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BackTable / Urology / Article
Managing Early-Stage Bladder Cancer: From Diagnosis to Resection
Sam Strauss • Updated May 12, 2025 • 35 hits
Managing low and intermediate-risk non–muscle invasive bladder cancer (NMIBC) requires careful attention to early decision-making, particularly when it comes to diagnosis, procedural planning, and surveillance. While these patients are typically at lower risk for progression, variations in tumor size, multifocality, and recurrence patterns demand a structured, guideline-informed approach. Even seemingly minor clinical choices—such as whether to perform cystoscopy in the office or the OR—can impact long-term outcomes.
This article walks through a pragmatic framework for approaching these cases, highlighting the nuances of resection technique, the value of immediate post-op gemcitabine installation, and the importance of aligning surveillance strategies with AUA risk groups. Key decision points include determining the optimal setting for initial evaluation, incorporating tools like blue light cystoscopy and cytology, and performing a thorough transurethral resection of bladder tumor (TURBT).
Additionally, timely administration of post-operative gemcitabine and applying AUA risk stratification guidelines are essential steps in ensuring appropriate follow-up intervals. These strategies form a structured approach to early-stage NMIBC that prioritizes both oncologic control and efficient delivery of care.
This article features excerpts from the BackTable Urology Podcast. You can listen to the full episode below.
The BackTable Urology Brief
• Office vs. OR-based cystoscopy should be guided by patient-specific factors, including tumor visibility, instrumentation tolerance, and likelihood of needing intervention.
• Blue light cystoscopy can enhance detection of flat lesions but may be best reserved for specific surgical settings.
• Cytology can add value in certain diagnostic scenarios, particularly when imaging or cystoscopy is inconclusive.
• Proper TURBT technique—including complete tumor resection and documentation of muscle in the specimen—is critical for accurate staging.
• Immediate post-op gemcitabine instillation remains standard for low-risk patients, but patient selection and workflow planning are key to consistent delivery.
• Risk stratification (low vs. intermediate) based on AUA guidelines helps determine surveillance intervals and the need for adjuvant treatment.
Table of Contents
(1) Determining the Clinical Setting for Initial Evaluation
(2) Executing an Effective TURBT in Early Stage Bladder Cancer
(3) Applying AUA Risk Categories for Follow-Up Care
Determining the Clinical Setting for Initial Evaluation
Initial evaluation for suspected bladder cancer often begins in the office with flexible cystoscopy, but determining whether to proceed directly to the operating room depends on several clinical factors. One of the most important distinctions is whether or not a lesion appears clearly visible and resectable without additional imaging or anesthesia. In patients with small, papillary-appearing tumors and good endoscopic access, office-based cystoscopy may suffice to confirm diagnosis and proceed with planning. However, in cases where lesions are poorly visualized, suspicious for carcinoma, or located in challenging anatomical positions, OR-based cystoscopy offers better control, lighting, and the opportunity for simultaneous resection.
Patient-specific factors also influence this decision. Many patients wish to avoid the OR all together, and would thus prefer a more simple in-office procedure. For patients who cannot tolerate office instrumentation—due to discomfort, prior trauma, or anxiety—a brief diagnostic cystoscopy under anesthesia can be more appropriate. In other cases, even when lesions are visible, the possibility of needing blue light cystoscopy or a more comprehensive evaluation may prompt early OR scheduling to avoid unnecessary delays.
Ultimately, the decision to perform cystoscopy in the office or operating room should be driven by clinical efficiency and diagnostic clarity. Choosing the right setting can streamline care, reduce redundant procedures, and improve the likelihood of a complete and effective initial TURBT.
[Dr. Aditya Bagrodia]
…New patient comes in with a bladder mass either on a CT scan or a cysto. How does that conversation look at that first visit?
[Dr. Amir Salmasi]
…We always review the imaging together and I let them know that, "We need to look into your bladder with a cystoscopy." I always recommend doing like a blue light system just in case that there is higher detection rate. I explain that everything depends on what we see, pathology. If we see the mass, we talk about that, "This is going to be most likely bladder cancer," but then next step depends on the size, the pathology, is it high-grade, low-grade, how deep is going to the bladder. This is my first conversation with them and briefly talk to them, possible follow-ups. I tell them, "You need to like me because you're going to see me a lot in the future." We start with that and then step by step, in the progress of the disease, we talk about next step.
[Dr. Aditya Bagrodia]
A lot of that resonates. Betsy, how about from your end, and maybe I'll ask you to specifically comment on office cystoscopies, cytology, adjunct tests, who, when, and how.
