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Follow-up care after treatment of bladder cancer

Patients who have undergone conservative treatment

Most patients in this group have primarily had a superficial tumor (T ≤ 1). Some of these patients have received curative radiation therapy for a muscle-infiltrating tumor in the bladder, and others have undergone a bladder resection.

After conservative treatment, there is over a 70% risk for recurrence, and 30% risk for development of an infiltrating tumor later. The risk is the highest for high/moderately high malignancy, and less for low grade malignancy. 

Life-long follow-up has been normally recommended with urine cytology and cystoscopy, as well as urography every year or every other year. Tumors of higher malignancy have a greater risk for recurrence than low grade tumors, and primary multifocal tumors have a higher risk than solitary tumors. A combination of low grade and solitary primary tumors have a low risk for recurrence(grade 1, T ≤ 1) if all primary tumor tissue is removed (no remaining tumor tissue/recurrence at the first follow-up check after primary treatment). Studies show that frequent and long-term follow-up is not necessary for this patient group. About half of patients with ≥ T1 urothelial cancer have a low risk of recurrence and minimal risk of progression. Patients with highly malignant tumors (grade 3), and patients with recurring grade 2 tumors should have frequent follow-up.

Follow-up should include

  • urine cytology x 2
  • cystoureteroscopy

Recommendations for follow-up

  • Patients with low-grade TaG1 tumors should be checked with cystoscopy 3 months postoperatively. If the cystoscopy is negative, the next examination should be 9 months postoperatively. After this, annually for 5 years.
  • High risk patients should have cystoscopy 3 months postoperatively. If the result is negative, the exam should be repeated every 3 months over a period of 2 years. Then every 4 months in the third postoperative year. After this, every 6 months for 5 years after the operation. Cystoscopy testing is then offered once annually. Annual urography should also be performed.
  • Patients in transition stages between these two groups (about 1/3 of all patients) should have a designated follow-up schedule individualized according to personal and subjective factors.

Patients with muscle-infiltrating urothelial cancer (≥ T2) after curative treatment

Follow-up of patients with infiltrating urothelial cancer after a cystectomy or radiation must identify local recurrence/distant metastases as early as possible. Additional treatment should be started if indicated.  Additional treatment should include salvage cystectomy, ureterectomy, nephroureterectomy, and/or secondary surgery of residual tumor. 

Intervention type (cystectomy/chemotherapy) and prognostic factors determine the follow-up regimen for the patient. The stage of pT and pN with additional risk factors such as pTis are the most important prognostic factors and are normal for the follow-up schedule.

After cystectomy

The first check 3 months postoperatively should include:

  • anamnesis 
  • serum creatinine and blood gas analysis to evaluate kidney function 
  • urine cytology
  • CT urography to check anastomosis function/ultrasound of kidneys, liver, and peritoneum 
  • thoracic X-ray

The examinations should be repeated annually with emphasis on urinary diversion and kidney function. 

After radiation therapy

The first follow-up 3 months after radiation therapy should include:

  • anamnesis of complications
  • serum creatinine
  • urine cytology x 2
  • cystoscopy under general anesthesia in addition to deep biopsies from the tumor area 
  • thoracic X-ray
Additional follow-up will resemble the schedule for superficial urothelial cancer.

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