In situ transitional cell carcinoma involvement of prostatic urethra: bacillus Calmette-Guérin therapy without previous transurethral resection of the prostate

Current Perspectives on the Diagnosis and Management of Primary Urethral Cancer: A Systematic Review

Primary urethral cancer (PUC) is a rare but highly aggressive malignancy that causes malignant urethral obstruction. We conducted a literature review using PubMed to identify original research studies that assessed the diagnosis and management of primary urethral cancer. PUC affects men more than women, is more common in African Americans than Caucasians, and is associated with history of chronic inflammation and irritation of the urinary tract. Patients suspected of PUC should undergo a complete work-up including cystoscopy, magnetic resonance imaging, and biopsy. In men and women, surgical monotherapy ranging from organ-sparing to more radical reconstructive procedures has adequate survival rates for early stage PUC and has been shown to be similarly as effective as radiation monotherapy, while multimodal therapy has become the standard of treatment for advanced stage PUC. Salvage surgery or radiation therapy has been linked with increased survival rates. Nodal involvement at the time of diagnosis is a negative prognosticator and should be treated with multimodal therapy. Further prospective studies with greater sample sizes and standardized clinical trials would allow for greater consistency in evaluating the different treatment modalities for PUC.

Systematic Review of the Role of BCG in the Treatment of Urothelial Carcinoma of the Prostatic Urethra

BACKGROUND

In patients with non-invasive urothelial carcinoma of the prostatic urethra (PUC), treatment with Bacillus Calmette-Guérin (BCG) could be beneficial.

OBJECTIVE

To assess the response rates to BCG in the different tumor stages, to describe the clinical impact of transurethral resection of the prostate (TURP) before BCG treatment, and to review the side effects of BCG treatment for PUC.

METHODS

A systematic search was conducted using the PubMed database to identify original studies between 1977 and 2019 reporting on PUC and BCG.

RESULTS

Of a total of 865 studies, ten were considered for evidence synthesis. An indication for BCG treatment was found in non-stromal invasive stages (Tis pu, Tis pd) and in stromal infiltrating cases (T1) of primary and secondary PUC when transitional cell carcinoma was the histology of origin. Studies including patients treated with TURP before BCG showed a better local response in the prostatic urethra with a higher disease free survival (DFS) (80-100% vs. 63-89%) and progression free survival (PFS) (90-100% vs. 75-94%) than patients in studies in which no TURP was performed. However, this difference in recurrence and progression in the prostate neither affected the total PFS (57-75% vs. 58-93%), nor the disease specific survival (70-100% vs. 66-100%).

CONCLUSIONS

The use of resection loop biopsies of the prostatic urethra in appropriate cases during the primary work-up for suspected PUC, as well as the use of the current TNM classification for PUC, need to be improved. BCG therapy for non-stromal invasive stages of PUC show a good local response. Local response is further improved by a TURP before BCG therapy, although the overall prognosis does not seem to be affected. Further evidence for BCG treatment in the rare cases of stromal invasive PUC is needed. Specific side effects of BCG treatment for PUC are not reported.

Revisiting an Old Conundrum: A Systematic Review and Meta-Analysis of Intravesical Therapy for Treatment of Urothelial Carcinoma of the Prostate

BACKGROUND

The optimal management of non-invasive (mucosal and/or ductal) urothelial carcinoma of the prostate remains elusive and there is a paucity of data to guide treatment.

OBJECTIVE

Our objective was to systematically review and synthesize treatment responses to conservative management of non-invasive prostatic urothelial carcinoma using intravesical therapy.

METHODS

A systematic literature search using MEDLINE, EMBASE, Cochrane Library, SCOPUS, and Web of Science databases from inception to November 2019 was performed. Risk of bias assessment was performed using the Newcastle-Ottawa scale for non-randomised studies. Pooled estimates of complete response in the bladder and prostate and prostate only were performed using a random effects model. Pre-specified subgroup analyses were generated to assess differences in complete responses for: BCG therapy vs other agents, ductal vs mucosal involvement, CIS vs papillary tumors and TURP vs no TURP.

RESULTS

Nine studies including 175 patients were identified for inclusion in the systematic review and meta-analysis. All were retrospective case series and most evaluated response to BCG therapy. The pooled global complete response rate for intravesical therapy was 60%(95%CI: 0.48, 0.72), and for prostate 88%(95%CI: 0.81, 0.96). Pre-specified analyses did not demonstrate statistically significant differences between subgroups of interest.

