Intravesical Therapy
Intravesical therapy treats non-muscle-invasive bladder cancer in the bladder itself — a single chemotherapy instillation reduces recurrence, while BCG immunotherapy (induction + maintenance) treats high-risk disease.
The big picture
Two tools delivered into the bladder. Chemotherapy (e.g. mitomycin) is cytotoxic and, given as a single early instillation after TURBT, lowers recurrence in low/intermediate-risk disease. BCG is a live immunotherapy that provokes a local immune response and, with maintenance, reduces recurrence and progression in high-risk NMIBC and CIS.
Right agent for the risk: single chemo instillation for low risk, BCG induction + maintenance for high risk — and never instil BCG into a traumatised or actively infected/bleeding bladder.
Mechanism pathway
Tap any step to see why it happens.
Drug selector
Single chemo instillation (mitomycin)
Low risk- Targets
- Direct cytotoxicity on residual cells
- Onset
- Immediate (peri-operative)
- Use when
- A single early post-TURBT instillation to reduce recurrence in low/intermediate-risk NMIBC
- Side effects
- Chemical cystitis; avoid with bladder perforation
Complications
- Recurrence and progression if undertreated
- Chemical cystitis (chemotherapy)
- BCG cystitis, flu-like illness
- Systemic BCG infection (BCGosis) — a medical emergency
- BCG sepsis after traumatic instillation
- Never instil BCG with traumatic catheterisation, gross haematuria or active UTI
- Avoid chemotherapy instillation if perforation is suspected
- Counsel on symptoms of systemic BCG infection
- Treat BCG cystitis symptomatically
- Systemic BCGosis: anti-tuberculous therapy and supportive care
- Escalate BCG-unresponsive disease to cystectomy
Follow-up
- Surveillance cystoscopy and cytology
- Tolerance of therapy
- Signs of BCG-unresponsive disease
- Scheduled cystoscopic surveillance during and after therapy
- No recurrence on surveillance; tolerated maintenance
- Recurrence/progression on therapy (BCG-unresponsive)
- Surveillance; upper-tract imaging per risk
- Cumulative bladder symptoms
- Need for cystectomy in unresponsive disease
Memory hooks
Low risk → one chemo instillation.
High risk/CIS → BCG induction + maintenance.
No BCG with trauma, gross haematuria or UTI.
BCG-unresponsive high risk → cystectomy.
Board traps
BCG instilled after a bloody traumatic catheterisation — risk of systemic BCG sepsis.
High-risk NMIBC given only a single chemo instillation — needs BCG.
BCG-unresponsive high-grade disease continued on BCG — should move to cystectomy.
Chemo instillation given despite suspected bladder perforation.
Clinical cases
After TURBT for high-grade T1 disease and carcinoma in situ, a patient is counselled about intravesical therapy. The nurse reports a traumatic, bloody catheterisation at the planned first BCG instillation.
What is the correct action?