A 55-year-old man presents with haematuria. Cystoscopy reveals a 3 cm papillary lesion at the right lateral wall; TURBT confirms pT1G3 (high-grade) urothelial carcinoma with lamina propria invasion, no muscularis propria in the specimen. What is the most appropriate next step?
- A Re-TURBT followed by intravesical BCG induction if no muscularis propria present in initial specimen ✓
- B Immediate radical cystectomy as pT1G3 has high progression risk
- C Intravesical mitomycin C single instillation and surveillance cystoscopy
- D CT urogram and surveillance cystoscopy at 3 months without repeat TURBT
Explanation
EAU guidelines mandate re-TURBT within 2–6 weeks for pT1 high-grade (G3) urothelial carcinoma when: muscularis propria is absent from the initial specimen (as here), the initial TURBT was incomplete, or T1 with concurrent CIS. Re-TURBT identifies residual T1 disease in approximately 33–50% and upstages to muscle-invasive disease (T2) in 10–15%, altering management. After re-TURBT confirms non-muscle-invasive disease, BCG induction and maintenance is the standard bladder-preserving treatment for high-grade T1. Immediate cystectomy is offered if re-TURBT confirms T1 or if BCG fails; it is not the first step here.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.