Elsevier

European Urology

Volume 59, Issue 6, June 2011, Pages 997-1008
European Urology

Guidelines
EAU Guidelines on Non–Muscle-Invasive Urothelial Carcinoma of the Bladder, the 2011 Update

https://doi.org/10.1016/j.eururo.2011.03.017Get rights and content

Abstract

Context and objective

To present the 2011 European Association of Urology (EAU) guidelines on non–muscle-invasive bladder cancer (NMIBC).

Evidence acquisition

Literature published between 2004 and 2010 on the diagnosis and treatment of NMIBC was systematically reviewed. Previous guidelines were updated, and the level of evidence (LE) and grade of recommendation (GR) were assigned.

Evidence synthesis

Tumours staged as Ta, T1, or carcinoma in situ (CIS) are grouped as NMIBC. Diagnosis depends on cystoscopy and histologic evaluation of the tissue obtained by transurethral resection (TUR) in papillary tumours or by multiple bladder biopsies in CIS. In papillary lesions, a complete TUR is essential for the patient's prognosis. Where the initial resection is incomplete or where a high-grade or T1 tumour is detected, a second TUR should be performed within 2–6 wk.

In papillary tumours, the risks of both recurrence and progression may be estimated for individual patients using the scoring system and risk tables. The stratification of patients into low-, intermediate-, and high-risk groups—separately for recurrence and progression—is pivotal to recommending adjuvant treatment. For patients with a low risk of tumour recurrence and progression, one immediate instillation of chemotherapy is recommended. Patients with an intermediate or high risk of recurrence and an intermediate risk of progression should receive one immediate instillation of chemotherapy followed by a minimum of 1 yr of bacillus Calmette-Guérin (BCG) intravesical immunotherapy or further instillations of chemotherapy. Papillary tumours with a high risk of progression and CIS should receive intravesical BCG for 1 yr.

Cystectomy may be offered to the highest risk patients, and it is at least recommended in BCG failure patients. The long version of the guidelines is available from the EAU Web site (www.uroweb.org).

Conclusions

These abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice.

Introduction

The first European Association of Urology (EAU) guidelines on bladder cancer were published in 2002 [1]. Since then the guidelines have been continuously updated, and the most recent version is available from the EAU Web site, www.uroweb.org. An overview of the updated 2011 EAU guidelines on non–muscle-invasive bladder cancer (NMIBC) (Ta, T1, and carcinoma in situ [CIS]) is provided here.

Section snippets

Evidence acquisition

The panel members performed a systematic literature search for each section of the guidelines. Medline, Web of Science, and Embase databases were searched for original and review articles published between 2004 and 2010. Panel members selected records with the highest level of evidence according to a modified classification system from the Oxford Centre for Evidence-Based Medicine levels of evidence (LEs) [2]. Recommendations were graded to provide transparency regarding the underlying LE for

Epidemiology

Bladder cancer is the most common malignancy of the urinary tract. The worldwide age standardised rate (ASR) is 10.1 per 100 000 for men and 2.5 per 100 000 for women. In Europe, the highest incidence of bladder cancer (ASR) has been reported in the western region (23.6 in men and 5.4 in women) and in the southern region (27.1 in men and 4.1 in women), followed by northern Europe (16.9 in men and 4.9 in women). The lowest incidence has been observed in eastern European regions (14.7 in men and

Risk factors

Urologists should be aware of the various types of occupational exposures that may be related to urothelial carcinogens [5]. Aromatic amines were recognised first. At-risk groups include workers in the following industries: printing, iron and aluminium processing, industrial painting, and gas- and tar manufacturing (LE: 3). Another prominent risk factor is cigarette smoking, which triples the risk of developing bladder cancer and leads to higher mortality rates [6] (LE: 3).

Classification

The Tumour, Node, Metatasis (TNM) classification approved by the Union Internationale Contre le Cancer, which was updated in 2009, is used in these guidelines (Table 1) [7]. The new classification for grading NMIBCs proposed by the World Health Organisation (WHO) and the International Society of Urological Pathology was published by the WHO in 2004 (Table 2) [8]. New categories were defined among flat and papillary lesions. Among papillary lesions, they are papillary urothelial neoplasms of low

Diagnosis

Haematuria is the most common finding in NMIBC. Lower urinary tract symptoms may appear in patients with CIS.

Prognosis of TaT1 tumours

The classic way to categorise patients with TaT1 tumours is to divide them into risk groups based on prognostic factors derived from multivariate analyses. To predict separately the short- and long-term risks of both recurrence and progression in individual patients, a scoring system and risk tables were developed by the European Organisation for Research and Treatment of Cancer (EORTC) [33]. The EORTC database provided individual data for 2596 patients diagnosed with TaT1 tumours who did not

One immediate postoperative intravesical instillation

TaT1 tumours recur frequently and progress to muscle-invasive disease in a limited number of cases. It is therefore necessary to consider adjuvant therapy in all patients.

The results of a meta-analysis of seven randomised trials demonstrated that one immediate instillation of chemotherapy after TUR significantly reduced recurrence compared with TUR alone (LE: 1a) [37]. In absolute values, the reduction was 11.7%, which implies a 24.2% decrease in the corresponding relative risk. The efficacy of

Cystectomy for non–muscle-invasive bladder cancer

Immediate cystectomy can be considered for those patients who are at high risk of progression. According to the EORTC tables (Table 4, Table 5), these patients have multiple recurrent high-grade tumours, high-grade T1 tumours, and high-grade tumours with concurrent CIS. Cystectomy is advocated in patients with BCG failure. Delaying cystectomy in these patients may lead to decreased disease-specific survival [69].

Follow-up

Patients need to be followed up because of the risk of recurrence and progression; however, the frequency and duration of cystoscopies and upper urinary tract investigations should reflect the degree of risk [33]. When planning a follow-up schedule, the following aspects should be considered:

  • Prompt detection of muscle-invasive and high-grade non–muscle-invasive recurrence is crucial because a delay in diagnosis and therapy can be life threatening.

  • Tumour recurrence in the low-risk group is

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