Challenging the EAU Guidelines on Non–Muscle-Invasive Bladder Cancer (NMIBC): Single Instillation of Chemotherapy After Transurethral Resection of NMIBC and Chemotherapy Versus Bacillus Calmette-Guérin in Treatment of Intermediate-Risk Tumours

Context: Although the 2008 European Association of Urology (EAU) guidelines provide an excellent evidence-based framework for the management of non– muscle-invasive bladder cancer (NMIBC), some topics have been questioned and discussed by many authors and remain controversial. Objective: To comment on the current EAU guidelines on NMIBC by taking into account new data published in 2009 in peer-reviewed urologic journals and once againdiscussingrelevantdata thatwereavailablewhentheguidelineswereprepared. Evidence acquisition: Two important guidelines have been challenged: (1) the use of a single instillation of a chemotherapeutic agent after transurethral resection (TUR) in all patients with NMIBC and (2) chemotherapy versus bacillus CalmetteGuérin (BCG) in the treatment of intermediate-risk tumours. The most important recent publications (2009), including randomised studies and meta-analyses, have been considered and evaluated. Evidence synthesis: Based on a review of the current EAU guidelines and recent literature, a single instillation of a chemotherapeutic agent after TUR should be administered only in primary, solitary, low-grade NMIBCs. The first-line treatment of intermediate-risk tumours should be the instillation of BCG once a week for 6 wk, followed bymaintenance for 1–3 yr. Mitomycin C is still the first treatment of choice for intermediate-risk and low-risk NMIBC patients (single, recurrent, low-grade tumour). Conclusions: A complete TUR of the bladder tumour plus immediate, postoperative, chemotherapeutic instillation is recommended for all patients with primary, solitary NMIBC, except in those with bladder wall perforation. For these low-risk tumours, no further therapy is required. For intermediate-risk disease, intravesical induction BCG plus maintenance should be considered the first choice, while intravesical chemotherapy should be considered for intermediate-risk and lowrisk tumours (single, recurrent, low-grade NMIBC). In these patients, one immediate single instillation of chemotherapy should not be administered after TUR. # 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.