Is intravesical chemotherapy for superficial bladder cancer still justified?

The apparent failure of intravesical therapy (irrespective of the substance used) to influence disease progression is surprising in the light of the evident reduction in tumour recurrence brought about by different intravesical agents. Normally it would be considered that tumour progression could not take place without recurrence. However, the beneficial influence of intravesical therapy on recurrence seems to have no effect on tumour progression. As to this apparent contradiction, three major points must be considered: The risk of progression in many of the trials was relatively low because of the inclusion of unselected combinations of patients with Ta, T1 tumours. In most comparative studies, almost all patients who had been initially randomized into the control arms left the study after developing their first recurrence and were managed as deemed appropriate by the attending urologist, i.e. with some form of intravesical instillation. Therefore, for progression, long-term analysis of prospective randomized trials compare early vs delayed instillation and not intravesical prophylaxis vs TUR alone. We are probably confronted with two different entities of 'superficial recurrent bladder tumours', i.e. one which is relatively benign, and tends to recur often with no progression, whereas the other group will progress towards muscle-invasive or high-grade disease quite often with the first recurrence. In conclusion, intravesical prophylaxis decreases the recurrence rate and time to recurrence in patients with superficial bladder cancer. BCG can be considered the 'gold standard' for managing CIS, but for papillary Ta, T1 bladder tumours differences between the therapy options seem minimal, and in our view, any long-term influence on disease progression remains to be proven.