After a 2.8 cm low‑grade (G1) non‑muscle‑invasive papillary bladder tumor was resected by TURBT, a second TURBT at the same time removed a small residual low‑grade focus, and no intravesical therapy was given, when is it appropriate to change cystoscopic surveillance from every 6 months to yearly?

Surveillance Transition for Low-Grade Non-Muscle-Invasive Bladder Cancer

After a negative 6-month surveillance cystoscopy following complete resection of low-grade Ta bladder cancer without additional intravesical therapy, you can transition to yearly cystoscopy surveillance. 1

Risk Stratification Context

Your patient meets criteria for low-risk disease based on:

• Low-grade histology (confirmed on both initial and re-resection TURBT) 1
• Stage Ta (non-invasive papillary carcinoma, no lamina propria or muscle invasion) 1
• Complete resection achieved (residual tumor fully resected at immediate re-TURBT) 2
• No carcinoma in situ 1

The 2.8 cm size places this tumor above the typical <3 cm threshold for "low-risk" classification, but the complete resection and low-grade pathology on repeat TURBT are favorable prognostic factors. 3

NCCN-Recommended Surveillance Schedule

The 2020 NCCN guidelines provide explicit direction for low-risk disease surveillance:

• First surveillance cystoscopy: 3-4 months after initial TURBT 1
• If negative at 3-4 months: Next cystoscopy at 6-9 months (total 9-12 months from TURBT) 1
• Subsequently: Yearly cystoscopy for up to 5 years 2, 1
• After 5 years: Cystoscopy only based on clinical indication (symptoms, hematuria, or other concerning findings) 2, 1

Your Patient's Timeline

Given your patient has completed 6-monthly surveillance through the specified date without recurrence, the transition to yearly surveillance is appropriate now. 1 The negative surveillance cystoscopies fundamentally change the risk stratification and justify extended intervals. 1

Important Surveillance Modifications for Low-Risk Disease

Urinary cytology is NOT routinely recommended for low-grade Ta tumors during surveillance. 1 Cytology should be reserved for high-grade disease (high-grade Ta, T1, or CIS). 2, 1

Upper tract imaging beyond baseline is NOT indicated for low-risk non-muscle-invasive bladder cancer unless symptoms develop. 2, 1 This contrasts with high-risk disease requiring upper tract imaging every 1-2 years. 2

Critical Pitfall to Avoid

The 2020 NCCN guidelines explicitly liberalized surveillance for low-risk disease compared to older protocols. 1 Do not apply outdated surveillance schedules that maintained 3-6 month intervals indefinitely—this represents overtreatment for truly low-risk disease. 3

Management of Future Recurrence

If recurrence is detected at any surveillance visit:

• Perform repeat TURBT to completely resect visible disease 2, 1
• Restratify based on pathology of the recurrent tumor 2, 1
• Consider single immediate postoperative intravesical chemotherapy (within 24 hours) for recurrent low-grade Ta disease 1
• BCG is NOT indicated for low-grade Ta tumors and should be reserved for high-grade disease 1, 4

Supporting Evidence for Extended Intervals

Research demonstrates that low-grade Ta bladder cancer poses minimal risk for progression (0.5-8% progression rate) and disease-specific mortality. 3, 5 A prospective study of 215 patients with low-grade papillary tumors followed for median 8 years showed only 8% progression and 0.5% cancer-specific mortality with 6-month surveillance intervals. 5 The International Bladder Cancer Group formally recommends that surveillance cystoscopy may be discontinued after 5 years for low-risk disease. 3