Treatment Guideline Chart

Bladder cancer is a heterogenous neoplasm that ranges from non-life-threatening, low-grade, superficial papillary lesions to high-grade invasive tumors that often metastasizes at the presentation.

It is the most common cancer involving the urinary system and it is the 11th most commonly diagnosed in the world.

Microscopic or gross painless hematuria is the most common presenting complaint.


  • Alternative treatment in patients unfit for or opposed to radical surgery or for local palliative treatment inpatients with metastatic disease
  • Preoperative radiation therapy (RT) prior to cystectomy may be considered in patients with invasive tumors 
  • May consider adjuvant pelvic irradiation for patients with pT3/pT4 pN0-2 disease who recently underwent radical cystectomy with ileal conduit
  • May consider intraoperative RT in highly selected T4b cases
  • Intraoperative RT may be considered in patients with tumors extending to the abdominal and/or pelvic wall 
  • Palliative RT combined with radiosensitizing chemotherapy is recommended especially in patients with metastasis or disease recurrence
  • Recommended dose: 1.8-2.0 Gy daily fractionation
    • Conventional or accelerated hyperfractionation of 39.6–50.4 Gy may be applied to the whole bladder with or without pelvic nodal irradiation
  • Absence of hydronephrosis and extensive CIS is a factor for positive treatment response


  • For muscle invasive bladder cancer, radical radiotherapy is given using a radiosensitizer (eg Mitomycin + Fluorouracil or Cisplatin plus Fluorouracil or Cisplatin plus Paclitaxel or Cisplatin alone)
    • Low-dose Gemcitabine may also be considered
  • Conventional fractional radiation therapy with a radiosensitizer may be used as palliative therapy in patients with advanced or metastatic disease
    • Recommended regimens include Cisplatin (preferred), taxanes (Docetaxel, Paclitaxel), Fluorouracil monotherapy, Fluorouracil + Mitomycin, low-dose Gemcitabine, or Capecitabine monotherapy
  • Concurrent chemoradiotherapy is an alternative option to radical cystectomy in patients with recurrent Ta-T1 disease (without extensive Tis) with history of BCG therapy and ineligible for cystectomy
    • Also recommended for patients in need of added tumor cytotoxicity
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