T1G3 transitional cell carcinoma of the bladder represents a highly malignant tumor with a variable and unpredictable biologic potential. The most critical aspect of management requires a detailed discussion with the patient regarding the treatment options. Both the physician and the patient should be willing to reconsider the treatment options as the disease continues to evolve. In most cases initial management involves complete resection of the tumor, accurate staging of the disease, and intravesical immunotherapy or chemotherapy. Rigorous surveillance with long-term follow-up is crucial for managing these cases. In selected cases with adverse prognostic factors immediate cystectomy should be considered. The choice and timing of the decision to abandon bladder preservation and proceed with cystectomy should be continuously reconsidered on an individual patient basis, in concordance with the evolution of the disease (Fig. 1). The goal is to spare the bladder when possible but not at the risk of death from metastatic disease. Radical cystectomy in high-grade stage T1 transitional cell carcinoma offers excellent results in regard to the prevention of recurrence and progression and survival. Improvements in urinary diversion and nerve-sparing techniques have decreased the magnitude of social implications related to cystectomy in most patients regardless of gender. The discovery of reliable markers may contribute to better selection of patients for bladder sparing. Until then, the optimal treatment for the T1G3 tumor remains controversial.
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