Introduction
Following BCG induction, rigid cystoscopy and biopsy is the standard method of surveillance. Optical enhancement with narrow band imaging allows more accurate assessment of potential bladder abnormalities and red patches seen after BCG. Flexible cystoscopy, in an outpatient setting, is more efficient and does not involve general anaesthetic, which is beneficial for our elderly, and often co-morbid, population. We present our experience of flexible cystoscopy with narrow band imaging in bladder cancer surveillance after initial BCG induction.
Patients and methods
Since 2014, 71 patients have received BCG treatment (intention was to give induction and maintenance) at our institution. Re-TUR was performed if there was no muscle in the specimen, T1 disease, large tumours or incomplete first resection. All TURBTs were performed by urologists with a specialist interest in bladder cancer. Flexible cystoscopy with narrow band imaging (performed by a single consultant urologist with a specialist interest in bladder cancer) and urine cytology was the default surveillance option after induction BCG. Oncological outcomes, including BCG failure, disease recurrence and progression were assessed.
Results
31 patients (44%) had G3pT1 bladder cancer (14 with CIS), 31 (44%) had G3pTa (8 with CIS), 3 had high grade G2pTa and 6 CIS only. 46 patients had a flexible cystoscopy as their first check cystoscopy. 6 had recurrent disease and required a subsequent rigid cystoscopy and resection. All were G3pT1 originally. 22 had a rigid cystoscopy as their first check cystoscopy - mainly through clinical decision or patient choice. 7 had recurrent disease. 3 are awaiting first check cystoscopy. 8 patients (12%) were BCG unresponsive (5 initially G3pT1 +/- CIS). 2 with CIS (3%) relapsed requiring BCG re-induction. 3 patients (4%) had low grade recurrence and 2 (3%) changed treatment due to BCG toxicity. 2 (3%) of those unresponsive to BCG were too frail for cystectomy and progressed to metastases.
Conclusions
Flexible cystoscopy with narrow band imaging, within a dedicated bladder cancer team, is an efficient and safe alternative to rigid cystoscopy and biopsy for surveillance of high risk non muscle invasive bladder cancer after BCG. Use of rigid cystoscopy in selected cases (significant initial disease) remains important.
The first author has received payments from Olympus for lecturing on narrow band imaging.