office
Note: No upper tract imaging after initial UT images, no cytology, no BCG or induction intravesical chemotherapy
​Medium Risk
LG Ta recurrence within 1 year
LG Solitary Ta >3cm
LG multifocal Ta
HG solitary Ta < or = 3cm
LG T1


Offer blue light, consider NBI
Cysto and document tumor size, location, configuration, number, and mucosal abnormalities
Upper tract imaging
Restaging TURBT within 6 weeks
intravesical chemo w/in 24 hrs (if no perforation or extensive resection)
CONSIDER six week course of induction intravesical chemotherapy or immunotherapy
IF RESPONDS TO INDUCTION BCG Maintenance BCG for 1 year
IF RESPONDS TO INTRAVESICAL CHEMO, can give maintenance therapy
1st surveillance cystoscopy within three to four months
If negative, cysto w/ CYTOLOGY q3-6mo for 2 years, then q6-12mo for 2 more years, then annually after
Cytology with every surveillance cysto
Consider UT imaging q1-2yrs

FAILED BCG

Consider prostate biopsy and upper tract imaging (if recurrence or positive cytology) prior to further intravesical therapy
If persistent or recurrent Ta disease after single course of induction BCG, offer a second course of BCG
If recurrent HG within 6mo of two courses BCG, do not prescribe further BCG
If recurrent after 2 BCG and not eligible for cystectomy, offer clinical trial and if none available can offer intravesical chemo
High Risk
HG T1
HG Ta recurrence
HG Ta, >3cm or multifocal
Any CIS
Any BCG failure
Any variant histology or LVI
Any HG prostatic urethral involvement
Offer blue light, consider NBI
Cysto and document tumor size, location, configuration, number, and mucosal abnormalities
Upper tract imaging
Restaging TURBT within 6 weeks
six-week induction course of BCG (if newly diagnosed CIS, high-grade T1, or high-risk Ta)
IF RESPONDS TO INDUCTION Maintenance BCG for 3 years
1st surveillance cystoscopy within three to four months
If negative, cysto w/ CYTOLOGY q3-4mo for 2yrs, then q6mo for next 2 yrs, then annually
Cytology with every surveillance cysto
Consider UT imaging q1-2yrs

FAILED BCG

Consider prostate biopsy and upper tract imaging (if recurrence or positive cytology) prior to further intravesical therapy
If persistent or recurrent Ta or CIS disease after single course of induction BCG, offer a second course of BCG
If recurrent HG or CIS within 6mo of two courses BCG, do not prescribe further BCG
If recurrent after 2 BCG and not eligible for cystectomy, offer clinical trial and if none available can offer intravesical chemo

CYSTECTOMY

Offer cystectomy if:
high grade T1 recurrence
T1 w/ CIS, LVI or variant histology
persistent/recurrence within 1yr of 2 BCG cycles

Note: no intravesical chemo
EORTC risk calculator
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