How to Treat Multifocal Ta High-grade Disease if Bacillus Calmette-Guerin Is Unavailable

A 71-yr-old man was transferred to our institution with multiple and recurrent high-grade pTa bladder cancer 26 mo after an initial presentation of multiple and large pTa low-grade tumors and concomitant carcinoma in situ, treated with transurethral resection plus 6-mo postoperative mitomycin C. This case discusses several treatment options in the absence of bacillus Calmette-Guerin (BCG). Immediate radical cystectomy is an option with excellent survival, since there is a substantial risk of understaging and disease progression; however, this results in overtreatment in similar to 50% of these patients. Therefore, a conservative approach could be intravesical combination therapy such as gemcitabine/docetaxel or epirubicin/interferon. In addition, device-assisted intravesical therapy is becoming an option to consider. Finally, patients could be included in trials such as immunotherapy trials. Patient summary: This 71-yr-old patient was diagnosed with recurrent, moderately severe noninvasive bladder tumors, which were removed. The recommended additional therapy, intravesical bacillus Calmette-Guerin (BCG) instillations, was not available. Both the pros and the cons of radical surgery (bladder removal) and a more conservative approach (other intravesical treatments) are discussed. (c) 2019 The Authors. Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).