5. Primary treatment by disease type
The type of treatment after TURBT is primarily based on the risk of disease progression. Table 3 outlines the treatment recommendations per risk group as defined by the EAU Guidelines on NMIBC [14].
Table 3. Treatment according to tumour risk category as defined by the EAU Guidelines on NMIBC [14]
| Risk category | Treatment |
|---|---|
| Low risk | A single post-operative instillation of chemotherapy reduces the risk of recurrence and is considered sufficient treatment in these patients. In all studies, the instillation was administered within 24 hours. |
| Intermediate risk | In these patients, induction chemotherapy with or without maintenance for a maximum of one year is a reasonable first-line option in the majority of patients [16]. An alternative option is one-year, full-dose BCG treatment (induction plus 3-weekly instillations at 3, 6 and 12 months). The final choice should reflect the individual patient’s risk of recurrence and progression, as well as the efficacy and side effects of each treatment modality. |
| High risk | In these patients, full-dose intravesical BCG for one to 3 years (induction plus 3-weekly instillations at 3, 6, 12, 18, 24, 30 and 36 months) is indicated. Due to the high risk of progression, immediate radical cystectomy (RC) can also be discussed with the patient. |
| Very high risk | Immediate RC should be discussed with these patients. If RC is not feasible or refused by the patient, full-dose intravesical BCG for one to 3 years should be offered. |
5.1 Contraindications for intravesical instillations
Intravesical administration of BCG and MMC is contraindicated in the following cases:
- in patients with visible haematuria
- any suspicion of extra- peritoneal or intraperitoneal bladder perforation
- hypersensitivity to the active substance
- breastfeeding [17]
- after traumatic catheterisation
- for two weeks after TURBT
- in patients with symptoms on both localised or systemic urinary tract infection (UTI) [18, 19]
Extravasation of chemotherapy may lead to serious adverse events. No data is available on the use of mitomycin in pregnant women. Mitomycin has a mutagenic, teratogenic and carcinogenic effect and therefore may impair the development of an embryo. Women must not become pregnant during treatment with mitomycin [17].
Asymptomatic bacteriuria, the presence of leukocyturia or nonvisible haematuria are not contraindications [18], and antibiotic prophylaxis is not necessary in these cases [20]. Other contraindications include active tuberculosis, hypersensitivity to BCG and previous radiotherapy of the bladder [18]. BCG should be used with caution in immunocompromised patients, although some small studies have shown similar efficacy and no increase in complications compared to non-immunocompromised patients. BCG administration is not recommended during pregnancy or when lactating, although relevant data are lacking [18].
5.1.1 Safety precautions for intravesical instillations
Atraumatic catheterisation is essential for the safe instillation of BCG. Major complications can appear after systemic drug absorption. Contraindications for BCG intravesical instillation should therefore be respected. In both cases nurses should observe the urine and ask the patient about UTI symptoms before the treatment and contact the physician in case of gross haematuria or signs of UTI.