What is the recommended surveillance schedule for recurrent bladder cancer?

Updated: Sep 10, 2019
  • Author: David A Levy, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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For patients with intermediate-risk, the American Urological Association/Society of Urologic Oncology recommends surveillance every 3-6 months for 2 years, 6-12 months for years 3-4 and at least yearly thereafter. [1] Similarly, the US National Comprehensive Cancer Network recommends initial cystoscopy and urinary cytology at 3, 6 and 12 months, every 6 months for year 2 and annually for years 3-5. Surveillance after 5 years as clinically indicated. [2]

The recommendation for cystoscopic tumor surveillance every 3 months dates back to at least 1936. Bladder cancer surveillance standards arose based primarily on expert opinion rather than as an evidence-based standard. The origin of the traditional timing (ie, beginning 3 months following bladder tumor removal) is not clear. One theory is that it may have arisen as the timeframe believed to be required for healing after tumor resection. Cystoscopic findings prior to this time would have been difficult to interpret because of numerous factors, including incomplete healing and edema, among others.

The high rate of recurrence (70%) is the key clinical concern in low- and intermediate-risk disease. The fairly high rate of progression to muscle-invasive disease (30%) in patients with high-risk NMIBC require more frequent monitoring by urine cytology and cystoscopy, the gold standard for detection of bladder cancer recurrence.

Patients who have undergone radical cystectomy require routine surveillance to monitor for local recurrence or the development of metastatic disease. Abdominal and pelvic CT scanning and chest radiography should be performed annually. Some patients with more adverse pathology at the time of cystectomy (eg, locally advanced disease, lymph node metastases) may require more frequent imaging.

The retained male urethra is at risk for cancer recurrence after radical cystoprostatectomy. Urethral recurrence occurs in approximately 7% of patients after cystoprostatectomy.

Cancer involving the prostate (urothelium or stroma) at the time of cystoprostatectomy is the most significant risk factor for urethral recurrence. Monitoring the retained urethra has historically included periodic urethral cytology with subsequent biopsy, if indicated. However, some small studies have suggested monitoring with urethral washings does not confer a survival benefit. [3]

Gross hematuria or bloody urethral discharge requires immediate workup. A positive urethral cytology or biopsy finding warrants immediate urethrectomy.

For more information, see Bladder Cancer and Bladder Cancer Guidelines.

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