T1G3 had a 70% recurrence rate and up to 50% progression rate. Whether or not normal detrusor muscle is present in the first TURBT, a second restaging TURBT should almost always be performed. Any abnormal mucosa should be biopsied to rule out cis. Bladder wash cytology at the second TURBT should always be done. If by 3 months the patient is not cancer free, after BCG then 80% will progress. Risk factors associated with progression and poor survival outcomes are:
These suggest early cystectomy and neobladder may be preferably to BCG. TUR and BCG is the gold standard in T1G3 and reduces recurrence by 30% compared with TUR alone. Still TUR and BCG have a 23-74% recurrence rate. Some maintenance BCG must be used to effect a reduction in progression (Lamm SWOG protocol). Despite all this up to 30-50% progress within 5 years. This makes this group of patients very high risk and early cystectomy should always be on the urologists mind. BCG failure is if BCG doesn’t work by 6 months, relapse is recurrence after 6 months, and intolerance is from side effects. In all these groups early cystectomy is advisable. 5-year survival rates drop from 90% if cystectomy is done pre-emptively and early down to 50% if it is delayed until progression is identified. It must be at all times remembered that despite the effectiveness of BCG, early cystectomy and ileal neobladder prevents local progression and metastases from bladder cancer especially now with improvements in continent diversion.