Guidelines on diagnosis and treatment of superficial bladder cancer.

This manuscript reviews the guidelines of the European Association of Urology (EAU) on superficial bladder tumors and adds new data which has come available since 2001. It emphasises the data which are evidenced based and clearly explained where still insufficient research is available to make clear recommendations. Intravenous urethrography (IVU) is only necessary in grade 3 tumors. A good transurethral resection (TUR), with muscle in the specimen is essential. Random biopsies are only necessary when there is positive urinary cytology or when tumor in situ (TIS) is suspected. The variability in pathology interpretation remains a problem which seems not to have been solved by the new WHO 1998 classification. A review of pathology seems indicated when aggressive therapy is planned or there is a discrepancy between the visual findings and pathology. The visual judgement of urologists in superficial bladder tumors is very good. Second resection is indicated whenever insufficient material is delivered and in any T1 G3 tumor. In the last infiltrative tumors are regularly found. The treatment largely depends on prognostic parameters. For recurrence rate multiplicity of the tumor is most important, followed by recurrence rate, volume of the tumor, grade and T category. For progression the most important tumor is the anaplasia grade and the T category. Up to 50% of T1 G3 tumors and TIS evaluate to invasive tumors. Even low risk tumors still have an important recurrence rate of at least 20%/year in the first years after diagnosis. One chemo instillation immediately after TUR is indicated in low and intermediate risk superficial bladder tumors. Intravesical chemotherapy prevents recurrence but not progression. Ideal dosage and schedule of instillation is not clearly defined. Longterm therapy is not worthwhile. Bacille Calmette-Guerin (BCG) therapy is indicated in all tumors at high risk for progression. In tumors at high risk for recurrence it is also superior to intravesical chemotherapy, but its side-effects are more pronounced. Local or systemic side-effects are not related to efficacy and side-effects do not increase over time. The ideal schedule for BCG has not yet been found. It is however clear that some kind of maintenance therapy is necessary to obtain good results. BCG failure is probably any tumor which recurs at 3 and 6 months under BCG therapy. One third dose seems as sufficient as a full dose BCG. That BCG can spare the bladder in T1g3 tumors is largely documented but the chance to save the bladder when the tumor is still present after 2 cycles of BCG is very low. Cystectomy is indicated in these BCG failures. Vitamin E, A, and Lactobacillus Casei are probably effective in the prevention of the disease. Stopping smoking is advocated. Cystoscopy is still the gold standard in follow-up. It is advocated at 3 months and thereafter according to the prognostic parameters. High grade tumors are at risk life long. Follow-up of 5 years for low risk tumors seems reasonable.