Question

Discuss management strategies for non-muscle invasive bladder cancer after primary TURBT.

Hint:

Prompt initiation of intravesical therapy, especially with BCG for high-risk NMIBC, and regular surveillance are key to preventing recurrence and progression after TURBT.

Answer 1

Non-muscle invasive bladder cancer (NMIBC) is confined to the mucosal and submucosal layers of the bladder and is commonly diagnosed after primary transurethral resection of bladder tumour (TURBT). Management strategies after TURBT aim to prevent recurrence, progression, and improve survival.
Step 1: Risk Stratification:
The first step in managing NMIBC is risk stratification. Based on the pathology of the tumour, such as tumour grade, stage, size, number, and presence of associated carcinoma in situ (CIS), patients can be classified into low, intermediate, or high risk. This classification helps guide the treatment approach and follow-up schedule.
Step 2: Intravesical Therapy:
The mainstay of treatment for NMIBC is intravesical therapy. This involves the instillation of therapeutic agents directly into the bladder: - Intravesical Bacillus Calmette-Guerin (BCG): BCG is the most effective treatment for high-risk NMIBC and reduces recurrence and progression. It is typically given after TURBT for patients with high-risk features such as high-grade tumours, multiple tumours, or CIS. - Intravesical Chemotherapy: Chemotherapy agents such as mitomycin C or gemcitabine are used for intermediate-risk NMIBC or as adjuvant therapy after TURBT for patients with low-grade tumours.
Step 3: Surveillance:
Post-TURBT, surveillance is crucial to monitor for tumour recurrence. Cystoscopy is the primary method for surveillance and is usually performed at 3-month intervals during the first 2 years, followed by every 6 months for the next 3 years. Regular urine cytology is also useful, particularly for detecting recurrence of high-grade tumours.
Step 4: Re-TURBT:
In some cases, particularly if there are incomplete resections or suspicion of muscle-invasive disease, a second TURBT is performed. Re-TURBT aims to ensure complete removal of the tumour and re-assess staging. It is particularly indicated for high-risk patients.
Step 5: Management of Recurrence or Progression:
In the case of recurrence or progression, treatment options may include: - Re-treatment with Intravesical Therapy: A repeat course of intravesical therapy with BCG or chemotherapy may be indicated for recurrent or persistent tumours. - Cystectomy: In cases where the tumour progresses to muscle-invasive disease, radical cystectomy may be required. This is typically reserved for patients with high-risk disease that does not respond to intravesical therapies.