Early radical cystectomy or bladder sparing therapy in high-risk patients with non-muscle invasive bladder cancer

Some patients with non-muscle invasive bladder cancer (NMIBC) have an increased risk of recurrence and progression. According to the EAU guidelines, high-risk are considered one of the following features: pT1 tumors, G3 (poorly differentiated), CIS (carcinoma in situ), pT1-G3 with concomitant CIS, pT1-G3 with CIS in the prostatic urethra, multiple and recurrent tumors pTa-G1-G2 larger than 3cm (well and moderately differentiated), micropapilary TCC. In today’s literature, there is an ongoing debate regarding the management of these patients. There are two feasible options: transurethral resection of bladder tumor (TUR-BT) followed by reTUR after 2-6 weeks and afterwards adjuvant BCG (Bacillus Calmette-Guerin) with maintenance for 1-3 years (option recommended by the EAU guidelines as the first treatment option) or early radical cystectomy with orthotopic neobladder in selected patients. In the light of increased morbidity and mortality, quality of life impairment and perioperative complications, radical cystectomy may seem an over-treatment at first glance. However, we must bear in mind that high-risk patients have an impaired prognosis with a poor overall survival, with metastatic disease at the time of the first diagnosis in some cases. Patients who refuse radical cystectomy and those unfit for this procedure due to associated comorbidities may receive adjuvant device-assisted chemotherapy, immunotherapy (especially interferon) or combination therapy, although these are considered inferior in terms of oncologic results. Given the current global BCG shortage due to production pending of BCG Connaught strain by the Sanofi Pasteur company in June 2012, the urologist is placed in the delicate situation of being unable to provide proper treatment according to the European guidelines and is forced sometimes to resort to early cystectomy in order not to compromise the survival rate of these high-risk patients.

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