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EAMC Urology > NCCN Bladder 6.2020 > Flashcards

NCCN Bladder 6.2020 Flashcards

(103 cards)

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1
Q

INITIAL EVALUATION

Suspicious bladder mass

A 
H and PE
Office cystoscopy
Consider cytology
Abdominal and pelvic imaging with upper tract collecting system BEFORE TURBT
Smoking screening

BL-1

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2
Q

PRIMARY EVALUATION and SURGICAL TREATMENT

Bladder mass

A

EUA/bimanual exam
TURBT
Single-dose intravesical chemotherapy within 24 hours of TURBT: Gemcitabine (preferred, cat 1) or mitomycin (cat 1)
Sessile or suspicious for high grade or Tis: selected mapping biopsies
Upper tract imaging if not yet done

BL-1

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3
Q

Initial workup for muscle-invasive bladder CA

A

CBC
Chemistry profile, with ALK PHOS
Chest imaging
Bone imaging, if suspicious/symptomatic

BL-1

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4
Q

Thanos FAQ!

“Sige, immediate intravesical chemotherapy reduces the ________ by ________ %.”

A

Immediate intravesical chemotherapy reduces 5-year RECURRENCE (rekerens) rate by 35 %, and has a NNT to prevent recurrence of 7.

Does NOT reduce risk of progression or mortality.

BL-1 footnote, BL-F

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5
Q

SECONDARY SURGICAL TREATMENT/ADJUVANT INTRAVESICAL TREATMENT

cTa, low grade

A

Observation
OR
Intravesical therapy

BL-2

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6
Q

SECONDARY SURGICAL TREATMENT/ADJUVANT INTRAVESICAL TREATMENT

cTa, high grade

A

Repeat TURBT if:

  1. Incomplete resection
  2. No muscle in specimen
Then:
BCG (preferred)
OR
Intravesical chemotherapy
OR
Observation

If BCG given –> give maintenance BCG (preferred)

BL-2

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7
Q

SECONDARY SURGICAL TREATMENT

cT1

A

Strongly advise repeat TURBT
OR
Consider cystectomy if high-grade

BL-2

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8
Q

ADJUVANT INTRAVESICAL TREATMENT
cT1
Repeat TURBT: (+) residual disease

A

BCG (cat 1)
OR
Cystectomy

If BCG given –> give maintenance BCG (preferred)

BL-2

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9
Q

ADJUVANT INTRAVESICAL TREATMENT
cT1
Repeat TURBT: (-) residual disease

A 
BCG (cat 1)
OR
Intravesical chemotherapy 
OR
Observation in highly selected cases: low grade, limited lamina propria invasion, no CIS

If BCG given –> give maintenance BCG (preferred)

BL-2

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10
Q

ADJUVANT INTRAVESICAL TREATMENT

Tis

A

BCG

BL-2

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11
Q

Evaluation and Treatment
Posttreatment cTa, T1, Tis recurrent or persistent
Cystoscopy: positive

A

TURBT
Single-dose intravesical chemotherapy within 24 hours of TURBT: gemcitabine (cat 1) or mitomycin (preferred, cat 1)

Based on tumor grade and stage: 
Adjuvant intravesical therapy
OR
Cystectomy
OR
Pembrolizumab

BL-3

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12
Q

Pembrolizumab is indicated for ________.

A

Pembrolizumab is indicated for treatment of patients with:
BCG-unresponsive high-risk, NMIBC with Tis or without papillary tumors

BL-3, footnote

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13
Q

Valrubicin is approved for ________.

A

Valrubicin is approved for BCG-refractory carcinoma in situ.

BL-3, footnote

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14
Q

Evaluation and Treatment
Posttreatment cTa, T1, Tis recurrent or persistent
Cystoscopy: suspicious for recurrence post-intravesical therapy (no more than 2 cycles)

A

TURBT
Single-dose intravesical chemotherapy within 24 hours of TURBT: gemcitabine (cat 1) or mitomycin (preferred, cat 1)

TURBT result:

  • No residual disease: maintenance BCG (preferred)
  • cTa, cT1, Tis: cystectomy (preferred for cT1 OR pembrolizumab (select patients) or change intravesical agent (consider)
  • T2 or higher: RESTAGE and manage accordingly