[Dr. Betsy Koehne]
That's a great question. To be honest, I would say that I don't have a super-defined pathway for whether I do an office cystoscopy before the OR. Usually, if they have a pretty convincing mass on imaging and I feel like when I meet the patient that we have a good rapport, then I'll just go to the OR with them and do the TURBT there. Sometimes I do like having the cystoscopy just because of getting the cytology, and I think it helps a little bit or sometimes a lot with counseling the patient and can help me just know what we're getting into in the operating room.
I think both ways of doing it on one hand, just going to the operating room and sparing the patient the cystoscopy in the office, that's nice, and then also there can be good information gleaned from the clinic cystoscopy too. Both are good. As Amir said, I try to indicate to the patient that we'll be seeing each other, but it's hard, when they're coming in with something and they think that they're going to get this one tumor treated. I feel like that's the worst part of-- really, the intermediate risk bladder cancer is just having in the back of my head that this is going to be a real pain and a nuisance as the lightest way to put it.
[Dr. Aditya Bagrodia]
I think a lot of that resonates, and this might be a bit of a less-common scenario, but if you referred somebody for either microscopic or gross hematuria, you take a look in their bladder in the clinic, are there scenarios, and let's just say you see a very small papillary tumor, nothing otherwise outstanding, no concern for carcinoma in situ, et cetera, would you ever just do a biopsy, cauterize it and then leave that as your initial diagnostic and therapeutic intervention?
[Dr. Amir Salmasi]
yYes. Again, Betsy said if imaging shows like a large mass, I just go directly to the OR, but for some macroscopic hematuria or some questionable lesion in the bladder with the imaging, when I see and it looks like a low-grade, a small papillary lesion, I just do biopsy and full-grade it because there's data. For the small masses in this size, like a papillary, looks like 80% we can be accurate and say, "This is going to be low-grade."
[Dr. Betsy Koehne]
I think it's definitely safe and can be nice to do that and that you're saving OR time which we all know is a very valuable resource. To be honest, I've done it a couple of times in my clinic, but usually I don't because I'm moving on to seeing other patients and it's just maybe as much trouble for me at that point to just add them on to the OR for TURBT later versus having the clinic get everything set up, which usually isn't set up just for a regular cystoscopy. That's probably the main reason why I don't do it more often, but certainly something that I think about and I'm open to tips that other folks have about making that run smoothly in their clinic.
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Executing an Effective TURBT in Early Stage Bladder Cancer
Transurethral resection of bladder tumor is a cornerstone in the management of non-muscle invasive bladder cancer. The primary goals are complete tumor removal, accurate staging, and obtaining detrusor muscle in the specimen. Achieving these goals often hinges on attention to tumor size, location, and visibility during resection. For small papillary tumors, a single-stage resection may be sufficient. However, in cases with bulky or sessile lesions, surgeons may opt for a two-stage approach: first removing the exophytic component, then resecting the base separately to ensure complete sampling.
Muscle presence in the resection specimen remains a key quality indicator. While its absence may not always require a re-resection—particularly in low-grade, low-volume disease—its presence improves confidence in staging and informs future surveillance. Care should be taken to avoid perforation during deeper resections, especially in thin-walled areas like the dome or posterior wall. Techniques such as reducing irrigation pressure or switching to intermittent flow can help maintain visibility and minimize risk.
Post-operative gemcitabine installation remains standard for low-risk patients following TURBT. Its use depends on identifying appropriate candidates and integrating it smoothly into surgical workflows. Administering gemcitabine within six hours of resection, ideally before catheter removal, has been shown to significantly reduce recurrence. Consistent implementation requires aligning OR teams, pharmacy, and recovery staff to avoid missed opportunities.
[Dr. Amir Salmasi]
…If imaging shows like a large mass, I just go directly to the OR, but for some macroscopic hematuria or some questionable lesion in the bladder with the imaging, when I see and it looks like a low-grade, a small papillary lesion, I just do biopsy and full-grade it because there's data. For the small masses in this size, like a papillary, looks like 80% we can be accurate and say, "This is going to be low-grade." Also, there's another data that showed that if you full-grade it versus like a TURBT for just a small solitary papillary lesion, they kind of have the same efficacy, so yes, I'll do it.
[Dr. Aditya Bagrodia]
This is I think post-operative installation, that's always one where-- I don't want to say that I'm leading the residents and some of it's like read my mind. It's such an important thing, right? It's one of the few things if you think of something at the point of care, it gets done. If you don't think about it, that's a missed opportunity. Who are we using a post-operative installation of-- gemcitabine I think these days is probably the preferred option over mitomycin.
[Dr. Betsy Koehne]
I think it's definitely safe and can be nice to do that and that you're saving OR time which we all know is a very valuable resource. To be honest, I've done it a couple of times in my clinic, but usually I don't because I'm moving on to seeing other patients and it's just maybe as much trouble for me at that point to just add them on to the OR for TURBT later versus having the clinic get everything set up, which usually isn't set up just for a regular cystoscopy. That's probably the main reason why I don't do it more often, but certainly something that I think about and I'm open to tips that other folks have about making that run smoothly in their clinic.
