What is the recommended treatment for a patient with low-grade Ta bladder cancer who has undergone Transurethral Resection of Bladder Tumor (TURBT) and presents with necrotic tissue on cystoscopy at 4 months?

Management of Low-Grade Ta Bladder Cancer with Necrotic Tissue at 4-Month Follow-up

For a patient with low-grade Ta bladder cancer who underwent TURBT and presents with necrotic tissue on cystoscopy at 4 months, a repeat TURBT is strongly recommended to remove the necrotic tissue and evaluate for recurrent disease, followed by consideration of intravesical chemotherapy.

Initial Assessment and Management

• The presence of necrotic tissue at 4-month follow-up cystoscopy requires immediate intervention as it may represent residual or recurrent disease 1
• Repeat TURBT is the standard approach to remove necrotic tissue and obtain tissue for pathologic evaluation to determine if recurrent disease is present 1
• Complete resection of all visible lesions is essential for accurate staging and optimal treatment outcomes 1

Post-TURBT Treatment Options

If Recurrent Low-Grade Ta Disease is Confirmed:

• Consider administering a single dose of immediate intravesical chemotherapy (not immunotherapy) within 24 hours of repeat TURBT 1
• Mitomycin C is the most commonly used agent for this purpose 1
• For patients with history of recurrences (as in this case), a 6-week induction course of intravesical chemotherapy is recommended following the immediate post-TURBT instillation 1

If No Recurrent Disease is Found:

• Close surveillance is recommended with more frequent follow-up cystoscopies due to the presence of necrotic tissue at the 4-month mark, which indicates higher risk 1

Risk Assessment Considerations

• Factors that influence treatment decisions include: tumor size, number, grade, prior recurrence (present in this case), and presence of concomitant CIS 1
• The presence of necrotic tissue at 4 months suggests potential for recurrence, warranting more aggressive follow-up 1
• Low-grade Ta tumors have a relatively high risk for recurrence (up to 45% within 1 year after TURBT alone) but low risk for progression to muscle-invasive disease (3-15%) 2

Follow-up Protocol

• After treatment, cystoscopy should be performed at 3-month intervals initially 1
• If no recurrences are detected during the first year, the interval between evaluations can be gradually increased 1
• For low-risk non-muscle-invasive bladder cancer with negative follow-up cystoscopies, subsequent cystoscopies can be performed at 6-9 month intervals and then yearly for up to 5 years 1

Important Considerations and Pitfalls

• BCG immunotherapy is not recommended for low-grade Ta tumors and should be reserved for high-grade disease 1
• Immediate intravesical chemotherapy should be avoided if the TURBT was extensive or if bladder perforation is suspected 1
• Failure to adequately treat recurrent disease can lead to more frequent recurrences and potentially progression to higher-grade disease 3
• The presence of necrotic tissue may complicate visualization during cystoscopy; consider using enhanced visualization techniques if available (fluorescence cystoscopy, narrow-band imaging) 1

Treatment Algorithm

1. Perform repeat TURBT to remove necrotic tissue and evaluate for recurrent disease
2. If recurrent low-grade Ta disease is confirmed:
   • Administer immediate single-dose intravesical chemotherapy (preferably mitomycin C) within 24 hours
   • Follow with 6-week induction course of intravesical chemotherapy
3. If no recurrent disease is found:
   • Implement close surveillance with cystoscopy at 3-month intervals
4. Adjust follow-up schedule based on subsequent findings