Rodolfo Hurle1, Luigi Castaldo1, Luisa Pasini1, Gianluigi Taverna1, Mauro Seveso1, Pierpaolo Graziotti1
  • 1 Istituto Clinico Humanitas (Rozzano)


To report our experience with a select group of patients with low-risk tumors included in an observation and monitoring program after the diagnosis of recurrence.
We performed a prospective cohort study in patients diagnosed with recurrent, non muscle-invasive bladder cancer (NMIBC) maintained under an active surveillance protocol.
Inclusion criteria were : small (<10 mm) papillary, asymptomatic tumor with negative urinary cytology was found on follow-up cystoscopy in patients who had previous resections of NMIBC (Stage pTa,pT1a),grade 1-2, bladder tumors, and number of tumors _<5. No symptomatic patients or those with carcinoma in situ or grade 3 tumors were included. All patients included in the observation group were closely monitorated with cytology and flexible cystoscopy every 3-4 months. All pathologic studies were performed by a single experienced uropathologist and fully dedicated cytologists

Methods and results

The data from 48 patients (63 active surveillance events) were analyzed. The mean patient age was 69.8 years. The median follow-up was 33.6 months. Pathologic characteristics before observation were pTa in 81.1%, Stage pT1a in 18.9%, grade 1 in 77.1%, and grade 2 in 22.9 %. The median time patients remained in observation was 12.7 months.
89.5% of the patients did not experience progression in stage and 86.8% in grade.
None of the patients experienced progression to muscle-invasive disease. The patients who discontinued the observation period and who underwent transurethral resection are those who have had an increase in the number and/or size of the lesions, symptoms (mainly hematuria), or if the surveillance urine cytology findings were positive for malignancy.


The observation of these tumors, without active treatment, is a common clinical practice; however, although routinely performed by some urologists, it has not been included in any clinical guidelines
Active surveillance protocol is reasonable in patients presenting with small , recurrent papillary bladder cancer after resection of low – grade T a T1 a tumor ( s ) . Many surgeries can be spared , and the risk for tumor progression in these patients is minimal . Whenever a significant change in tumor morphology or size is noted , the patient should be referred for a standard transurethral resection of the tumor .