BL-3

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15
Q

Evaluation and Treatment

Cytology: positive
Imaging: negative
Cytoscopy: negative

A 
Selected mapping biopsies including transurethral prostate biopsy
AND
Upper tract cytology
AND
Consider URS
AND 
Enhanced cystoscopy (if available)

BL-4

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16
Q

Treatment

Cytology: positive
Imaging: negative
Cytoscopy: negative

After workup: bladder, prostate, upper tract negative

A

Follow-up at 3 mo, then at longer intervals
OR
If prior BCG, maintenance BCG (optional)

BL-4

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17
Q

Treatment

Cytology: positive
Imaging: negative
Cytoscopy: negative

After workup: bladder positive

A

BCG, then:
If no evidence of disease (NED): maintenance BCG (preferred)
If persistent r recurrent disease:
Cystectomy OR pembrolizumab (select pxs) OR change intravesical agent (if incomplete response, cystectomy OR pembrolizumab)

If BCG-unresponsive:
Cystectomy OR pembrolizumab (in select patients)

BL-4

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18
Q

WORKUP

Cytology: positive
Imaging: negative
Cytoscopy: negative

After workup: prostate positive

A

Urothelial CA of the Prostate!

DRE 
Cystoscopy (with bladder biopsy)
TUR biopsy of prostate to include stroma
PSA
Needle biopsy if DRE is abnormal (in selecte patients)
Imaging of upper tract collecting system
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19
Q

PRIMARY TREATMENT

Cytology: positive
Imaging: negative
Cytoscopy: negative

After workup: prostate positive: MUCOSAL prostatic urethra

A

TURP and BCG

If on ffup imaging: local recurrence, then cystoprostatectomy + urethrectomy

UCP-1

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20
Q

PRIMARY TREATMENT

Cytology: positive
Imaging: negative
Cytoscopy: negative

After workup: prostate positive: ductal + acini

A

CXR + abdominal/pelvic CT

Cystoprostatectomy + urethrectomy
OR
TURP and BCG, then if on ffup imaging: local recurrence, then cystoprostatectomy + urethrectomy

UCP-1

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21
Q

PRIMARY TREATMENT

Cytology: positive
Imaging: negative
Cytoscopy: negative

After workup: prostate positive: stromal invasion

A

CXR + abdominal/pelvic CT

Cystoprostatectomy + urethrectomy + neoadjuvant chemotherapy

then consider adjuvant chemotherapy (if neoadjuvant not given)

UCP-1

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22
Q

PRIMARY TREATMENT

Cytology: positive
Imaging: negative
Cytoscopy: negative

After workup: prostate positive: metastatic

A

Systemic therapy

UCP-1

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23
Q

PRIMARY TREATMENT and ADJUVANT TREATMENT

Stage II, cystectomy candidates

A

Neoadjuvant cisplatin-based combination chemotherapy followed by radical cystectomy (cat 1)
OR
Neoadjuvant cisplatin-based combination chemotherapy followed by partial cystectomy (highly selected patients with solitary lesion in a suitable location, no Tis)
OR
Cystectomy alone for those not eligible to receive cisplatin-based chemotherapy
OR
Concurrent chemoradiotherapy (cat 1) then reassess after 2-3 mos –> no tumor: observe;
–> tumor: Tis Ta T1: intravesical BCG OR surgical consolidation OR treat as metastatic

BL-5

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24
Q

PRIMARY TREATMENT and ADJUVANT TREATMENT

Stage II, NON-cystectomy candidates

A

Concurrent chemoradiotherapy (cat 1, preferred)
OR
RT
OR TURBT

Then reassess after 2-3 mos –> no tumor: observe;
–> tumor: Systemic therapy OR concurrent chemoRT or RT alone if no prior RT or TURBT and best supportive care

