AUA releases new guidelines on bladder cancer, ureteral stones

AUA has announced the release of new guidelines on the management of two common urologic conditions: nonmuscle-invasive bladder cancer and ureteral calculi.

Highlights of the bladder cancer guidelines include the following conclusions, based on current literature:

• Accurate clinical staging upon which to base treatment decisions is critically important. The guidelines panel recommends performing a repeat transurethral resection of bladder tumors prior to intravesical therapy in situations where there is high-grade T1 disease without muscularis propria in the specimen and in select cases even when there is muscle present.

• A single, postoperative instillation of a chemotherapeutic agent may decrease recurrence risk in patients with superficial disease who have undergone uncomplicated resection of the tumor(s).

• There is no clear superiority of immunotherapy over chemotherapy for low-risk disease. Induction courses of either intravesical chemotherapy or immunotherapy (eg, bacillus Calmette-Guerin [TheraCys, TICE BCG]) should be administered in patients with an increased risk of tumor recurrence but low risk of progression.

• An induction course of mitomycin C (Mutamycin) in conjunction with maintenance therapy enhances the effectiveness of the drug in preventing recurrence; however, no determinations have been made in regard to optimal maintenance dose, schedule, or duration.

• An induction course of BCG in conjunction with maintenance BCG therapy decreases recurrence and possibly progression in patients with higher-risk tumors. Though no determinations on optimal schedule and duration have been made, data are available that supports the Southwest Oncology Group regimen.

The guidelines include updated treatment algorithms. However, the panel said many accepted studies used to develop these algorithms did not provide stratified outcomes data, and little data were available regarding disease progression and survival.

“We may know more than ever about the disease’s clinical behavior and molecular biology, but we need a larger body of strong research in order to educate physicians and make treatment recommendations,” said guidelines panel chair Craig Hall, MD, of Piedmont Urological Associates, High Point, NC.

The new ureteral stone guidelines, a collaborative effort between AUA and the European Association of Urology, point out the following:

• Data now support ureteroscopy for stones in all locations. Ureteroscopy also is now considered appropriate for stones of any size in the proximal ureter. Ureteroscopic management of stones in the middle ureter, a location that has traditionally posed significant challenges for surgical stone treatments, is supported by the analyzed data.

• There are deficiencies in the number of randomized controlled trials (RCTs) available for extraction, and the panel identified a need for RCTs comparing interventional techniques and pharmacologic studies of stone-expulsion therapies as double-blinded RCTs.

“The panel believes that the report will help both the clinician and the patient choose the most appropriate treatment modality for managing ureteral calculi and believes that future collaboration between the European Association of Urology and the American Urological Association will serve to establish a set of internationally approved guidelines, offering physician and patient guidance throughout the world,” said panel co-chairman Glenn M. Preminger, MD, of Duke University Medical Center, Durham, NC.

Look for more on both guidelines in upcoming issues of Urology Times.