Bladder%20cancer Management

Non-Muscle Invasive Bladder Cancer

• After TURBT, first cystoscopy should be done after 3 months because it is an important prognostic indicator for recurrence and progression in patients with Ta, T1 tumors and CIS
• For low-risk patients, cystoscopy should be done at the 3rd month post-treatment
  • If negative, subsequent cystoscopy is suggested 12 months later, then annually thereafter up to the 5th year post-treatment
  • Baseline imaging is suggested during the 1st year, then may obtain follow-up imaging studies as clinically indicated
• Intermediate-risk patients with Ta tumors should have an in-between follow-up scheme using cystoscopy and cytology according to personal and subjective factors
  
  • Cystoscopy and urinary cytology at 3, 6, and 12 months on the 1st year, every 6 months on the 2nd year, then once a year thereafter is suggested

• Patients with high-risk tumors should undergo cystoscopy and urinary cytology at 3-month intervals for the 1st 2 years, at 6-month intervals on the 3rd to 5th year, then annually thereafter
  
  • Baseline imaging of the upper tract should be obtained during the 1st follow-up and after 12 months, every 1 to 2 years until 10 years post-treatment, then as clinically indicated
  • Urine cytology is recommended every 3 months in the 1st 2 years, then at 6-month intervals for the next 3 years, and annually thereafter

• For post-cystectomy patients:
  • CT or MRI urography at 3 and 12 months is recommended, then annually until 5 years post-cystectomy, and annual renal ultrasound afterwards
  • Hematologic tests for creatinine and electrolytes and liver function tests (LFTs) every 3-6 months are recommended on the 1st year of follow-up, then annually
    • Annual B12 levels should be obtained every year after the 1st year post-cystectomy
    • If chemotherapy was given, CBC and comprehensive metabolic panel every 3-6 months for the 1st year of follow-up should be considered
  • Urine cytology at 6- to 12-month intervals for the 1st year is recommended
  • Consider urethral wash cytology every 6-12 months, particularly if Tis was found within the bladder or prostatic urethra 
• During follow-up in patients with positive cytology and no visible tumor in the bladder, selective mapping or random biopsies or biopsies with photodynamic diagnosis and investigation of extravesical locations including CT urography and prostatic urethra biopsy are recommended

Muscle Invasive Bladder Cancer

• After a radical cystectomy follow-up should include:
  
  • Imaging of the chest, upper tracts, abdomen and pelvis should be conducted every 3-6 months for 2 years based on the risk of recurrence and then as clinically indicated
  • CT or MRI urography and chest radiography or CT scan every 3-6 months are recommended for the 1st 2 years and annually thereafter
    • Annual renal ultrasound is recommended after 5 years of follow-up
  • FDG-PET/CT may be obtained to confirm the presence of metastatic disease
  • Recommended schedule for creatinine and electrolytes, LFTs, B12 levels, CBC, comprehensive metabolic panel and urine cytology is the same with patients treated for non-muscle invasive bladder cancer

• After a partial cystectomy or chemoradiation, follow-up is similar to that for a radical cystectomy, with the addition of monitoring for relapse in the bladder by serial cytologic examinations and cystoscopies at 3-month intervals for the first 2 years, at 6-month intervals at year 3-4, annually until 10 years post-cystectomy, then according to clinical discretion

• Most Asian centers have a check using cystoscopy at 3 months after adjuvant intravesical treatment, then increasing intervals as appropriate
  
  • Urinary urothelial markers (eg nuclear matrix protein 22 and bladder tumor antigen) can be used in Asian countries

Metastatic Disease

• Serial cystoscopy should be done every 3-6 months as clinically indicated
  • Urine cytology should be done during cystoscopy if bladder in situ
• CT or MRI urography and CT scan of the chest, abdomen and pelvis should be done every 3-6 months if clinically indicated, or if with new symptoms or clinical change
• Hematologic studies such as CBC and comprehensive metabolic panel every 1-3 months are recommended
• Annual B12 levels should be requested for post-cystectomy patients