I recently had a patient diagnosed with a T1a high-grade urothelial carcinoma with focal invasion of the lamina propria sized at 3 × 2 × 1 cm. The patient recently underwent a TUR but is unaware if the clinicians performed a chemotherapy instillation following the procedure. I am interested in knowing the gold standard of care with bladder tumor removal, follow-up, recurrence, and instillation guidelines for chemotherapy.—Elizabeth Fitzpatrick, MS, APRN, GNP-BC

A TURBT (transurethral resection of bladder tumor) allows examination and determination of histology, depth of invasion, and involvement beyond the bladder. A patient with a primary tumor without muscle invasion should undergo TURBT; if there is significant risk of recurrence and/or progression, intravesical therapy is recommended. A patient with a tumor without invasion should undergo radical cystectomy with urinary diversion. Neoadjuvant cisplatin-based chemotherapy should be considered with a goal to increase survival. Adjuvant chemotherapy may have a role in high-risk invasive carcinoma in patients who are otherwise candidates for chemotherapy; however, results of randomized controlled trials are controversial.

If the patient is unable or unwilling to undergo radical cystectomy with urinary diversion, TURBT followed by radiation and chemotherapy can be offered (“bladder sparing” approach). All tumors are at risk for recurrence; long-term surveillance is required. After cystectomy, lab studies (urine cytology, liver enzymes, renal function, and electrolytes) should be done every 3 months for the first year, every 6 months for the second and third year, and annually thereafter for up to 5 years. Imaging (CT scan of chest, abdomen, and pelvis) should be done every 6 months for 3 years. After bladder preservation therapy, more frequent surveillance is required to look for local recurrence and detect new cancers.—Claire O’Connell, MPH, PA-C

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