CONCLUSIONS

Management of non-invasive prostatic urothelial carcinoma using intravesical therapy yields satisfactory results. Caution should be taken in treating patients with papillary tumors and ductal involvement, as data for these populations is limited. TURP may not improve efficacy, but is required for staging. Current recommendations are based on low quality evidence, and further research is warranted.

The conundrum of prostatic urethral involvement

The presence and depth of urothelial cancer involvement in the prostatic urethra can significantly affect the management of a patient with non-muscle invasive bladder cancer. This article presents an overview of the incidence, diagnosis, management, and follow-up of urothelial cancer.

Predictive factors for recurrence progression and cancer specific survival in high-risk bladder cancer

PURPOSE OF REVIEW

Despite standard treatment with transurethral resection (TUR) and adjuvant Bacillus Calmette-Guérin (BCG), a large percentage of high-risk bladder cancer (HRBC) recur, and some progress. On the basis of review of the current guidelines and literature, we have developed actualized clinical and molecular prognostic factors of recurrence, progression and cancer specific survival (CSS) in patients with HRBC.

RECENT FINDINGS

A Medline search was conducted to identify the current literature updating the most important clinic and pathological predictive factors published in the last years. Also, there have been reviewed the new molecular markers that can assess prognosis and BCG response.

SUMMARY

Despite different methodological bias, as short follow-up, a small number of patients and a different definition of prognostic factors, increased evidence supports sex, age, grade, stage, multifocality, history of previous recurrences, carcinoma in situ in the prostatic urethra and early recurrence as prognostic factors for recurrence, progression and CSS in nonmuscle invasive bladder cancer. Also lymphovascular invasion in TUR and new molecular markers (galectin-3, profilin-1, and combination of markers) are increasingly useful in predicting prognosis and BCG response. Moreover, there is enough evidence to consider the implementation of new specific risk tables for patients treated with BCG. In cases with poor prognostic factors after TUR in HRBC early cystectomy should be considered.

[Prostatic involvement by urothelial carcinoma in patients with bladder cancer and their implications in the clinical practice]

OBJECTIVES

Urothelial carcinoma (UC) is a multifocal disease that may develop in any location of the urinary tract, including the prostate. We analyze the types of prostate involvement due to UC, their diagnosis, risk factors and the clinical implications of this entity.

MATERIAL AND METHODS

Analysis of original, review articles and publications related to prostate involvement due to UC. The study included works published in the period of 1985-2011, most of which were obtained from the search in PubMed.

RESULTS

Prostate involvement due to UC has been observed frequently in both non-muscle invasive bladder cancer (NMIBC) series and prolonged follow-up (39%) as in radical cystectomy series (15-48%). Prostatic involvement may occur in the mucosa and ducts (superficial involvement) or prostate stroma (invasive involvement), a fact that has prognostic and therapeutic implications. Stromal involvement may have both a bladder and intraurethral origin. Carcinoma in situ, multifocality, bladder neck/trigone cancer, and previous history of tumor recurrence are the factors that have been m ore consistently associated to prostate involvement due to UC. The incidence of prostatic involvement by UC in patients with NMIBC increases over time when risk factors exist. In these cases, a prostatic urethral biopsy should be performed during the follow-up. Conservative treatment with transurethral resection and BCG is possible in case of superficial involvement of the prostatic urethra, assuming its risk of progression. Patients subjects to cystectomy and with prostate involvement due to UC have a greater risk of urethral recurrence. The elevated incidence of prostatic adenocarcinoma and prostatic involvement by UC in cystectomy specimens makes it necessary to be very selective when indicating prostate-sparing cystectomy. Chemotherapy may be an option in an attempt to improve survival of patients with prostatic stromal involvement.

CONCLUSIONS

Prostatic involvement by UC is not uncommon and it has important implications in the management of patients with NMIBC and in those who have an indication for or have undergone radical cystectomy.

