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Beyond the TURBT: Understanding Your NMIBC Treatment Options

  • Writer: Polygon Health Team
    Polygon Health Team
  • May 5
  • 12 min read

I. Introduction: Understanding NMIBC and the Role of Post-TURBT Treatments


Non-Muscle Invasive Bladder Cancer (NMIBC) represents the early stages of bladder cancer where the cancerous cells are confined to the inner lining of the bladder or the layer of connective tissue just beneath it. Critically, in NMIBC, the cancer has not yet invaded the deeper muscle layer of the bladder wall.1 This superficial nature of the disease distinguishes it from more advanced, muscle-invasive bladder cancer.1 Within the classification of NMIBC, doctors identify specific stages, including Ta, where the tumor is located on the bladder lining; T1, indicating the cancer has grown into the connective tissue; and Carcinoma in Situ (CIS), which is a flat, high-grade cancer also situated on the bladder lining.1 Recognizing this limited depth of invasion is fundamental to understanding why treatments that act directly within the bladder can be highly effective.


The initial step in managing NMIBC typically involves a procedure known as Transurethral Resection of Bladder Tumor (TURBT).7 During this procedure, a urologist inserts a cystoscope, a slender tube equipped with a light and camera, through the urethra and into the bladder.13 This allows for the visualization and removal of any visible tumors within the bladder.13 Importantly, the tissue samples obtained during TURBT are then examined under a microscope by a pathologist to determine the precise stage and grade of the bladder cancer.3 This information is critical as it guides subsequent treatment strategies. A thorough initial resection is vital for accurate staging and effective management.10

Despite the effectiveness of TURBT in removing visible tumors, NMIBC has a notable tendency to recur.3 To address this, treatments given after the initial surgery, known as adjuvant therapies, play a crucial role in destroying any remaining microscopic cancer cells, thereby reducing the risk of the cancer returning and preventing its progression to a more invasive form.12 A common approach for delivering adjuvant therapy in NMIBC is through intravesical therapy, where medication is directly instilled into the bladder.12 This report will delve into two of the most frequently used intravesical therapies: Bacillus Calmette-Guérin (BCG) and chemotherapy.



II. Intravesical BCG Therapy for NMIBC


  • Goals of Intravesical BCG Therapy:

  • Stimulating the Immune System: Intravesical Bacillus Calmette-Guérin (BCG) therapy is a form of immunotherapy that harnesses the power of the body's own immune system to combat bladder cancer.12 BCG is a vaccine originally developed against tuberculosis.13 When introduced directly into the bladder, it triggers a local immune response.12 This activation involves immune cells that then target and destroy the bladder cancer cells.13 It is important to understand that BCG is an immunotherapy, not a chemotherapy, meaning it stimulates the body's immune system rather than directly attacking cancer cells with drugs.15

  • Reducing the Risk of Recurrence: A primary objective of intravesical BCG therapy is to significantly lower the likelihood of the bladder cancer returning after it has been initially removed via TURBT.12 Clinical studies have consistently demonstrated that a six-week induction course of BCG can effectively reduce the risk of tumor recurrence.22 Furthermore, maintenance BCG therapy, administered for a longer duration, has been shown to enhance this effect, particularly in patients with high-risk NMIBC.22

  • Reducing the Risk of Progression: Beyond preventing recurrence, BCG therapy also aims to lower the risk of the cancer progressing to a more advanced stage, specifically muscle-invasive bladder cancer.12 By effectively controlling the superficial cancer cells, BCG helps to prevent them from developing the capacity to invade the deeper muscle layer of the bladder wall.22 This is particularly important for patients with high-risk NMIBC, who have a greater likelihood of such progression.

