Clinical Practice Recommendations for the Management of Non–Muscle Invasive Bladder Cancer

ContextAlthough the European Association of Urology (EAU), First International Consultation on Bladder Tumors (FICBT), National Comprehensive Cancer Network (NCCN), and American Urological Association (AUA) guidelines all provide an excellent evidence-based background for the management of non–muscle invasive bladder cancer (NMIBC), the four guidelines vary with respect to important issues such as the definitions of risk levels and the appropriate management strategies for patients in these risk categories.ObjectiveTo build on the existing framework provided by the EAU, FICBT, NCCN, and AUA guidelines and to provide consensus on the definitions of low-, intermediate-, and high-risk NMIBC as well as practical recommendations for the management of patients in each of these risk categories.Evidence acquisitionA committee of internationally renowned leaders in bladder cancer management, known as the International Bladder Cancer Group (IBCG), identified current key influencing guidelines and published English-language literature related to the treatment and management of NMIBC available as of March 2008. The IBCG met on four occasions to review the main findings of the identified literature and the current clinical practice guidelines of the EAU, FICBT, NCCN, and AUA.Evidence synthesisOn the basis of a review of the current literature and the EAU, FICBT, NCCN, and AUA guidelines, the IBCG developed a user-friendly treatment algorithm and practical recommendations for the management of patients with low-, intermediate-, and high-risk NMIBC.ConclusionsA complete transurethral resection of the bladder tumour (TURBT) plus an immediate, postoperative chemotherapeutic instillation is recommended for all patients with NMIBC except those with obvious or suspected bladder wall perforation. For intermediate-risk disease, intravesical induction bacillus Calmette-Guérin (BCG) plus maintenance or intravesical chemotherapy are recommended; for high-risk disease, BCG induction plus maintenance is the recommended management strategy. The appropriate management of recurrences depends on the patient's level of risk, whereas the management of treatment failures depends on both the type of failure and the patient's level of risk for recurrence and disease progression.