[Treatment of primary urethral carcinoma. Guidelines from the French Urological Association. Cancer committee]

The litterature dealing with the treatment of primary uretral carcinoma is very limited. Most of it is based on small series, case report or expert opinions. These guidelines are level IV. The treatment modality is mainly based on the lesion topography and not on the histology. For anterior T1 or 2 lesions, surgery is the most often used modality. In women, radiotherapy might be an attractive option. For more advanced lesions, the combination of radiotherapy and chemotherapy is the standard of care. The optimal protocol remains to be defined. Intradiverticular lesions in women are mainly adenocarcimoma. Surgery only is often inadequate.

Dilemmas in the treatment of urothelial cancers of the prostate

OBJECTIVES

The objective of this paper is to examine the contemporary incidence, diagnosis, and treatment of prostatic urothelial carcinoma and make recommendations on the current dilemmas of treating urothelial cancer of the prostate.

METHODS

A review of English-language literature from 1990 to the present was performed utilizing the U.S. National Library of Medicine's Pub Med database. Keywords used were urothelial cell carcinoma, prostatic urethral involvement, prostatic duct/acini involvement, carcinoma in situ. Bibliographies of reviewed articles were also searched.

RESULTS

Transitional cell carcinoma of the bladder with involvement of the prostate has been reported in multiple studies with an incidence between 12% and 48%. Stromal invasion of the prostate has a reported incidence between 7% and 17%. The incidence of primary transitional cell carcinoma of the prostate has been estimated at 1% to 4% of prostatic malignancies. Degree and depth of prostatic invasion has prognostic significance with 5-year survival rates being 100% for those with urethral mucosal involvement, 50% with ductal/acinar involvement, and 40% with prostatic stromal invasion. The actual anatomic path that urothelial carcinoma invasion occurs also has prognostic significance. Those with contiguous malignant involvement had a 7% 5-year survival rate compared with those with noncontiguous involvement and a 46% 5-year survival rate.

CONCLUSIONS

Prostatic urothelial carcinoma is often under appreciated and not well understood. Malignant involvement of different anatomic locations of the prostate (i.e., mucosa, ducts, acini, and stroma) influence not only diagnosis but treatment of disease. Although debate exists regarding optimal therapy for mucosal involvement, if the prostatic stroma is involved, radical cystoprostatectomy is the treatment of choice.

Prostatic transitional cell carcinoma: pathologic features and clinical management

Prostatic involvement by transitional cell carcinoma (pTCC) in patients with bladder cancer is a frequent finding, particularly in patients with high-grade invasive tumor and urothelial carcinoma in situ. Various patterns and levels of prostatic involvement have been described, and their impact in patients' management and their prognosis recognized. The role of prostatic urethral biopsy and intraoperative frozen section in the management of bladder cancer, tailoring to the bladder tumor stage is still not well defined and universally accepted. This review discusses the current understanding of the biology and histological patterns of pTCC and their clinical significance and management options. A rational approach for management of pTCC in patients with bladder cancer will be proposed on the basis of our experience and our review of literature.

Urothelial carcinoma in the prostatic urethra and prostate: current controversies

We reviewed the literature on urothelial carcinoma in the prostatic urethra and prostate. We concluded that the incidence of urothelial carcinoma in the prostatic urethra and prostate is probably underestimated. This fact warrants thorough follow-up of patients with high-risk bladder cancers and also whole-mount examination of the prostate after cystectomy to recognize the true incidence and extent of such tumor involvement. Resectoscope loop biopsy is the method of choice to detect urothelial carcinoma in the prostatic urethra/prostate and such biopsies should include the area around the verumontanum to ensure optimal sensitivity. Carcinoma in situ in the prostatic urethra should be treated with intravesical Bacillus Calmette-Guérin and a transurethral resection of the prostate prior to that treatment might increase the contact of Bacillus Calmette-Guérin with the prostatic urethra, improve staging and in itself treat the prostatic involvement. Conservative treatment of carcinoma in situ in the prostatic ducts is an option, although radical surgery is probably best for treating extensive intraductal involvement, since data on the former strategy are inconclusive. Patients with stromal invasion should undergo radical surgery. It is necessary to take the route of prostatic involvement into account when estimating prognosis in each individual patient, since contiguous growth into the prostate is associated with worse prognosis. Prospective studies using a whole-mount technique to investigate the prostate are needed to clarify both the role of different routes of prostate invasion and the prognostic significance of different degrees of prostate invasion. At cystectomy, when urothelial carcinoma is present in the prostatic urethra and/or prostate, it is necessary to balance the risk of urethral recurrence and decreased sexual function against opinion and expectations expressed by the patient during preoperative counseling regarding urinary diversion and primary urethrectomy.

