Challenging the EAU Guidelines on Non–Muscle-Invasive Bladder Cancer (NMIBC): Single Instillation of Chemotherapy After Transurethral Resection of NMIBC and Chemotherapy Versus Bacillus Calmette-Guérin in Treatment of Intermediate-Risk Tumours

Abstract

Context Although the 2008 European Association of Urology (EAU) guidelines provide an excellent evidence-based framework for the management of non–muscle-invasive bladder cancer (NMIBC), some topics have been questioned and discussed by many authors and remain controversial. Objective To comment on the current EAU guidelines on NMIBC by taking into account new data published in 2009 in peer-reviewed urologic journals and once again discussing relevant data that were available when the guidelines were prepared. Evidence acquisition Two important guidelines have been challenged: (1) the use of a single instillation of a chemotherapeutic agent after transurethral resection (TUR) in all patients with NMIBC and (2) chemotherapy versus bacillus Calmette-Guérin (BCG) in the treatment of intermediate-risk tumours. The most important recent publications (2009), including randomised studies and meta-analyses, have been considered and evaluated. Evidence synthesis Based on a review of the current EAU guidelines and recent literature, a single instillation of a chemotherapeutic agent after TUR should be administered only in primary, solitary, low-grade NMIBCs. The first-line treatment of intermediate-risk tumours should be the instillation of BCG once a week for 6 wk, followed by maintenance for 1–3 yr. Mitomycin C is still the first treatment of choice for intermediate-risk and low-risk NMIBC patients (single, recurrent, low-grade tumour). Conclusions A complete TUR of the bladder tumour plus immediate, postoperative, chemotherapeutic instillation is recommended for all patients with primary, solitary NMIBC, except in those with bladder wall perforation. For these low-risk tumours, no further therapy is required. For intermediate-risk disease, intravesical induction BCG plus maintenance should be considered the first choice, while intravesical chemotherapy should be considered for intermediate-risk and low-risk tumours (single, recurrent, low-grade NMIBC). In these patients, one immediate single instillation of chemotherapy should not be administered after TUR.