BL-6

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25
PRIMARY TREATMENT ADJUVANT TREATMENT | Stage IIIA, cystectomy candidates
Neoadjuvant cisplatin-based combination chemotherapy followed by radical cystectomy (cat 1) OR Cystectomy alone for those not eligible to receive cisplatin-based chemotherapy OR Concurrent chemoradiotherapy (cat 1) then reassess after 2-3 mos --> no tumor: observe; --> tumor: Tis Ta T1: intravesical BCG OR surgical consolidation OR treat as metastatic BL-7
26
PRIMARY TREATMENT and ADJUVANT TREATMENT | Stage IIIA, NON-cystectomy candidates
Concurrent chemoradiotherapy (cat 1) then reassess after 2-3 mos; - no tumor: observe; - tumor: systemic therapy OR TURBT OR best supportive care OR RT BL-7
27
Optimal candidates for bladder preservation with chemoRT:
Patients with tumors WITHOUT hydronephrosis NO concurrent or extensive Tis < 6 cm Tumors should allow visually complete or maximally debulking TURBT BL-7
28
ADJUVANT TREATMENT | Stage IIIA, cystectomy candidates
Based on pathologic risk (pT3-T4 or positive nodes or positive margins: Consider adjuvant cisplatin-based chemotherapy or adjuvant RT (cat 2B) if no neoadjuvant given BL-7
29
PRIMARY TREATMENT | Stage IIIB, downstaging systemic therapy option
Downstaging systemic therapy, then reassess tumor status 2-3 mo after treatment Complete response: Consolidation cystectomy OR consolidation chemoRT OR observation Partial response: Cystectomy OR chemoRT OR treat as metastatic Progression: treat as metastatic BL-8
30
PRIMARY TREATMENT | Stage IIIB, concurrent chemoradiotherapy
Reassess tumor status 2-3 mo after treatment Complete response: ffup algorithm Partial response: Tis, Ta, T1 consider intravesical BCG OR surgical consolidation OR treat as metastatic Progression: treat as metastatic disease BL-8
31
PRIMARY TREATMENT | Stage IVA, M0
Systemic therapy --> 2-3 cycles, reassess with cystoscopy, EUA, TURBT, and imaging of abd/pelvis OR Concurrent chemoRT, then reassess after 2-3 months - No tumor: consolidation systemic therapy OR chemoradiotherapy (if no previous RT) and/or cystectomy - Tumor present: systemic therapy OR chemoRT (if no previous RT) and/or cystectomy BL-9
32
PRIMARY TREATMENT | Stage IVA, M1a disease
Systemic therapy, then evaluate with cystoscopy, EUA, TURBT, and imaging of abd/pelvis If CR: Concurrent chemoRT OR cystectomy Stable disease or progression: treat as metastatic BL-9
33
WORKUP and PRIMARY TREATMENT | Metastatic Stage IVB
``` Bone scan Chest CT Consider CNS imaging GFR scan, to assess cisplatin eligibility Consider biopsy if feasible Molecular/genomic testing ``` Systemic therapy AND/OR Palliative RT BL-10
34
TREATMENT Local recurrence or persistent disasese; Preserved bladder Muscle-invasive
``` Cystectomy OR ChemoRT (if no prior RT) OR Systemic therapy OR Palliative TURBT and best supportive care ``` BL-11
35
TREATMENT Local recurrence or persistent disasese; Preserved bladder Tis, Ta, or T1
``` Consider intravesical therapy --> if no response --> cystectomy OR Cystectomy OR TURBT ``` BL-11
36
TREATMENT Cytology: positive Preserved bladder Cystoscopy, EUA, selected mapping biopsy: negative
Retrograde selective washings of the upper tract Prostatic urethral biopsy Upper tract positive --> UTUC Prostate positive --> UCP BL-11
37
TREATMENT | Metastatic or local recurrence postcystectomy
``` Systemic therapy OR ChemoRT (if no previous RT) OR RT ``` BL-11
38
TURBT: muscle may be omitted in _________.
Documented low-grade Ta disease BL-B
39
TURBT: suspected or known CIS:
Biopsy adjacent to papillary tumor Consider prostate urethral biopsy BL-B
40
TURBT: Papillary appearing tumor (likely NMIBC) - repeat TURBT after 6 weeks if:
Incomplete resection No muscle in original specimen for high-grade Large (>= 3 cm) or multi-focal lesions Any T1 lesion BL-B
41
TURBT: Sessile/flat or invasive appearing tumor (likely MIBC), repeat TURBT if:
