Guidelines

Non-muscle-invasive Bladder Cancer

1. INTRODUCTION

1.1. Aim and scope

This overview represents the updated European Association of Urology (EAU) Guidelines for Non-muscle-invasive Bladder Cancer (NMIBC), TaT1 and carcinoma in situ (CIS). The information presented is limited to urothelial carcinoma, unless specified otherwise. The aim is to provide practical recommendations on the clinical management of NMIBC with a focus on clinical presentation and recommendations.

Separate EAU Guidelines documents are available addressing upper tract urothelial carcinoma (UTUC) [1], muscle-invasive and metastatic bladder cancer (MIBC) [2] and primary urethral carcinoma [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 references/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 on NMIBC consists of an international multidisciplinary group of clinicians, including urologists, uro-oncologists, a pathologist, and a statistician. Members of this Panel have been selected based on their expertise and to represent the professionals treating patients suspected of suffering from bladder cancer. In the course of 2021 two patient representatives have formally joined the NMIBC Panel. 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: https://uroweb.org/guideline/non-muscle-invasive-bladder-cancer/.

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 latest publication dating to 2022 [4], as are a number of translations of all versions of the EAU NMIBC Guidelines. All documents are accessible through the EAU website Uroweb: https://uroweb.org/guideline/non-muscle-invasive-bladder-cancer/.

1.4. Publication history and summary of changes

1.4.1. Publication history

The EAU Guidelines on Bladder Cancer were first published in 2000. This 2022 NMIBC Guidelines document presents a limited update of the 2021 publication.

1.4.2. Summary of changes

Additional data has been included throughout this document text. In particular in Chapters/Sections:

  • 5.4 Imaging – with the introduction of Vesical Imaging-Reporting and Data System [VI-RADS]).
  • 5.7.3 Surveillance of non-muscle-invasive bladder cancer – inclusion of urine biomarkers in a surveillance strategy of an individual patient.
  • 5.8 Cystoscopy – inclusion of the procedural chance (‘bag squeeze’). The recommendation was amended accordingly.

Recommendations

Strength rating

In men, use a flexible cystoscope, if available and apply irrigation ‘bag squeeze’ to decrease procedural pain when passing the proximal urethra.

Strong

  • 5.10.2.2 Evaluation of resection quality, resulting in a recommendation change.

Recommendations

Strength rating

Performance of individual steps

Take biopsies from abnormal-looking urothelium. Biopsies from normal-looking mucosa (mapping biopsies from the trigone, bladder dome, right, left, anterior and posterior bladder wall) are recommended if cytology or urinary molecular marker test is positive. If the equipment is available, perform fluorescence-guided (PDD) biopsies.

Strong

  • 7.2.1.3.2 Device-assisted intravesical chemotherapy - Microwave-induced hyperthermia effect (RITE)
  • New section 7.3 Chemoablation and neoadjuvant treatment was added.
  • 7.6.3 Treatment of BCG unresponsive tumours, late BCG-relapsing tumours, low-grade (LG) recurrences after BCG treatment and patients with BCG intolerance, two recommendations were amended.

General recommendations

Strength rating

In patients with high-risk tumours, full-dose intravesical bacillus Calmette-Guérin (BCG) for one to three years (induction plus 3-weekly instillations at 3, 6, 12, 18, 24, 30 and 36 months), is indicated. The additional beneficial effect of the second and third years of maintenance should be weighed against its added costs, side effects and problems connected with BCG shortage. Immediate radical cystectomy (RC) may also be discussed with the patient.

Strong

In patients with very high-risk tumours offer immediate RC. Intravesical full-dose BCG instillations for one to three years to those who refuse or are unfit for RC.

Strong

7.8 Guidelines for the treatment of TaT1 tumours and carcinoma in situ according to risk stratification

Recommendations

Strength rating

EAU risk group: High

Offer intravesical full-dose BCG instillations for one to 3 years or discuss immediate radical cystectomy (RC).

Strong

  • Chapter 8 – Additional information on imaging modalities and urinary markers.