Treatment of Non-Muscle-Invasive Bladder Cancer in Elderly Men

Initial Surgical Management

The American Urological Association recommends performing complete TURBT with resection deep into the detrusor muscle for all visible tumors, with the pathology specimen including detrusor muscle tissue for accurate staging 1, 4, 6
For tumors less than 1 cm, resect en bloc with underlying bladder wall, and for larger tumors, perform fractional resection until normal muscle is exposed 1, 4
Repeat TURBT should be performed within 2-6 weeks for incomplete initial resection, absence of muscle tissue in initial specimen, and high-grade tumors 1, 4, 5, 3

The European Association of Urology recommends administering single-dose intravesical chemotherapy within 24 hours of TURBT for all patients unless contraindicated, which reduces 5-year recurrence from 59% to 45% 4, 2, 3
For low-risk disease, single immediate intravesical chemotherapy instillation is sufficient, while for intermediate-risk disease, intravesical chemotherapy for up to 1 year or BCG therapy can be chosen 2, 3
For high-risk disease, full-dose BCG for 1-3 years is the standard of care, with induction and maintenance protocols 2, 3

The International Consultation on Urological Diseases recommends evaluating comorbidities that may affect surgical candidacy or tolerance of intravesical therapy, and considering performance status and life expectancy when deciding between aggressive treatment vs. surveillance 8, 9
For elderly patients unable to tolerate lithotomy position, TURBT is not feasible, and office fulguration may be considered as an alternative to repeat TURBT 1, 7, 10

The American Urological Association defines BCG failure as BCG-refractory, BCG-relapsing, or BCG-intolerant, and recommends radical cystectomy as the gold standard for BCG-unresponsive disease in elderly patients if fit for surgery 2, 3