Surveillance Strategy for High-Grade Bladder TCC Post-BCG Treatment
Continue surveillance cystoscopy every 3 months with urine cytology, and do not extend the interval to 6 months at this time. 1, 2
Rationale for Continued Intensive Surveillance
Your patient has high-grade bladder TCC treated with BCG in 2017, which places him in a high-risk category requiring ongoing vigilant monitoring despite the negative cystoscopy in May 2025:
High-grade tumors require cystoscopy and urinary cytology at 3-month intervals for the first 1-2 years after treatment, then at increasing intervals over the next 2 years, and annually thereafter. 1, 2
The NCCN guidelines specifically state that imaging of the upper tract should be considered every 1-2 years for high-grade tumors. 1, 3 Given his occasional left flank discomfort, upper tract imaging is warranted now.
The hallmark of transitional cell carcinoma is multiplicity and high recurrence rates, even after successful initial treatment. 4 This patient's 8-year disease-free interval is encouraging but does not eliminate recurrence risk.
Critical Issues Requiring Immediate Attention
Asymptomatic Bacteriuria Management
Do not treat the E. faecalis bacteriuria. The patient is asymptomatic (no fever, dysuria, or systemic symptoms), has normal renal function (creatinine 0.95), and treating asymptomatic bacteriuria in elderly males without urologic intervention planned provides no benefit and promotes antibiotic resistance.
Upper Tract Evaluation
Order CT urography or MRI urography now to evaluate the left flank discomfort and screen for upper tract disease. 1 This is overdue given:
- His high-grade bladder cancer history
- The 1-2 year recommended interval for upper tract imaging has likely passed
- New symptom of left flank discomfort
- Nearly 2-4% of patients with bladder cancer develop upper tract TCC 4
Surveillance Schedule Going Forward
Current Phase (8 Years Post-Treatment)
- Cystoscopy with urine cytology every 3-6 months 1
- At 8 years post-treatment with consistently negative surveillance, transitioning to 6-month intervals is reasonable, but maintain at least this frequency
- Annual surveillance is premature given his high-grade disease history
Surveillance Components
- Cystoscopy with directed biopsies if any suspicious lesions 1
- Urine cytology at each visit 1, 2
- Upper tract imaging (CT or MRI urography) every 1-2 years 1, 3
- Consider urine molecular markers as adjunct (category 2B), though specificity is lower than cytology 1
Management of Current Symptoms
Lower Urinary Tract Symptoms
The patient is already on Vesicare (solifenacin) for his nocturia 2-3 times and occasional frequency. Since he reports satisfaction with micturition, continue current anticholinergic therapy without escalation. 1
Monitoring Considerations
- The combination of negative cystoscopy and negative urine cytology has 100% sensitivity and 92.3% specificity for detecting recurrence 5, providing reassurance when both are negative
- However, low-grade recurrences can be missed by cytology alone 5, emphasizing the need for continued cystoscopic surveillance
Common Pitfalls to Avoid
- Do not extend surveillance intervals too quickly - high-grade disease warrants prolonged vigilance even with years of negative surveillance 1, 2
- Do not ignore new symptoms like flank discomfort - upper tract involvement occurs in 2-4% of bladder cancer patients 4
- Do not treat asymptomatic bacteriuria - this provides no benefit and promotes resistance
- Do not rely on cytology alone - cystoscopy remains the gold standard, with cytology as an important adjunct 5, 4
Next appointment: Schedule 3-month follow-up cystoscopy with cytology, and order CT urography before that visit to evaluate the left flank discomfort and screen upper tracts. 1, 2, 4