Endoscopic evaluation and transurethral resection are the most important steps in the management of patients with bladder cancer. While multifocality is primarily a prognostic factor with respect to tumor recurrence, tumor grade and depth of invasion are prognostic regarding progression in stage. Transurethral resection biopsies of the prostate should always been obtained in patients with high grade tumors. Follow-up of patients should be individualized: patients with risk for progression, but not necessarily for recurrence, should be followed more closely than patients with low-grade tumors and low risk for progression. In this setting cytology is especially helpful because most high-grade tumors will be detected by cytology. Intravesical therapy is indicated in patients with high-grade tumors, carcinoma in-situ and multiple low grade tumors. While there is a growing body of evidence that BCG is superior to intravesical chemotherapy, one also has to take into account the more frequent and more serious side effects of BCG when compared with mitomycin C or thiotepa.
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