[Dr. Aditya Bagrodia]
…I think it is a relatively uncommon scenario, and not to get super out in the ether fringe here, but older, sicker patient, you're trying to save them a trip to the OR, small little pathway thing. For the first initial one, it seems like doing a TURBT is like the textbook answer for any trainees out there taking the OR, getting a good bite. I think in the real world, if you will, a patient that may not tolerate anesthesia so well, it may be an option.
…Your tools in your toolkit, you have imaging, so that kind of checks the boxes on your CT scan and office cystoscopy and their pros and cons.
Applying AUA Risk Categories for Follow-Up Care
Accurate risk stratification is essential to developing a follow-up plan for patients with non–muscle invasive bladder cancer. The AUA classifies NMIBC into low-, intermediate-, and high-risk categories based on tumor grade, size, multifocality, and presence of carcinoma in situ. For patients with low-grade, unifocal tumors under 3 cm, most clinicians favor minimal surveillance with cystoscopy every 3 to 6 months and annual upper tract imaging. In contrast, patients with intermediate-risk features—such as multifocal disease or larger tumor size—require closer monitoring and may benefit from intravesical therapy depending on recurrence patterns.
In practice, the application of these risk categories also depends on individual clinician style, institutional workflow, and patient-specific considerations. There is a range in how different providers will manage different levels of risk. Some urologists prefer re-TURBT for any tumor lacking muscle in the initial specimen, while others may take a more conservative approach if the tumor is small, low-grade, and completely resected. In all cases, aligning the pathology report with a clearly documented surveillance plan helps streamline future decision-making and reinforces continuity of care.
It is important to make sure that patients are aware of the importance of follow-up appointments, even in low-risk situations. While high-risk NMIBC falls outside the scope of this article, understanding how to manage low and intermediate-risk disease with structured surveillance can reduce recurrence, support timely retreatment, and prevent overtreatment in patients unlikely to progress.
[Dr. Betsy Koehne]
A little bit going back to our earlier conversation, if they had a cystoscopy in clinic or maybe by myself or one of my partners in the cytology was negative, and then we're expecting it's probably just based on the visual inspection, it's probably going to be a low-grade tumor, usually for all tumors that I think are low grade, I just do the intravesical chemotherapy. I think there's some evidence that in people who have recurrent tumors, multifocal low-grade tumors, the one-hour adjuvant intravesical chemotherapy probably isn't going to change outcomes, and those people really just need a full adjuvant course after the procedure. I usually just do it at that time to keep things more consistent from case to case.
[Dr. Amir Salmasi]
Absolutely. I agree with you. I think the data shows that if we're effective for small solitary tumors, but again, if I feel like anyone is a low-grade tumor, usually I give it like a gemcitabine after the surgery. Also, we have to make sure that there's no perforation.
[Dr. Aditya Bagrodia]
I agree… Like you guys are saying, older, sicker patients, recurrent low-grade, you haven't perfed them, you know their natural history, that the downside is somewhat limited, and if you can save them a trip to the OR. One question that came up fulgurating, so multifocal papillary low-grade appearing tumors, any strong opinions on resecting versus cauterizing those?
[Dr. Aditya Bagrodia]
A couple of good ones. You're feeling like you've got a good sampling, you haven't cauterized it to kingdom come so the pathologist can make some sense of it and that's that. All right, very good. We get them out and they're coming back into their clinic and maybe this is a good time just to make sure we're all in the same wavelength here. Low and intermediate-risk bladder cancer, that's the title and the topic of today's conversation. You're looking at that pathology report, you're about to sit down with the patient, you're just checking out things one more time before you go in. What are the critical bits here on the pathology report to review?
[Dr. Betsy Koehne]
A low-grade, well, low-risk bladder cancer, a low-risk non-muscle-invasive bladder cancer will be a low-grade TA tumor, so a low-grade non-invasive tumor less than three centimeters, and then essentially, any low-grade that is larger than that or multifocal will be intermediate risk and then small high-grade tumors will also be intermediate risk.
Podcast Contributors
Dr. Elizabeth Koehne
Dr. Betsy Koehne is a urologist at the University of WIsconsin-Madison School of Medicine in Madison, Wisconisin.
Dr. Amir Salmasi
Dr. Amir Salmasi is a urologist at UC Sand Diego Health in San Diego, California.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Cite This Podcast
BackTable, LLC (Producer). (2024, December 6). Ep. 204 – Managing Low & Intermediate Risk Bladder Cancer [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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