A 45-year-old man presents with painless hematuria. Cystoscopy reveals a papillary tumor. TURBT shows high-grade non-muscle-invasive bladder cancer (NMIBC) with lamina propria invasion (T1 G3), carcinoma in situ (CIS), and size >3 cm. Risk stratification places him in the 'very high risk' NMIBC group. The most appropriate intravesical treatment per EAU guidelines for very high-risk NMIBC is:
- A Intravesical mitomycin C single instillation post-TURBT
- B Intravesical BCG (Bacille Calmette-Guérin) induction 6 weeks + 3-year maintenance; early radical cystectomy offered if BCG fails ✓
- C Immediate radical cystectomy without BCG trial
- D Intravesical gemcitabine induction for 6 weeks
Explanation
Very high-risk NMIBC (T1G3 + CIS, or T1G3 >3 cm, or multiple T1G3, or BCG-unresponsive disease) requires BCG induction + 3-year maintenance (per EORTC/SWOG protocol) — the Lamm schedule of 6+3 provides superior recurrence-free survival. EAU 2024 guidelines recommend offering early radical cystectomy to patients who accept it for very high-risk NMIBC because of the high risk of progression to muscle invasion (25-50%). Single-dose mitomycin is for low-risk NMIBC. BCG maintenance for 3 years (not 1 year) is superior for high-risk disease (Sylvester meta-analysis). Re-TURBT at 2-6 weeks is also mandatory for T1 disease to ensure complete resection.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.