  • Preferred for High-Risk NMIBC: Intravesical BCG therapy is often the preferred initial treatment for individuals diagnosed with high-risk NMIBC.3 This includes patients with high-grade tumors, those with stage T1 disease, and individuals with Carcinoma in Situ (CIS).3

  • The General Process of Receiving Intravesical BCG Therapy:

  • Administration: The process of receiving intravesical BCG therapy involves the direct instillation of a liquid solution containing the BCG vaccine into the bladder using a urinary catheter.13 The catheter is gently inserted through the urethra into the bladder, and the BCG solution is then instilled.

  • Induction Course: The initial phase of BCG therapy typically consists of an induction course, where the treatment is administered once a week for a period of six weeks.13 This intensive initial treatment aims to stimulate a robust immune response within the bladder.

  • Retention Time: After the BCG solution is instilled, the catheter is usually removed, and the patient is instructed to retain the solution in their bladder for approximately one to two hours before voiding.13 This allows sufficient time for the BCG to come into contact with the bladder lining and trigger the desired immune reaction.

  • Maintenance Therapy: For individuals who show a positive response to the initial induction course, particularly those with intermediate- and high-risk NMIBC, a longer course of maintenance therapy may be recommended.13 This may involve instillations administered less frequently, such as weekly for three weeks at months 3, 6, 12, 18, 24, 30, and 36 following the initial treatment.43 The total duration of maintenance therapy can vary, often lasting from one to three years depending on the patient's risk profile.13

  • Precautions After Treatment: Because BCG contains live, weakened bacteria, patients must take specific precautions for approximately six hours after each treatment when urinating.13 This includes sitting down to urinate to minimize splashing, followed by disinfecting the urine in the toilet with an equal amount of undiluted bleach and allowing it to sit for 15 minutes before flushing.13 Thorough handwashing after urination is also essential.13

  • Common Side Effects: Treatment with BCG can cause a range of side effects, the most common being flu-like symptoms such as fever, chills, fatigue, and body aches, which can last for a couple of days after each treatment.13 Patients may also experience bladder-related symptoms, including a burning sensation during urination, increased urinary frequency, and sometimes blood in the urine.13 While serious complications are rare, it is important to report any persistent or severe symptoms to the healthcare provider.



III. Intravesical Chemotherapy for NMIBC


  • Goals of Intravesical Chemotherapy:

  • Directly Killing Cancer Cells: Intravesical chemotherapy involves the direct instillation of chemotherapy drugs into the bladder to kill actively growing cancer cells.13 These drugs work by interfering with the growth and division of cancer cells, leading to their destruction.13

  • Reducing the Risk of Recurrence: Similar to BCG therapy, a primary goal of intravesical chemotherapy is to reduce the likelihood of the bladder cancer recurring after TURBT.13 This is particularly relevant for patients with low- and intermediate-risk NMIBC.

  • Alternative to BCG: Intravesical chemotherapy is often considered as an alternative treatment option when BCG therapy is not effective, not tolerated, or when there are issues with its availability.13 The global shortage of BCG in recent years has further highlighted the importance of having effective alternatives like chemotherapy.17

  • Used for Low- and Intermediate-Risk NMIBC: While BCG is often preferred for high-risk NMIBC, intravesical chemotherapy is frequently used for patients with low- and intermediate-risk disease.13 It can be effective in reducing the recurrence of tumors in these risk categories.

  • The General Process of Receiving Intravesical Chemotherapy:

  • Administration: Similar to BCG, intravesical chemotherapy is administered as a liquid solution directly into the bladder through a urinary catheter that is inserted via the urethra.13 The catheter allows the chemotherapy drug to come into direct contact with the bladder lining.

  • Common Chemotherapy Drugs: Several chemotherapy drugs can be used for intravesical instillation, with mitomycin and gemcitabine being the most common.13 Other drugs like valrubicin, epirubicin, and doxorubicin may also be used in certain situations.13

  • Retention Time: Similar to BCG, the chemotherapy drug is typically held in the bladder for approximately one to two hours before being drained or voided.13 This dwell time allows the drug to have maximum contact with the bladder lining and exert its effect on any remaining cancer cells.

