NMIBC Guidelines Flashcards
What should a clinician do at the time of resection of suspected bladder cancer?
Perform a thorough cystoscopic examination of the entire urethra and bladder, documenting tumor size, location, configuration, number, and mucosal abnormalities.
Clinical Principle
What should a clinician do at the initial diagnosis of bladder cancer?
Perform complete visual resection of the bladder tumor(s) when technically feasible.
Clinical Principle
What imaging should be performed as part of the initial evaluation of bladder cancer?
Upper urinary tract imaging.
Clinical Principle
What should be considered for a patient with a history of NMIBC with normal cystoscopy and positive cytology?
Consider prostatic urethral biopsies, upper tract imaging, enhanced cystoscopic techniques, ureteroscopy, or random bladder biopsies.
Expert Opinion
How should a clinician classify a patient at each occurrence/recurrence of bladder cancer?
Assign a clinical stage and classify the patient as ‘low-‘, ‘intermediate-‘, or ‘high-risk.’
Moderate Recommendation; Grade C
When should a pathology review be done by an experienced genitourinary pathologist?
When there is any doubt regarding variant or suspected variant histology, such as micropapillary, nested, plasmacytoid, neuroendocrine, sarcomatoid, or extensive squamous or glandular differentiation.
Moderate Recommendation; Grade C
What should be done if a bladder-sparing approach is being considered for a patient with variant histology?
Perform a restaging TURBT within 4-6 weeks of the initial TURBT.
Expert Opinion
What should be considered due to the high rate of upstaging associated with variant histology?
Consider offering initial radical cystectomy.
Expert Opinion
Should urinary biomarkers be used in place of cystoscopic evaluation for NMIBC surveillance?
No, urinary biomarkers should not be used as a replacement for cystoscopic evaluation.
Strong Recommendation; Grade B
Should a clinician use urinary biomarkers or cytology during surveillance for a patient with low-risk cancer and normal cystoscopy?
No, routine use is not recommended.
Expert Opinion
When may biomarkers be used in NMIBC patients?
To assess response to intravesical BCG and adjudicate equivocal cytology.
Expert Opinion
What should be done if the initial resection of non-muscle invasive disease was incomplete?
Perform repeat TURBT or endoscopic treatment of all remaining tumors if technically feasible.
Strong Recommendation; Grade B
What is recommended for high-risk, high-grade Ta tumors after initial TURBT?
Consider repeat TURBT within 6 weeks of the initial procedure.
Moderate Recommendation; Grade C
What should a clinician do for T1 disease following the initial TURBT?
Perform a repeat TURBT to include muscularis propria within 6 weeks.
Strong Recommendation; Grade B
When should a clinician consider administering a single postoperative instillation of intravesical chemotherapy?
For low- or intermediate-risk bladder cancer within 24 hours of TURBT, unless there is suspected perforation or extensive resection.
Moderate Recommendation; Grade B
Should induction intravesical therapy be given to low-risk patients?
No, it is not recommended.
Moderate Recommendation; Grade C
What is recommended for intermediate-risk patients regarding intravesical therapy?
Consider a 6-week course of induction intravesical chemotherapy or immunotherapy.
Moderate Recommendation; Grade B
What should be administered to high-risk patients with newly diagnosed CIS, high-grade T1, or high-risk Ta urothelial carcinoma?
A 6-week induction course of BCG.
Strong Recommendation; Grade B
What is recommended for intermediate-risk patients who completely respond to induction intravesical chemotherapy?
Consider maintenance therapy.
Conditional Recommendation; Grade C
What should a clinician consider for intermediate-risk patients who completely respond to induction BCG?
Maintenance BCG for one year, as tolerated.
Moderate Recommendation; Grade C
How long should maintenance BCG be continued for high-risk patients who respond to induction BCG?
Up to three years, as tolerated, based on availability.
Moderate Recommendation; Grade B
What should be considered for intermediate- or high-risk patients with persistent or recurrent disease after intravesical therapy?
Perform prostatic urethral biopsy and upper tract evaluation before administering additional intravesical therapy.
Conditional Recommendation; Grade C
What should be offered to intermediate- or high-risk patients with persistent or recurrent Ta or CIS disease after a single induction course of BCG?
A second course of BCG.
Moderate Recommendation; Grade C
What is recommended for patients with high-grade T1 disease after a single induction course of BCG if they are fit for surgery?
Offer radical cystectomy.
Moderate Recommendation; Grade C
Should additional BCG be prescribed to a patient intolerant of BCG or with documented recurrence within six months of two induction courses of BCG?
No, it is not recommended.
Moderate Recommendation; Grade C
What options are available for patients with persistent or recurrent high-grade NMIBC within 12 months of adequate BCG therapy and unfit for cystectomy?
Clinical trials, alternative intravesical therapies, or systemic immunotherapy with pembrolizumab.
Conditional Recommendation; Grade C
Should radical cystectomy be performed for patients with low- or intermediate-risk Ta disease before other treatments fail?
No, bladder-sparing modalities should be tried first.
Clinical Principle
When should initial radical cystectomy be considered for high-risk patients?
If there is persistent high-grade T1 disease on repeat resection, or T1 tumors with CIS, LVI, or variant histologies.
Moderate Recommendation; Grade C
What should be offered to high-risk patients with persistent or recurrent disease within one year after two induction cycles of BCG?
Radical cystectomy.
Moderate Recommendation; Grade C
What is recommended at the time of TURBT for NMIBC patients to increase detection and reduce recurrence?
Offer blue light cystoscopy (BLC), if available.
Moderate Recommendation; Grade B
When should narrow-band imaging (NBI) be considered for NMIBC patients?
To increase detection and reduce recurrence.
Conditional Recommendation; Grade C
When should the first surveillance cystoscopy be performed after initial evaluation and treatment of NMIBC?
Within 3-4 months.
Expert Opinion
What is the recommended surveillance schedule for a low-risk patient after a negative first surveillance cystoscopy?
Six to nine months later, then annually; further follow-up is based on shared decision-making.
Moderate Recommendation; Grade C
Should routine surveillance upper tract imaging be performed for asymptomatic patients with low-risk NMIBC?
No, it should not be performed routinely.
Expert Opinion
What alternative treatment can be considered for patients with low-grade Ta disease and sub-centimeter papillary tumors?
In-office fulguration as an alternative to resection under anesthesia.
Expert Opinion
What is the recommended follow-up surveillance schedule for intermediate-risk patients after the first negative cystoscopy?
Every 3-6 months for 2 years, then 6-12 months for years 3 and 4, and annually thereafter.
Expert Opinion
What follow-up schedule is recommended for high-risk patients after the first negative cystoscopy?
Every 3-4 months for 2 years, then every 6 months for years 3 and 4, and annually thereafter.
Expert Opinion
When should surveillance upper tract imaging be considered for intermediate- or high-risk patients?
At 1- to 2-year intervals.
Expert Opinion
