Muscle-invasive and Metastatic Bladder Cancer

Full Text Guidelines Summary of Changes Scientific Publications & Appendices Pocket Guidelines Archive Panel

ISBN 978-94-92671-07-3

J.A. Witjes (Chair), H.M. Bruins, R. Cathomas, E. Compérat, N.C. Cowan, G. Gakis, V. Hernández, A. Lorch, M.J. Ribal (Vice-chair), G.N Thalmann, A.G. van der Heijden, E. Veskimäe
Guidelines Associates: E. Linares Espinós, M. Rouanne, Y. Neuzillet


1.1.Aims and scope

The European Association of Urology (EAU) Guidelines Panel for Muscle-invasive and Metastatic Bladder Cancer (MIBC) have prepared these guidelines to help urologists assess the evidence-based management of MIBC and to incorporate guideline recommendations into their clinical practice.

Separate EAU guidelines documents are available addressing upper urinary tract (UUT) tumours [1], non-muscle-invasive bladder cancer (TaT1 and carcinoma in situ) (NMIBC) [2], and primary urethral carcinomas [3].

It must be emphasised that clinical guidelines present the best evidence available to the experts but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients, but rather help to focus decisions - also taking personal values and preferences/individual circumstances of patients into account. Guidelines are not mandates and do not purport to be a legal standard of care.

1.2.Panel Composition

The EAU Guidelines Panel consists of an international multidisciplinary group of clinicians, including urologists, oncologists, a pathologist and a radiologist.

All experts involved in the production of this document have submitted potential conflict of interest statements which can be viewed on the EAU website Uroweb:

1.3.Available publications

A quick reference document (Pocket Guidelines) is available, both in print and as an app for iOS and Android devices. These are abridged versions which may require consultation together with the full text version.

Several scientific publications are available (the most recent paper dating back to 2017 [4]), as are a number of translations of all versions of the EAU MIBC Guidelines. All documents are accessible through the EAU website:

1.4.Publication history and summary of changes

1.4.1.Publication history

The EAU published its first guidelines on bladder cancer (BC) in 2000. This document covered both NMIBC and MIBC. Since these conditions require different treatment strategies, it was decided to give each condition its own guidelines, resulting in the first publication of the MIBC Guidelines in 2004. This 2020 document presents a limited update of the 2019 version.

1.4.2.Summary of changes

New relevant references have been identified through a structured assessment of the literature and incorporated in the various chapters of the 2020 EAU MIBC Guidelines.

Key changes in the 2020 print are:

  • New section - 3.2.5 - Metabolic disorders – has been added, also providing a recommendation.

3.2.9 Summary of evidence and guidelines for epidemiology and risk factors


Strength rating

Do not prescribe pioglitazone to patients with active bladder cancer or a history of bladder cancer.


  • Chapter 6 - Markers – this section has been completely revised.
  • Section 7.1 - Treatment failure of non-muscle-invasive bladder cancer – this section has been updated to align with the 2020 NMIBC guidelines; in particular with respect to discussing unsuccessful treatment with intravesical BCG.

7.1.2 Guidelines for treatment failure of non-muscle-invasive bladder cancer


Strength rating

Offer patients with BCG-unresponsive tumours, who are not candidates for RC due to comorbidities, preservation strategies (intravesical chemotherapy, chemotherapy and microwave-induced hyperthermia, electromotive administration of chemotherapy, intravesical- or systemic immunotherapy; preferably within clinical trials).


  • Section - Radical cystectomy in women – this section has been revised.
  • Section - Patient selection and preparations for surgery – additional information on thromboprophylaxis has been included, as well as the final findings of the systematic review conducted to assess the impact of hospital and surgeon volume on treatment outcomes, resulting
    in two new recommendations.

7.4.10 Summary of evidence and guidelines for radical cystectomy and urinary diversion


Strength rating

Perform at least 10, and preferably > 20 radical cystectomies per hospital/per year


Offer pharmacological prophylaxis, such as low molecular weight heparin to RC patients, starting the first day post-surgery, for a period of 4 weeks.


  • Section 7.8 – Metastatic disease – this section has been completely restructured, also incorporating updated information on novel programmed death ligand 1 (PD-1) and PD-L1 inhibitors.

7.8.6 Summary of evidence and guidelines for metastatic disease


Strength rating

First-line treatment in patients ineligible (unfit) for cisplatin

Offer checkpoint inhibitors pembrolizumab or atezolizumab to PD-L1-positive patients.


Second-line treatment

Only offer vinflunine to patients for metastatic disease as subsequent-line treatment if immunotherapy or combination chemotherapy or FGFR3-inhibitor therapy or inclusion in a clinical trial is not feasible.


  • Section 7.9 – Quality of life – a new section 7.9.2 - Neoadjuvant chemotherapy has been included.

A number of text sections will include statements resulting from the EAU-ESMO consensus [5,6], notably:

  • Pathology – Section 3.3.4
  • Diagnostic evaluation – Section 5.1.10
  • Markers - Section 6.5.1
  • Treatment failure of NMIBC – Section 7.1.3
  • Pre- and post-operative radiotherapy in MIBC – Section 7.3.4
  • Radical surgery and urinary diversion - Section 7.4.11
  • Unresectable tumours - Section
  • Bladder-sparing treatments for localised disease - Section
  • External beam radiotherapy - Section
  • Multimodality bladder-preserving treatment - Section
  • Adjuvant therapy – Section 7.7.4
  • Oligometastatic disease - Section
  • Metastatic disease - Section 7.8.7
  • Follow up - Section 8.6