No muscle in original specimen for high-grade Any T1 lesion First resection does not allow adequate staging for treatment selection Incomplete resection and considering tri-modality bladder preservation therapy BL-B
42
Maximal TURBT + concurrent chemoRT is most suitable for patients with:
``` Solitary tumors Negative nodes No CIS No tumor-related hydronephrosis Good pretreatment bladder function ``` BL-B
43
Regional lymphadenectomy recommended for:
High-grade upper GU tract tumors BL-B
44
Regional lymphadenectomy for: | Left-sided renal pelvic, upper ureteral, and midureteral tumors
Paraaortic LNs from renal hilum to aortic bifurcation Midureteral tumor: include common iliac, external iliac, obturator, hypogastric LNs BL-B
45
Regional lymphadenectomy for: | Right-sided renal pelvic, upper ureteral, and midureteral tumors
Paracaval LNs from renal hilum to IVC bifurcation Midureteral tumor: include common iliac, external iliac, obturator, hypogastric LNs BL-B
46
Regional lymphadenectomy for: | Distal ureteral tumors
Common iliac External iliac Obturator Hypogastric LNs BL-B
47
Pelvic Exenteration (cat 2B)
For recurrence in female patients with >= T2 primary carcinoma of the urethra Ilioinguinal lymphadenectomy and/or chemoRT for >=T3 BL-B
48
TURP is the primary treatment option for:
Urothelial carcinoma of the prostate with ductal/acini or prostatic urethral pathology. Postsurgical intravesical BCG recommended. BL-B
49
TUR of urethral tumor is the primary treatment for:
Tis, Ta, and T1 primary carcinoma of the urethra. Consider postsurgical intraurethral therapy BL-B
50
Partial cystectomy indications
``` cT2 muscle-invasive disease with solitary lesion amenable to resection with adequate margins Select situations (including cancer in bladder diverticulum) No CIS as determined by random biopsies ``` Give: neoadjuvant cisplatin-based chemotherapy Bilateral pelvic lymphadenectomy: common iliac, internal and external iliac, obturator nodes BL-B
51
Radical nephrouretectomy with bladder cuff is the primary treatment for:
Non-metastatic high-grade upper GU tract tumors (UTUC) Consider single-dose immediate postop intravesical chemotherapy (decrease in intravesical recurrence) Neoadjuvant chemotherapy: consider in high-grade disease BL-B
52
Favorable criteria for nephron preservation in UTUC
Low-grade tumor based on cytology and biopsy Papillary architecture Tumor size <1.5 cm Unifocal tumor Cross-sectional imaging showing no concern for invasive disease BL-B
53
Less favorable criteria for nephron preservation in UTUC
``` Multifocal tumors Flat or sessile tumor architecture Tumor size > 1.5 cm High-grade tumors cT2-T4 Mid and proximal tumor due to technical challenges Tumor crossing the infundibulum or UPJ ``` BL-B
54
Imperative indications for conservative therapy of UTUC
Bilateral renal pelvis and/or urothelial carcinoma of the ureter Solitary or solitary functioning kidney Chronic kidney disease/renal insufficiency Hereditary predisposition (HNPCC) BL-B
55
Mixed histology urothelial cancer should be treated in a similar manner to:
Pure urothelial carcinoma BL-D
56
Pure squamous cell carcinoma of the bladder
No proven role for neoadjuvant chemotherapy Local control with surgery + RT recommended Clinical trial for advanced disease Paclitaxel + ifosfamide + cisplatin for selected patients Postoperative RT for positive margins Best supportive care BL-D
57
Pure adenocarcinoma including urachal, localized disease
No proven role for neoadjuvant chemotherapy Local control with surgery + RT recommended Urachal with localized disease: Partial or complete cystectomy with en bloc resection of the urachal ligament with umbilicus and LN dissection Best supportive care BL-D
58
Pure adenocarcinoma including urachal, node-positive and advanced disease
FOLFOX: oxaliplatin, leucovorin, and 5-FU or GemFLP: 5-FU, leucovorin, gemcitabine, and cisplatin BL-D
59
Treatment for any small-cell component
