One third of all tumours in urology are urothelial cancer of the bladder. In a joint presentation by the EAU guidelines panels on Non-muscle-invasive Bladder Cancer and Muscle-invasive and Metastatic Bladder Cancer, the most important and recently established guidelines for diagnosis and treatment of bladder cancer were highlighted with practical case presentations.
Diagnosis and initial treatment steps
Cystoscopy is still the best way to detect as well as to monitor tumours of the bladder and cannot be replaced by cytology, other urinary tumours markers, or any imaging technique. If a tumour is found it is recommended to perform TURB in one piece in tumours < 1 cm or in separate fractions in lesions > 1 cm. In primary tumours, detrusor musculature must be always present in the specimen. If the equipment is available, fluorescence guided biopsy should be performed when CIS is suspected.
In patients with NMIBC, a second resection should be performed in 2-6 weeks if the initial resection was incomplete or in case of a T1 or G3 tumour.
Risk stratification and individual tailoring of adjuvant treatment in NMIBC after complete TURB should be performed with the help of the EORTC Risk Tables. In patients with tumours at high risk of progression, BCG intravesical treatment is recommended, in patients at highest risk immediate cystectomy may even be offered .
For muscle-infiltrating tumours either MRI with fast dynamic contrast-enhancement or CT with contrast enhancement are recommended if the patient is considered suitable for radical treatment. The guidelines on Muscle-invasive and Metastatic Bladder Cancer describe the “radical cystectomy” as the recommended treatment in T2, T4a, N0 M0 and high risk non-muscle-invasive bladder tumours. This includes a standard lymph node dissection and complete removal of the bladder, prostate, and seminal vesicles in males, and bladder and anterior vagina in females.
Preoperative bowl preparation is not mandatory, “fast-track” measurements may reduce the time of bowl recovery. An orthotopic bladder cancer substitute should definitely be included for both male and female patients, unless there are any contraindications. Neoadjuvant chemotherapy is recommended in patients fit for Cisplatinum and patients with non-organ confined disease. Adjuvant chemotherapy is advised within clinical trials only and not as a routine therapeutic option.
Follow-up for non-muscle-invasive disease depends on the EORTC-risk stratification of recurrence and progression. A list of follow-up procedures for muscle-invasive disease regarding oncological outcome can be found in the extended version of the guidelines.
In metastatic disease Cisplatinum-containing combination therapy is strongly recommended. In those patients unfit for Cisplatinum, Carboplatin combination therapy or single-agents should be used. Patients progressing after platinum-based combination chemotherapy for metastatic disease should be offered Vinflunin. Zoledronic acid and Denosumab are recommended as supportive treatment for bone metastasis.