Current intravesical therapy for non-muscle invasive bladder cancer

Introduction: Transurethral resection of the bladder tumour (TURBT) is still the standard initial treatment for non-muscle invasive bladder cancer (NMIBC). However, even after a radical resection, recurrence (30 - 80%) and progression (1 - 45%) are commonly seen. Intravesical therapy provides direct contact of the agent with the bladder mucosa and clearly has improved the outcome, especially in high-risk disease. Areas covered: The role of a good initial TURBT is emphasized. Risk assessment tools are discussed. Different intravesical therapies are enumerated according to the latest literature, with the emphasis on Bacillus Calmette-Guerin (BCG), including the discussion on the optimal dose and schedule. New developments are mentioned. Expert opinion: A radical TURBT is essential for good prognosis. For optimal visualisation of tumours, fluorescence techniques should be used with low threshold, especially in case of suspicion of carcinoma in situ (CIS). Increased completeness of the resection will lead to less persisting disease and less need for adjuvant treatment. A re-TURBT should be done when in doubt of radical resection (judged by the pathologist or the surgeon). Risk assessment is essential, but the available tools are outdated. A single post-operative instillation (SPI) with chemotherapy is only indicated in low-risk disease. BCG is the treatment of choice for high-grade disease. BCG should be given as maintenance. Awareness of deterioration of the prognosis after progression is of great importance. In BCG failures, cystectomy should be strongly advised. Chemotherapy in combination with hyperthermia seems to be a new promising treatment.