A 72-year-old man presents with painless total hematuria. Flexible cystoscopy reveals a 3 cm papillary lesion on the posterior wall. TURBT confirms high-grade pT1 urothelial carcinoma. What is the most appropriate next step per EAU guidelines?

• A Immediate radical cystectomy
• B Repeat TURBT (re-TURBT) within 4–6 weeks followed by intravesical BCG ✓
• C Intravesical mitomycin C instillation alone
• D Single instillation of intravesical mitomycin C immediately post-TURBT and discharge

Explanation

EAU guidelines recommend re-TURBT within 4–6 weeks for all high-grade T1 tumors because: (1) initial TURBT may be incomplete with residual tumor in 40–80% of cases, (2) muscle sampling is often absent in initial resection, and (3) re-TURBT upstages to T2 in 10–20% of patients. Following adequate re-TURBT confirming pT1 high-grade disease without muscle invasion, intravesical BCG (induction + maintenance) is the recommended adjuvant therapy. Immediate radical cystectomy is reserved for BCG-unresponsive disease or very high-risk features. Mitomycin C alone is for low-grade disease. Single immediate instillation is for low-risk TURBT, not high-grade T1.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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