Urothelial Carcinoma of the Prostate

This study was conducted to explore the diagnosis and management of urothelial carcinoma of the prostate in superficial disease and carcinoma in situ, stromal invasion, primary urothelial carcinoma, and urethral recurrence after radical surgery. A consensus conference convened by the World Health Organization (WHO) and the Société Internationale d'Urologie (SIU) reviewed the diagnosis and management of urothelial carcinoma of the bladder. English-language literature about urothelial carcinoma of the prostate was identified and reviewed. Evidence-based recommendations for the diagnosis and management of urothelial carcinoma were made. Many recommendations were level 3 or 4 citations involving the diagnosis and management of superficial urothelial carcinoma; a few were level 2 citations. Level 1 citations related only to chemotherapy and radiotherapy in patients with stromal invasion, although these were not related specifically to invasive prostatic involvement. More than 130 reviewed citations are summarized in this review. Published reports on the diagnosis and treatment of superficial urothelial disease of the prostate primarily consist of short case series from individual centers. Prospective and multicenter trials are needed to identify the real incidence and the best management of these patients. In invasive disease of the prostate, the only large series were designed to investigate invasive bladder cancer.

Intravesical Instillations with Bacillus Calmette-Guérin for the Treatment of Carcinoma In Situ Involving Prostatic Ducts

OBJECTIVES

Bacillus Calmette-Guérin (BCG) has proven its efficacy in the treatment of carcinoma in situ (CIS) of the prostatic urethra. We performed a retrospective study to evaluate the use of intravesical instillations of BCG in patients with carcinoma in situ involving prostatic ducts after complete transurethral resection (TUR).

MATERIAL AND METHODS

Eligibility for the study was CIS of the prostatic urethra involving prostatic ducts. Previous instillation with BCG was an exclusion criterion. Patients were treated with intravesical BCG Connaught (81 mg) administered once a week, over a 6-wk period. TUR loop biopsies of the prostate were performed only when a macroscopic tumor was present.

RESULTS

In this retrospective study of 11 patients, 8 (73%) presented with macroscopic tumor in the prostatic urethra. Ten patients (91%) had a simultaneous superficial bladder carcinoma. Eight patients (73%) had tumoral involvement of the bladder neck region. After a median follow-up of 27 mo (n=10 patients), the response in the prostatic urethra was 82%, and the response in the bladder due to superficial tumor recurrence was 64%. Two patients with residual ductal disease in the prostatic urethra were subsequently treated with cystoprostatectomy and are currently free of disease. In one of those patients, the cystoprostatectomy specimen did show prostatic stromal invasion. Another patient developed distant metastatic disease and died a few months after diagnosis. Thus, progression was encountered in two patients (18%). Currently, 90% of patients are alive without evidence of disease and 72.7% have benefitted from this bladder preservation strategy.

CONCLUSION

Intravesical BCG is a feasible treatment option for patients with CIS involving prostatic ducts. In this retrospective study, bladder preservation was successful in 8 of 11 patients (70%) and there was only one oncologic death. Obviously, these patients need a careful follow-up with cystoscopy and cytology to detect either recurrence or progression and in those with persistent disease after the initial BCG induction therapy, prompt cystectomy is indicated.

Current state of immunotherapy for bladder cancer

Bacillus Calmette-Guerin (BCG) has been shown to be the most effective agent for the treatment of superficial bladder cancer since its approval by the US Food and Drug Administration for the treatment of carcinoma in situ of the bladder in 1990. Recently, augmentation of BCG immunotherapy with interferon-alpha2b and other agents is emerging as salvage therapy for those patients who fail initial treatment. This review summarizes the role of various immunotherapeutic agents in the treatment of bladder cancer, with special emphasis on the appropriate administration and schedule of BCG therapy as well as salvage with the combination of BCG with interferon-alpha2b.

Cystectomy in patients with high risk superficial bladder tumors who fail intravesical BCG therapy: pre-cystectomy prostate involvement as a prognostic factor

PURPOSE

To review understaging and outcome of patients who underwent radical cystectomy (RC) for high risk superficial bladder cancer after bacillus Calmette-Guérin (BCG) failure.

