Bladder Cancer

Page updated Winter 2021.
DisclaimerMedicine is an ever-changing science.  We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable resources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original resources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.


Non-Muscle Invasive Bladder Cancer

TURBT
TURBT is performed to remove all visible tumors and to
provide specimens for pathology to 
determine stage and grade of cancer.

Repeat TURBT within 6 weeks

Should be done in following situations:
- Incomplete initial resection in a patient with non-muscle invasive disease

- T1 disease
- High-grade Ta tumors


Intravesical Instillation
Low risk disease:
We recommend  a single postoperative instillation of gemcitabine or mitomycin C within 24 hours of TURBT, unless there is a suspected perforation or if we performed extensive resection.
Intermediate risk disease:
We recommend  a single postoperative instillation of gemcitabine or mitomycin C within 24 hours of TURBT, unless there is a suspected perforation or if we performed extensive resection. 

We recommend a six week course of induction intravesical chemotherapy (Mitomycin C, Doxorubicin, Epirubicin) or BCG in this group. 

In patients who completely respond to induction chemotherapy or BCG, we recommend a maintenance chemotherapy or BCG instillation for one year, if  tolerated.
High risk disease:
We recommend a six-week induction course of BCG in this group.
In patients who completely respond to induction BCG, we recommend maintenance BCG instillation for three year, if  tolerated.

Second BCG Induction

Will be offered if there is persistent or recurrent Ta or CIS disease in an intermediate- or high-risk patient. 

Please note we did not include high grade T1 disease here. We offer cystectomy for high grade T1 disease. 


Non-Muscle Invasive Bladder Cancer

Contraindications to intravesical chemotherapy

Pregnancy

Lactating

Bladder perforation

Any allergy or adverse reactions to the chemotherapeutic agent

Contraindications to intravesical BCG

Bladder or prostate surgery or biopsy - Within 7 to 14 days

Traumatic catheterization - Within 7 to 14 days

Gross hematuria at the day of treatment

Symptomatic urinary tract infection

Febrile illness

Personal history of BCG sepsis

Personal history of tuberculosis

Immunosuppressed patients 

On certain antibiotics that may interfere with effectiveness of BCG

Total incontinence (patient will not retain BCG)

Liver disease (precludes treatment with isoniazid if sepsis
occurs

Advanced age

Radical Cystectomy

Initial radical cystectomy: Will be offered in following settings:

-Persistent high-grade T1 disease on repeat resection

-T1 tumors with associated with CIS

-T1 tumors with associated with Lymphovascular invasion 

-T1 tumors with associated with variant histologies. These include: micropapillary, nested, plasmacytoid, neuroendocrine, sarcomatoid, and extensive squamous or glandular differentiation

Radical cystectomy after intravesical therapy: 

Will be offered in following settings:


For a high-grade T1 disease after a single course of induction intravesical BCG

For a high-risk disease with persistent or recurrent disease within one year following treatment with two induction cycles of BCG, or on BCG maintenance.


Muscle-Invasive Bladder Cancer


Radical Cystectomy Candidate

For clinically resectable stage cT2-T4a N0 M0 disease

Neoadjuvant Chemotherapy

We recommend cisplatin-based neoadjuvant chemotherapy to T2–T4a N0 M0 patients.

Cystectomy should then will be done within 12 weeks of completion of treatment.

Adjuvant Chemotherapy

We recommend adjuvant chemotherapy to pT3/T4 and/or N+ patients who have not received cisplatin-based neoadjuvant chemotherapy.

Multi-Modal Bladder Preserving Therapy

This is an option in highly selected patients.

This modality includes maximal TURBT, chemotherapy and external beam radiation therapy.

In case residual or recurrent muscle-invasive disease following bladder preserving therapy, radical cystectomy with bilateral pelvic lymphadenectomy should be done.

In case of non-muscle invasive recurrence following bladder preserving therapy, either TURBT with intravesical therapy, or radical cystectomy should be done.

Metastatic Bladder Cancer

First-line treatment for cisplatin-eligible patients

GC, MVAC, HD-MVAC, PCG

First-line treatment if ineligible for cisplatin

PD-L1-positive patients: Pembrolizumab or atezolizumab

PD-L1 is negative patients: Carboplatin

Second-line treatment

pembrolizumab

Supportive treatment in case of bone metastasis

Zoledronic acid or denosumab

Chemotherapy Regimens

GC: Gemcitabine + cisplatin

MVAC: Methotrexate + vinblastine + doxorubicin + cisplatin

HD-MVAC: High-dose-intensity chemotherapy MVAC

PCG: Paclitaxel+ cisplatin + gemcitabine