Focused Review © JNCCN—Journal of the National Comprehensive Cancer Network | Volume 11 Number 4 | April 2013 477 Abstract The role for a single dose of intravesical chemotherapy (IVC) after transurethral resection (TUR) remains unclear in patients with non– muscle-invasive bladder cancer (NMIBC). Several recent random- ized clinical trials (RCTs) have evaluated its effect on recurrence, prompting this systematic review of RCTs comparing a single im- mediate postoperative dose of IVC versus placebo within 24 hours of TUR of NMIBC, and this meta-analysis using a random-effects model to predict the pooled relative risk (RR) of tumor recurrence. Subanalyses pooled studies by drug type and a meta-regression was performed to determine the effect of underlying patient risk factors on the effcacy of a single dose of IVC. A total of 3103 pa- tients were randomized in the 18 RCTs that met inclusion criteria. The recurrence rate in patients receiving perioperative IVC and TUR was 37% versus 50% in the TUR-alone group. The pooled RR of recurrence for IVC and TUR was 0.67 (95% CI, 0.56–0.79), cor- responding to a 13% absolute reduction and a number needed to treat of 7.2 patients to avoid 1 recurrence. The proportions of patients with tumor risk factors (T1, high-grade, multifocal, or re- current) were not associated with IVC effcacy. A single dose of IVC administered within 24 hours of TUR of NMIBC was found to result in a reduction in tumor recurrence (RR, 0.67; 95% CI, 0.56–0.79). Patients with higher-risk tumor features seem to beneft at a simi- lar rate. (JNCCN 2013;11:477–484) 73,510, with a 3:1 male-to-female ratio, and accounted for 14,880 deaths. 1 At initial presentation, 75% to 85% are non–muscle-invasive bladder cancers (NMIBCs), which include stages Ta, T1, and Tis. 2 Several studies have shown a beneft of immediate intravesical che- motherapy (IVC) after transurethral resection (TUR) in reducing tumor recurrence. In 2004, Sylvester et al 3 performed a meta-analysis of 7 randomized clinical trials (RCTs) comparing cancer recurrence rates in patients undergoing TUR alone against a combination of TUR and a single immediate postoperative dose of IVC. The study found that over a median follow-up of 3.4 years, 37% of patients in the combined group had experienced a recurrence compared with 48% in the TUR-alone group (odds ratio, 0.61; 95% CI, 0.49–0.75). Since the Sylvester meta-analysis, several addition- al RCTs have been performed, some with new chemo- therapeutic agents, showing conficting results regard- ing the effect of single-dose IVC on NMIBC recurrence. As a result, existing clinical guidelines provide differing recommendations to practitioners. For example, the American Urologic Association does not recommend the routine use of a single dose of IVC immediately after TUR for patients without a diagnosis of bladder cancer because of diagnostic uncertainty and increased cost. 4 Rather it is listed as optional for men with small- volume, low-grade Ta bladder cancer. The European Association of Urology, however, does recommend that a single dose of immediate postoperative IVC be admin- istered after TUR of a bladder lesion, with additional therapy decisions based on EORTC risk category. 2 Fi- nally, NCCN recommends a single dose of IVC within 24 hours of a “nonextensive” TUR of a bladder tumor during which the bladder was not perforated. 5 In light of new RCTs and conficting clinical guide- lines, the authors sought to reassess the effect of im- From the Division of Urology, Duke University Medical Center, Durham, North Carolina. Submitted August 15, 2012; accepted for publication March 21, 2013. The authors have disclosed that they have no fnancial interests, arrangements, affliations, or commercial interests with the manufacturers of any products discussed in this article or their competitors, nor have they received any fnancial support for the research presented. Correspondence: Brant A. Inman, MD, MS, FRCSC, Box 2812, Duke University Medical Center, Durham, NC 27710. E-mail: brant. inman@duke.edu Perioperative Intravesical Chemotherapy in Non–Muscle-Invasive Bladder Cancer: A Systematic Review and Meta-Analysis Michael R. Abern, MD; Richmond A. Owusu, BS; Mark R. Anderson, MD; Edward N. Rampersaud, MD; and Brant A. Inman, MD, MS, FRCSC Currently, 2.4% of all people born in the United States will develop bladder cancer during their lifetime. 1 In 2012, the estimated incidence of bladder cancer was