What are the treatment options for a patient with recurrent bladder cancer, considering their overall health, previous treatments, and disease stage?

Treatment of Recurrent Bladder Cancer

For recurrent bladder cancer, treatment depends critically on the stage and grade at recurrence, prior therapies received, and whether the patient has muscle-invasive disease—with radical cystectomy being the definitive treatment for high-risk recurrences after BCG failure, while repeat TURBT followed by alternative intravesical therapy remains appropriate for lower-risk recurrences after chemotherapy failure. 1

Non-Muscle-Invasive Recurrences

After Initial Intravesical Chemotherapy Failure

• Perform repeat TURBT to completely resect all visible disease and obtain accurate restaging. 2, 1
• Switch to BCG induction therapy (6 weekly instillations) rather than repeating the same chemotherapy agent. 2, 1
• BCG is superior to mitomycin C for preventing recurrence in T1 disease, with a 32% reduction in recurrence risk when maintenance is included. 2
• After a 4-6 week rest period, perform full reevaluation at 3 months with cystoscopy and cytology. 1, 2
• If complete response is achieved, administer maintenance BCG (3 weekly instillations at 3,6, and 12 months). 2
• For high-risk features such as multifocal T1 disease, continue maintenance up to 3 years with additional instillations at 18,24,30, and 36 months. 2

After BCG Failure

The grade of recurrent tumor after BCG is the critical determinant of next steps:

Low-Grade Recurrence After BCG

• Repeat TURBT followed by additional intravesical therapy (repeat BCG induction plus maintenance or alternative chemotherapy) is appropriate. 1
• However, even low-grade recurrences after BCG carry a 14.4% estimated 5-year progression rate to muscle-invasive disease, requiring careful counseling. 3
• Patients with low-grade recurrence have significantly better 5-year progression-free survival (85.6%) compared to high-grade recurrence (67.9%). 3

High-Grade Recurrence After BCG

• Radical cystectomy is the preferred treatment for high-grade Ta or any T1 recurrence after adequate BCG therapy. 1
• "Adequate BCG" is defined as at least 5 of 6 induction doses plus either a second induction course or at least 2 of 3 maintenance doses. 1
• Earlier cystectomy (within 2 years of initial BCG) improves 15-year disease-specific survival compared to delayed cystectomy. 1
• Deferring cystectomy until progression to muscle-invasive disease negatively impacts survival. 1

BCG-Unresponsive Disease

• Defined as persistent or recurrent high-grade disease at 6-12 months despite adequate BCG induction plus maintenance. 4
• Radical cystectomy is the safest curative option. 4
• If cystectomy is refused or patient is unfit, consider clinical trial enrollment or combination intravesical chemotherapy/device-assisted therapy. 4

Muscle-Invasive Recurrences (Stage II-III)

Standard Treatment Approach

• Administer 2-3 cycles of neoadjuvant cisplatin-based combination chemotherapy (gemcitabine-cisplatin or MVAC) followed by radical cystectomy with extended bilateral pelvic lymphadenectomy. 5, 1
• This represents the gold standard with proven survival benefit, particularly for T2 disease. 5
• Extended lymphadenectomy should include common iliac, internal iliac, external iliac, and obturator nodes. 5

Bladder Preservation Alternative

Maximal TURBT followed by concurrent chemoradiotherapy (64-66 Gy) is an alternative for highly selected patients who refuse cystectomy. 5, 1

Strict selection criteria must ALL be met: 5

• T2 tumor <5 cm in size
• Solitary lesion
• No carcinoma in situ present
• No hydronephrosis (absolute contraindication)
• Visibly complete or maximal TURBT achievable
• Good performance status
• Adequate bladder capacity

Chemotherapy options for bladder preservation: 5

• 5-fluorouracil plus mitomycin C is the highest-level evidence regimen (BC2001 trial: 67% locoregional survival, 54% disease-free survival). 5
• Concurrent cisplatin monotherapy on days 1 and 21 is an established alternative. 5
• For cisplatin-ineligible patients (GFR <60 mL/min), 5-FU plus mitomycin C remains preferred. 5

Expected outcomes with bladder preservation: 5

• Complete response rate: 70-87%
• 5-year overall survival: 50-67%
• Bladder-intact survival at 5 years: 40-54%

Metastatic or Locally Recurrent Disease After Cystectomy

• Platinum-based combination chemotherapy (gemcitabine-cisplatin or MVAC) is first-line treatment for metastatic disease. 1
• Checkpoint inhibitors (pembrolizumab, atezolizumab, nivolumab) are now options for subsequent-line therapy or for cisplatin-ineligible patients. 1, 6
• Palliative radiotherapy may induce tumor-related symptom relief. 1
• For isolated nodal recurrence, consider nodal biopsy and manage as T4b disease with potential for cystectomy and lymph node dissection in selected cases. 1

Surveillance Protocols

After Radical Cystectomy

• Urine cytology, liver function tests, creatinine, and electrolytes every 3-6 months for 2 years, then as clinically indicated. 1, 5
• Chest/abdomen/pelvis imaging every 3-12 months for 2 years based on recurrence risk, then as clinically indicated. 1, 5
• Urethral wash cytology every 6-12 months, particularly if Tis was present in bladder or prostatic urethra. 1

After Bladder Preservation

• Cystoscopy with cytology every 3 months for first 2 years, then every 6 months thereafter. 1, 5
• Upper tract imaging every 1-2 years for high-grade tumors. 1, 5
• Same systemic surveillance as post-cystectomy patients. 1

For Non-Muscle-Invasive Disease Under Surveillance

• Cystoscopy and urinary cytology at 3-month intervals for first 1-2 years. 1, 2
• Increase intervals over next 2 years, then annually thereafter. 1
• Upper tract imaging every 1-2 years for high-grade tumors. 1

Critical Pitfalls to Avoid

• Never give more than 2 consecutive induction courses of the same intravesical agent—this represents treatment failure requiring a different approach. 2
• Never substitute carboplatin for cisplatin in bladder preservation settings, even with borderline renal function. 5
• Never attempt bladder preservation in patients with any degree of hydronephrosis—this is an absolute contraindication. 5
• Do not skip maintenance BCG after successful induction—much of the benefit in preventing progression comes from maintenance therapy. 2
• Do not defer cystectomy until progression to muscle-invasive disease in BCG-unresponsive high-risk patients—this negatively impacts survival. 1
• Avoid bladder preservation in patients with diffuse CIS—concurrent extensive CIS significantly reduces success rates. 5
• Do not give adjuvant chemotherapy after cystectomy if neoadjuvant chemotherapy was already administered. 5
• Never give immediate post-TURBT chemotherapy when BCG induction is planned—the patient needs full induction therapy, not a single instillation. 2