Proposal for changes in cystoscopic follow up of patients with bladder cancer and adjuvant intravesical chemotherapy

Abstract

A famous surgeon observed that the most important instrument for the management of superficial bladder cancer was a typewriter because it facilitated the organisation of the regular follow up examinations that are so important in controlling this disease. Cystoscopic follow up must be lifelong, and the cost, in the broadest sense, to both patient and health service is considerable. A recent study has suggested that the conventional frequency of bladder examinations may not be necessary and that most patients could be spared many cystoscopies. Instillation of cytotoxic drugs in the bladder has been shown to reduce the recurrence of tumours destroyed endoscopically and the development of new tumours elsewhere in the bladder. Because intravesical instillations are inconvenient, expensive, and may be toxic they have been reserved for patients thought to be at greatest risk of recurrence. However, two clinical trials have shown that a single cytotoxic instillation may be beneficial for low risk patients. If this is verified in everyday practice, the routine use of intravesical chemotherapy for all patients at the time of initial treatment could reduce the need for cystoscopies even further. Such changes should improve the quality of life of the 7000 new patients with superficial bladder cancer each year in England and Wales and allow savings to be made in the NHS. The management of superficial bladder cancer accounts for a considerable proportion of urologists' workload. At the time of initial diagnosis most of these tumours are confined to the superficial layers of the bladder wall and are described by the tumour, node, metastases (TNM) classification as either Ta (papillary but not invading beneath the basement membrane of the urothelium) or T1 (invading the connective tissue core of papillary fronds or the submucosa but not the underlying detrusor muscle).1 Initial treatment is by transurethral resection, …