This protocol applies to a precisely defined, high-stakes subset of patients with non-muscle-invasive bladder cancer whose tumour characteristics place them in the very high-risk category — a group where the probability of disease progression is extremely high and where treatment selection has direct prognostic consequences.
Patients qualify for this very high-risk group if they meet any of the following criteria:
Carcinoma in situ in the prostatic urethra is absent in this scenario. Patients in this group carry an extremely high risk of tumour progression.
For this very high-risk population, radical cystectomy is the preferred surgical option. For patients who decline surgery or are medically unfit, intensive intravesical BCG immunotherapy is an established alternative — the complete protocol, sequencing, treatment duration, and available combination strategies are detailed in the full regimen.
The 3-month cystoscopic assessment after resection is an important prognostic indicator for both recurrence and progression.
T1 HG/G3 and CIS with at least one risk factor.
T1 HG/G3 no CIS with all three risk factors.
Ta HG/G3 and CIS with all three risk factors.
T1 G2 and CIS with at least two risk factors.
All patients with CIS in the prostatic urethra, with certain subtypes of UC, or with LVI, should be included in the very high-risk group.
Patients in the very high-risk group have an extremely high risk of tumour progression.
In patients with very high-risk tumours, discuss immediate RC.
Offer RC or intravesical full-dose BCG instillations for one to three years, particularly to those who decline or are unfit for RC.
The first cystoscopy after TURBT at three months is an important prognostic indicator for recurrence and progression.
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