  • Treatment Schedules: The schedule for intravesical chemotherapy can vary. A single instillation is often given immediately after TURBT, particularly for low-risk tumors.13 For intermediate-risk disease, a course of weekly instillations for several weeks (induction therapy) may be followed by less frequent maintenance treatments.13 The specific schedule is determined by the type of drug used and the patient's risk level.

  • Common Side Effects: The most common side effects of intravesical chemotherapy are typically localized to the bladder and may include irritation, a burning sensation during urination, increased urinary frequency, urgency, and blood in the urine.13 Systemic side effects, such as hair loss or nausea, are less common with intravesical chemotherapy because the drugs are primarily confined to the bladder.13



IV. Conclusion: Key Considerations for NMIBC Treatment Beyond TURBT


In summary, both intravesical BCG and chemotherapy are vital treatment options for Non-Muscle Invasive Bladder Cancer following the initial TURBT procedure. BCG therapy primarily works by stimulating the immune system to target and destroy cancer cells within the bladder, aiming to reduce the risk of both recurrence and progression, particularly in high-risk NMIBC.37 The process involves weekly instillations for about six weeks, followed by a retention period, and potentially maintenance therapy for responders. Common side effects include flu-like symptoms and bladder irritation.37 On the other hand, intravesical chemotherapy directly kills actively growing cancer cells in the bladder and also reduces the risk of recurrence, often used for low- and intermediate-risk NMIBC or when BCG is not suitable.37 It involves instillation of chemotherapy drugs like mitomycin or gemcitabine, with retention times similar to BCG and treatment schedules that can range from a single post-TURBT dose to weekly courses with maintenance.37 The main side effects are localized bladder irritation and blood in the urine.37

The decision regarding which adjuvant therapy to use is significantly influenced by the individual patient's risk of recurrence and progression.1 This risk is determined by various factors, including the tumor's grade, stage, size, and whether CIS is present. Therefore, a thorough discussion between the patient and their urologist is paramount to determine the most appropriate and personalized treatment plan. This conversation should cover the specific goals, processes, and potential side effects of each therapy, taking into account the patient's individual circumstances and preferences. While BCG and chemotherapy are common, other treatment options exist for NMIBC, such as alternative intravesical agents or, in certain high-risk cases or if intravesical therapies fail, radical cystectomy.13 Ultimately, with the array of available treatments and ongoing advancements in the field, patients with NMIBC have reason to be optimistic about achieving positive outcomes.

Comparison of Intravesical BCG and Chemotherapy

Feature

Intravesical BCG

Intravesical Chemotherapy

Primary Goal

Stimulate immune system to destroy cancer cells

Directly kill cancer cells

Mechanism of Action

Immunotherapy; activates the body's immune response

Cytotoxic; directly damages cancer cell DNA

Typical Use

Often preferred for high-risk NMIBC, including CIS

Often used for low- and intermediate-risk NMIBC

Common Side Effects

Flu-like symptoms, bladder irritation, blood in urine

Bladder irritation, burning sensation, blood in urine


V. References


  1. Intravesical Therapy for Bladder Cancer. Cancer.Net. Last Updated: April 17, 2025. URL: https://www.cancer.org/cancer/types/bladder-cancer/treating/intravesical-therapy.html 37

  2. Bladder Cancer Treatment. Cancer.Net. Last Updated: September 12, 2024. URL: https://www.cancer.gov/types/bladder/treatment/by-stage 40

  3. Bladder Cancer (Non-Muscle Invasive) Guideline. American Urological Association. Last Updated: 2024. URL: https://www.auanet.org/guidelines-and-quality/guidelines/bladder-cancer-non-muscle-invasive-guideline 22

  4. Non-Muscle Invasive Bladder Cancer: Intravesical Therapy. Urology Health. Last Updated: Not specified. URL: https://www.urologyhealth.org/healthy-living/urologyhealth-extra/magazine-archives/spring-2019/non-muscle-invasive-bladder-cancer-intravesical-therapy 31


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