Concurrent chemoRT or neoadjuvant chemotherapy followed by local treatment (cystectomy or radiotherapy) Neoadjuvant chemotherapy: Etoposide + cisplatin Ifosfamide + doxorubicin with etoposide + cisplatin If cisplatin ineligible: etoposide + carboplatin BL-D
60
AUA Risk Stratification for NMIBC: | Low Risk
Low grade solitary Papillary urothelial neoplasm of LMP BL-E
61
AUA Risk Stratification for NMIBC: | Intermediate Risk
``` Recurrence within 1 year, LG Ta Solitary LG Ta > 3 cm LG Ta, multifocal High grade (HG) Ta, =< 3 cm LG T1 ``` BL-E
62
AUA Risk Stratification for NMIBC: | High Risk
``` HG T1 Any recurrent, HG Ta HG Ta, > 3 cm or multifocal Any CIS Any BCG failure in HG patient Any variant histology Any lymphovascular invasion Any HG prostatic urethra involvement ``` BL-E
63
FOLLOW-UP | Low-Risk, NMIBC
Cystoscopy: 3 and 12 mo, then annually Upper tract and abdominal/pelvic imaging: baseline imaging, then annually as clinically indicated BL-E
64
FOLLOW-UP | Intermediate Risk, NMIBC
Cystoscopy: 3, 6, 12 mo, then every 6 mo for year 2, then annually for years 3-5 Upper tract and abdominal/pelvic imaging: baseline imaging in year 1, then as indicated Urine cytology: 3, 6, 12 in year 1, urine cytology every 6 mo in year 2, then annually until year 5 BL-E
65
FOLLOW-UP | High Risk, NMIBC
Cystoscopy: every 3 mo in years 1-2, every 6 mo in years 3-5, then annually UT imaging: baseline imaging in year 1, then every 1-2 y Abdominal/pelvic imaging: baseline at year 1, then as indicated BL-E
66
FOLLOW-UP | Postcystectomy NMIBC: cystoscopy schedule
Wala na siyang bladder! 😢
67
FOLLOW-UP | Postcystectomy NMIBC
CTU or MRU at 3 and 12 mo in year 1, then annually until year 5, then US annually Renal function tests, LFTs, CBC, CMP, B12 every 3-6 mo if received chemo in year 1, then annually Urine cytology and urethral wash cytology every 6-12 mo until year 2, then as indicated BL-E
68
FOLLOW-UP | Postcystectomy muscle invasive BC
CTU or MRU, CXR or chest CT every 3-6 mo until year 2, then annually until year 5, then renal US annually FDG PET/CT (cat 2b) if suspected metastatic disease Renal function tests, LFTs, CBC, CMP, B12 every 3-6 mo if received chemo in year 1, then annually Urine cytology and urethral wash cytology every 6-12 mo until year 2, then as indicated BL-E
69
FOLLOW-UP | Post-bladder sparing (partial cystectomy or chemoRT)
Cystoscopy: every 3 mo in years 1-2, then every 6 mo in years 3-4, then annually years 5-10 Imaging: CTU or MRU, CXR or chest CT every 3-6 mo in years 1-2 FDG PET/CT if mets suspected Renal function tests, LFTs, CBC, CMP, B12 every 3-6 mo if received chemo in year 1, then annually Urine cytology every 6-12 mo in years 1-2, then as indicated BL-E
70
Immediate postoperative intravesical chemotherapy timing:
Single instillation within 24 hours of surgery (ideally 6 hours) BL-F
71
Immediate intravesical agents
Gemcitabine (preferred due to better tolerability) (cat 1) Mitomycin (cat 1) NOT effective: thiotepa BL-F
72
Immediate postoperative intravesical chemotherapy NOT effective in:
Patients with elevated EORTC recurrence risk score >= 5, includes patients with >= 8 tumors and those with >= recurrence per year. BL-F
73
Immediate postoperative intravesical chemotherapy contraindications:
Bladder perforation Known drug allergy BL-F
74
Induction (adjuvant) intravesical chemo or BCG is a treatment option for:
NMIBC BL-F
75
In the event of a BCG shortage, prioritize induction of:
High-risk patients (high-grade T1 and CIS) BL-F
76
In the event of a BCG shortage, multiple patients may be treated by:
splitting the dose of BCG (1/2 or 1/3) BL-F
77
Induction intravesical chemotherapy or BCG timing:
Start: 3-4 weeks after TURBT with or without maintenance Weekly for 6 weeks, maximum of 2 consecutive cycle inductions without complete response BL-F
78
BCG contraindications:
``` Traumatic catheterization Bacteriuria Persistent gross hematuria Persistent severe local symptoms Systemic symptoms ``` BL-F
79
Maintenance intravesical BCG SWOG regimen
