Answer
Periodic cystoscopy is unanimously recommended by all guidelines with early initial cystoscopy at 3-4 months after treatment and cytology with subsequent cystoscopy for patients at intermediate- or high-risk. Recommendations for risk-stratified surveillance schedules vary, with none of the guidelines offering high-level evidence in support of a specific schedule. Uniquely, the NICE guidelines recommend that patients with low-risk NMIBC who are free from recurrence at 12 months may be discharged from routine urologic follow-up. [17] The interval recommended by each organization is summarized in the table below. [1, 2, 18, 19, 20, 17]
Table. Risk-stratified surveillance recommendations (Open Table in a new window)
| Risk | Organization | Year | Cystoscopy interval |
|---|---|---|---|
| Low-risk | NCCN | 2018 | after initial cystoscopy, at 3 and 12 months; annually for years 2-5; then as clinically indicated |
| AUA/SUO | 2016 | 6-9 months after initial cystoscopy, annually for years 2-5; then in the absence of recurrence, continued surveillance should be based on shared-decision making between the patient and clinician | |
| EUA | 2016 | 9 months after initial cystoscopy, then annually for 5 years. Consider stopping after 5 years without recurrence. | |
| CUA | 2015 | annually after initial cystoscopy | |
| ESMO | 2014 | every 3–6 months based on risk during the first 2 years, and every 6–12 months thereafter | |
| NICE | 2015 | 3 months and 12 months after diagnosis. Do not offer routine cystoscopy follow-up after 12 months | |
| Intermediate-risk | NCCN | 2018 | after initial cystoscopy, at 3, 6 and 12 months; every 6 months for year 2; annually for years 3-5; then as clinically indicated |
| AUA/SUO | 2016 | after initial cystoscopy, every 3-6 months for 2 years, 6-12 months for years 3 and 4, and then annually thereafter | |
| EUA | 2016 | surveillance interval between low and high risk recommendation | |
| CUA | 2015 | every 3-4 months for first 2 years; every 6 months for years 3-4; annually thereafter | |
| ESMO | 2014 | every 3–6 months based on risk during the first 2 years, and every 6–12 months thereafter | |
| NICE | 2015 | 3, 9, 18 months and then annually therafter. Consider discharging to PCP after 5 years of disease free follow-up | |
| High-risk | NCCN | 2018 |
every 3 months for first 2 years; every 6 months for years 3-5; annually for years 5-10; then as clinically indicated |
| AUA/SUO | 2016 | every 3-4 months for first 2 years; every 6 months for years 3-4; annually thereafter | |
| EUA | 2016 | every 3 months for first 2 years; every 6 months for years 3-5; annually thereafter | |
| CUA | 2015 | every 3-4 months for first 2 years; every 6 months for years 3-4; annually thereafter | |
| ESMO | 2014 | every 3–6 months based on risk during the first 2 years, and every 6–12 months thereafter | |
| NICE | 2015 | every 3 months for first 2 years; every 6 months for years 3-4; annually thereafter | |
| Upper tract evaluation | All | every 1–2 years for high-risk NMIBC |
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The classic appearance of carcinoma in situ as a flat, velvety patch. However, using special staining techniques such as 5-aminolevulinic acid, it has been shown that significant areas of carcinoma in situ are easily overlooked by conventional cystoscopy. Courtesy of Abbott and Vysis Inc.
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Papillary bladder tumors such as this one are typically of low stage and grade (Ta-G1). Courtesy of Abbott and Vysis Inc.
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Sessile lesions as shown usually invade muscle, although occasionally a tumor is detected at the T1-G3 stage prior to muscle invasion. Courtesy of Abbott and Vysis Inc.
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Flexible cystoscopes such as this one facilitate endoscopic tumor surveillance with minimal morbidity and excellent visualization of the urothelium. Courtesy of Olympus America Inc.
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The latest development in surveillance involves advances that integrate video chip technology on to the end of flexible cystoscopes. Courtesy of Olympus America Inc.
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Rigid cystoscopes such as this one allow biopsy collection via in-office fulguration of small tumors. Such fulguration may be performed using electrocautery or laser. Courtesy of Olympus America Inc.
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Resection of all visible tumors is possible using modern resectoscopes. Courtesy of Olympus America Inc.
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Photograph in which fluorescence in situ hybridization centromere staining identifies aneuploidy of chromosome 3. Multiple instances of overexpression of the chromosome (note the multiple red dots, which identify centromeres of this chromosome) prove aneuploidy.
Tables
| Risk | Organization | Year | Cystoscopy interval |
|---|---|---|---|
| Low-risk | NCCN | 2018 | after initial cystoscopy, at 3 and 12 months; annually for years 2-5; then as clinically indicated |
| AUA/SUO | 2016 | 6-9 months after initial cystoscopy, annually for years 2-5; then in the absence of recurrence, continued surveillance should be based on shared-decision making between the patient and clinician | |
| EUA | 2016 | 9 months after initial cystoscopy, then annually for 5 years. Consider stopping after 5 years without recurrence. | |
| CUA | 2015 | annually after initial cystoscopy | |
| ESMO | 2014 | every 3–6 months based on risk during the first 2 years, and every 6–12 months thereafter | |
| NICE | 2015 | 3 months and 12 months after diagnosis. Do not offer routine cystoscopy follow-up after 12 months | |
| Intermediate-risk | NCCN | 2018 | after initial cystoscopy, at 3, 6 and 12 months; every 6 months for year 2; annually for years 3-5; then as clinically indicated |
| AUA/SUO | 2016 | after initial cystoscopy, every 3-6 months for 2 years, 6-12 months for years 3 and 4, and then annually thereafter | |
| EUA | 2016 | surveillance interval between low and high risk recommendation | |
| CUA | 2015 | every 3-4 months for first 2 years; every 6 months for years 3-4; annually thereafter | |
| ESMO | 2014 | every 3–6 months based on risk during the first 2 years, and every 6–12 months thereafter | |
| NICE | 2015 | 3, 9, 18 months and then annually therafter. Consider discharging to PCP after 5 years of disease free follow-up | |
| High-risk | NCCN | 2018 |
every 3 months for first 2 years; every 6 months for years 3-5; annually for years 5-10; then as clinically indicated |
| AUA/SUO | 2016 | every 3-4 months for first 2 years; every 6 months for years 3-4; annually thereafter | |
| EUA | 2016 | every 3 months for first 2 years; every 6 months for years 3-5; annually thereafter | |
| CUA | 2015 | every 3-4 months for first 2 years; every 6 months for years 3-4; annually thereafter | |
| ESMO | 2014 | every 3–6 months based on risk during the first 2 years, and every 6–12 months thereafter | |
| NICE | 2015 | every 3 months for first 2 years; every 6 months for years 3-4; annually thereafter | |
| Upper tract evaluation | All | every 1–2 years for high-risk NMIBC |
