Collaborative Review – Bladder Cancer An Updated Critical Analysis of the Treatment Strategy for Newly Diagnosed High-grade T1 (Previously T1G3) Bladder Cancer Girish S. Kulkarni a, *, Oliver W. Hakenberg b , Juergen E. Gschwend c , George Thalmann d , Wassim Kassouf e , Ashish Kamat f , Alexandre Zlotta g a Division of Urology, Department of Surgery, University of Toronto, University Health Network, Toronto, Canada b Department of Urology, Rostock University, Rostock, Germany c Department of Urology, Rechts der Isar Medical Centre, Technical University of Munich, Munich, Germany d Department of Urology, University of Bern, Anna Seiler Haus, CH-3010, Bern, Switzerland e Division of Urology, Department of Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Canada f Department of Urology and Cancer Biology, MD Anderson Cancer Centre, Houston, USA g Division of Urology, Department of Surgery, University of Toronto, Mount Sinai Hospital, Toronto, Canada EUROPEAN UROLOGY XXX (2009) XXX–XXX available at www.sciencedirect.com journal homepage: www.europeanurology.com Article info Article history: Accepted August 26, 2009 Published online ahead of print on September 1, 2009 Keywords: Bladder Cancer T1 High grade T1G3 BCG Cystectomy Treatment Abstract Context: High-grade T1 (formerly T1G3) bladder cancer (BCa) has a high propen- sity to recur and progress. As a result, decisions pertaining to its treatment are difficult. Treatment with bacillus Calmette-Gue ´ rin (BCG) risks progression and metastases but may preserve the bladder. Cystectomy may offer the best oppor- tunity for cure but is associated with morbidity and a risk of mortality, and it may constitute potential overtreatment for many cases of T1G3 tumours. For purposes of this review, we continue to refer to high-grade T1 lesions as ‘‘T1G3.’’ Objective: To review the current literature on the management of T1G3 BCa and to provide recommendations for its treatment. Evidence acquisition: A National Center for Biotechnology Information (NCBI) PubMed search for relevant articles published between 1996 and 9 January 2009 was performed using the Medical Subject Headings ‘‘T1G3’’ or ‘‘T1’’ and ‘‘Bladder cancer.’’ Articles relevant to the treatment of T1G3 BCa were retained. Evidence synthesis: The diagnosis of T1G3 disease is difficult because pathologic staging is often unreliable and because of the risk of significant understaging at initial transurethral resection (TUR) of bladder tumour. A secondary restaging TUR is recommended for all cases of T1G3. A single dose of immediate post-TUR che- motherapy is recommended. For a bladder-sparing approach, intravesical BCG should be given as induction with maintenance dosing. Immediate or early radical cystectomy (RC) should be offered to all patients with recurrent or multifocal T1G3 disease, those who are at high risk of progression, and those failing BCG treatment. Conclusions: Both bladder preservation and RC are appropriate options for T1G3 BCa. Risk stratification of patients based on pathologic features at initial TUR or at recurrence can select those most appropriate for bladder preservation compared to those for whom cystectomy should be strongly considered. # 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Division of Urology, Department of Surgery, University of Toronto, 610 University Avenue, Suite 3-130, Toronto, ON, Canada M5G 2M9. E-mail address: girish1975@gmail.com (G.S. Kulkarni). EURURO-3181; No of Pages 11 Please cite this article in press as: Kulkarni GS, et al. An Updated Critical Analysis of the Treatment Strategy for Newly Diagnosed High-grade T1 (Previously T1G3) Bladder Cancer, Eur Urol (2009), doi:10.1016/j.eururo.2009.08.024 0302-2838/$ – see back matter # 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2009.08.024