Staging work-up:
Besides what was previously presented by Dr. Kamat’s, Dr. Kassouf’s group recommend doing an exam under anesthesia (EUA) at the time of initial TURBT (Grade C).
Prognostic factors for BCa:
Patient-related
- Age – older age associated with worse disease (LOE 2)
- Gender – female patients have higher recurrence risk (LOE 3)
- Race – equivocal, especially regarding patients of African origin
- Smoking (LOE 3)
- Other factors (infection, family history, exposures) – uncertain
- Tumor size > 3cm
- Multifocality – higher recurrence, ? effect on progression
- Recurrence (time to recurrence, > 1 recurrence/year)
- Quality of TUR
- Stage (Grade 2)
- Grade (Grade 2
- Concomitant CIS (Grade 3)
- Prostatic involvement (Grade 3)
- Lymphovascular involvement (Grade 3)
- Variant histology (LE 3)
- T1 substaging
- Urine markers (previously discussed) – LOE 2 per this group
- Somatic mutations (LOE 3)
- Molecular subtyping (LOE 3)
- Most widely used risk stratification tools: EORTC and CUETO.
- AUA/SUO lists small volume (<3 cm) HG Ta as intermediate risk. Most others list any HG as high-risk
- Most widely used risk stratification tools: EORTC and CUETO.
AUA/SUO lists small volume (<3 cm) HG Ta as intermediate risk. Most others list any HG as high-risk
- R/o extravesical disease (LOE 3, Grade C)
o Random bladder biopsies
o Photodynamic evaluation
- If all negative, then bilateral ureteroscopy with biopsy
- If also negative, then close surveillance
Prostatic urethral involvement
- Routine biopsy on initial evaluation not warranted (LOE 3)
- TUR loop biopsy is preferable to a cold cup biopsy (LOE 3)
- HG pTa/T1 or TIS in prostatic urethra
o If recurs, radical cystectomy + urethrectomy (LOE 3)
- TIS in prostatic ducts
o RC if extensive in ducts (LOE 3)
o Alternative it TURP + BCG
- Prostatic stromal invasion – treat as MIBC
Management of low-risk and intermediate risk NMIBC
No significant change from the 2012 guidelines
Single dose instillation therapy recommended within 6 hours (MMC, epirubicin, pirarubicin) if low-risk
If intermediate risk, ongoing instillations
Intermediate risk – risk-adapted approach recommended, based on EORTC risk calculator
In-clinic fulgeration is acceptable for patients with recurrent TaLG with no prior history of high-risk disease of CIS, and negative cytology
New – expectant management for LG Ta is acceptable (Grade B)
Urine cytology must be followed and be negative
A protocol must be established and followed
Management of high-risk NMIBC
- Repeat TURBT guidelines – similar to what was presented by Dr. Kamat
- Patients with variant histology, LVI or deeply invasive T1 may not be candidates for bladder sparing therapies and should be considered for early cystectomy (LOE 3, Grade C)
- BCG recommendations are unchanged
- BCG failure
o Refractory: disease progression after one cycle induction or persistent/worsening after two cycles of induction (LOE 3, Grade B)
o Unresponsive: BCG refractory and BCG relapsing high risk within 6 months of last BCG exposure
o RC is the gold standard for treatment (LOE 3, Grade C)
- Salvage intavesical therapy only if refuse RC and clinical trials
- Brief discussion without strong recommendations for alternative therapy (hyperthermia, etc)
Dr. Kassouf covered a lot of ground in this section. Very little was significantly different from the prior edition. Full details to be published in the printed chapter.
Presented by: Wassim Kassouf
Author: Wassim Kassouf
Affiliaiton: McGill University, Quebec, Montreal, Canada
Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, Twitter: @tchandra_uromd at the 37th Congress of Société Internationale d’Urologie - October 19-22, 2017- Lisbon, Portugal