Muscle-invasive and Metastatic Bladder Cancer

Muscle-invasive and Metastatic Bladder Cancer 2020


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


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


  • 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


RecommendationStrength 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


Recommendations Strength rating
Perform at least 10, and preferably > 20 radical cystectomies per hospital/per year.Strong
Offer pharmacological prophylaxis, such as low molecular weight heparin to RC patients, starting the first day post-surgery, for a period of 4 weeks.Strong


  • 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


Recommendations Strength rating
First-line treatment in patients ineligible (unfit) for cisplatin
Offer checkpoint inhibitors pembrolizumab or atezolizumab to PD-L1-positive patients.Strong
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.Weak


  • 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 conference, 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