6-week induction course, then maintenace with 3 weekly instillations at months 3, 6, 12, 18, 24, 30, and 36. BL-F
80
What does "sessile" mean? 😅
Sessile means "flat", as opposed to papillary which is pedunculated. Flat tumors are more likely to be CIS or invasive.
81
Perioperative chemotherapy (neoadjuvant or adjuvant)
Preferred: DDMVAC + growth factor suppport x 3-4 cycles Gemcitabine and cisplatin x 4 cycles (21 days preferred) Other: CMV (cisplatin, methotrexate, and vinblastine) x 3 cycles BL-G
82
What does DDMVAC mean?
Dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin BL-G
83
First-line systemic therapy for locally advanced or metastatic disease (Stage IV) Cisplatin eligible
Gemcitabine and cisplatin (cat 1) followed by avelumab maintenance therapy DDMVAC with growth factor support (cat 1) followed by avelumab maintenance therapy BL-G
84
First-line systemic therapy for locally advanced or metastatic disease (Stage IV) Cisplatin INeligible
Preferred: Gemcitabine and carboplatin followed by avelumab maintenance therapy Atezolizumab or Pembrolizumab ONLY for PD-L1 expressing tumors BL-G
85
Second-line systemic therapy for stage IV, post-PLATINUM
Preferred: Pembrolizumab (cat 1) ``` Alternative preferred: Atezolizumab Nivolumab Durvalumab Avelumab Erdafitinib ``` BL-G
86
Second-line systemic therapy for stage IV, post-CHECKPOINT INHIBITOR
Preferred for cisplatin ineligible, chemo naive: Gemcitabine/carboplatin Cisplatin eligibile: Gemcitabine/cisplatin DDMVAC with GF support BL-G
87
Subsequent-line systemic therapy for stage IV
Preferred: Enfortumab vedotin 🧐 Erdafitinib BL-G
88
Radiosensitizing chemotherapy regimens for organ-preserving chemoradiation
``` Preferred: Cisplatin and 5-FU Cisplatin and paclitaxel 5-FU and mitomycin Cisplatin alone ``` BL-G
89
Bladder | T1
Invades the lamina propria (subepithelial connective tissue) ST-1
90
Bladder T2a T2b
Invades the superficial (T2a) and deep (T2b) muscularis propria ST-1
91
T3a | T3b
Invades perivesical tissue microscopically (T3a) or macroscopically (T3b) ST-1
92
T4a | T4b
Extravesical tumor directly invades any of the following: prostatic stroma, seminal vesicles, uterus, vagina, pelvic wall, abdominal wall ST-1
93
Bladder | N1
Single regional LN metastasis in the true pelvis (perivesical, obturator, internal and external iliac, or sacral LN) ST-1
94
Bladder | N2
Multiple regional LN metastasis in the true pelvis (perivesical, obturator, internal and external iliac, or sacral LN) ST-1
95
Bladder | N3
Lymph node metastasis to the common iliac LN ST-1
96
Bladder | M1a
Distant metastasis limited to LNs beyond the common iliacs ST-1
97
Bladder | M1b
Non-LN distant metastases ST-1
98
UTUC | T1
Subepithelial connective tissue ST-1
99
Adjuvant intravesical chemotherapy | Alternatives to BCG
``` Mitomycin or gemcitabine Epirubicin Valrubicin Docetaxel Sequential gemcitabine/docetaxel or gemcitabine/mitomycin ``` Split dose BCG: 1/3 or 1/2 dose BL-F
100
Adjuvant intravesical chemotherapy | Timing
Start: 3-4 weeks after TURBT with or without maintenance x weekly dose for 6 weeks Maximum 2 cycles w/o complete response BL-F
101
Adjuvant/maintenance intravesical chemotherapy | Contraindications to BCG
``` Traumatic catheterization Bacteriuria Persistent gross hematuria Persistent severe local symptoms Systemic symptoms ``` BL-F
102
Immediate postop intravesical chemotherapy Dose and Timing Details Contraindications
Single dose of gemcitabine or mitomycin within 24 hours (ideally within 6 hours) Reduces recurrence by 35% NNT to prevent recurrence of 7 NOT effective in: EORTC >= 5, >=8 tumors, >=1 recurrence per year Contraindications to gemcitabine/mitomycin: Drug allergy, bladder perforation
103
Maintenance intravesical BCG | SWOG regimen
6-week induction course of BCG then Maintenance: 3 weekly instillations at months 3, 6, 12, 18, 24, 30, 36 Intermediate risk: given for 1 year High-risk: given for 3 years

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