PATIENTS AND METHODS

We carried out a retrospective study of 62 cases in which RC was indicated for clinical stage Tis, Ta, T1 transitional cell bladder tumors that failed transurethral resection (TUR) and BCG treatment. We used BCG (81 mg/Connaught BCG) in patients with superficial grade 3 tumors and CIS. We considered BCG failure a high-grade recurrence at 3 months of the first BCG course or after 2 courses. RC indications, correlation between their clinical and pathological stage and the ensuing progress were analyzed. We assessed the existence of any pre-cystectomy clinical or pathological factor related to understaging and survival.

RESULTS

RC was performed in 22 patients with carcinoma in situ (CIS) (35%), 7 with Ta (11,2%), 31 with T1 (50%), and 2 with Tx tumors (3%). All 62 but one were high-grade tumors (grade 3 and/or CIS). Tumor was clinically understaged with stages pT2 or greater on the RC specimen in 17 patients (27%). The presence of tumor in the prostatic urethra at the moment of endoscopic staging before RC was the only factor associated with clinical understaging (p=0.003) and shorter survival (p<0.0002). Five-year disease-specific survival rate was significantly lower in understaged (38%) as compared with not-understaged patients (90%) after a median follow-up of 40-months (range 1-142) (p=0.006). Overall five-year disease-specific survival was 79%.

CONCLUSIONS

RC should be performed prior to progression in high risk superficial tumors that fail after TUR and BCG. In patients with clinical and pathological nonmuscle invasive disease, RC provides an excellent disease-free survival. One third of patients with HRSBT who underwent RC after BCG failure were understaged and had a shorter survival. Tumor in the prostatic urethra at endoscopic staging was the only factor associated to understaging and shorter survival.

Conservative Management of Mucosal Prostatic Urethral Involvement in Patients with Superficial Transitional Cell Carcinoma of the Bladder

OBJECTIVE

Treatment of patients with mucosal prostatic urethral transitional cell carcinoma (TCC) is controversial. In this study, we evaluated the outcome of patients with mucosal prostatic urethral TCC who were managed conservatively.

METHODS

The data of 290 consecutive male patients with superficial TCC of the bladder who were treated at our institution were reviewed. Median age was 63 years and median follow-up was 63 months. Initially, all patients with mucosal PU involvement without evidence of ductal and/or stromal involvement underwent intravesical BCG or Epirubicin therapy.

RESULTS

Nineteen patients (6.6%) had mucosal involvement of the prostatic urethra (PU) and concomitant multifocal TCC of the bladder. Of those, 12 patients (12/19, 4.2%) had macroscopic mucosal involvement of the PU, while the other 7 patients (7/19, 2.4%) had microscopic PU tumor. Seven of 12 patients who were treated with BCG and 2 of 7 patients who were treated with Epirubicin achieved complete response. Progression occurred in 3 patients who received BCG and no patients progressed in the Epirubicin group.

CONCLUSIONS

Prostatic urethral sampling should be considered necessary in intermediate and high risk patients with superficial TCC of the bladder. Intravesical therapy, especially with BCG seems to be an effective treatment alternative in the management of mucosal PU involvement.

BCG (Bacillus of Calmette Guerin) therapy of high-risk superficial bladder cancer

BCG (Bacillus of Calmette Guerin) has been used for more than 20 years and is currently the most active agent for superficial bladder cancer therapy. Intravesical BCG therapy is effective in prophylaxis after transurethral resection of papillary tumours and in the treatment of carcinoma in situ (cis). In most series BCG is more effective than intravesical chemotherapy, although it is more toxic. There is some evidence that BCG therapy improves survival and progression rates of patients with high-risk superficial bladder cancer decreasing the proportion who require radical cystectomy. A review of the current information on BCG therapy of high-risk superficial bladder cancer is reported.

Immunotherapy for bladder cancer

The primary role of immunotherapy for bladder cancer is to treat superficial transitional cell carcinomas (ie, carcinoma in situ, Ta, and T1). Immunotherapy in the form of bacille Calmette-Guérin (BCG), interferon, bropirimine, keyhole limpet hemocyanin, and gene therapy is intended to treat existing or residual tumor, to prevent recurrence of tumor, to prevent progression of disease, and to prolong survival of patients. Presently, BCG is commonly used and is the most effective immunotherapeutic agent against superficial transitional cell carcinoma. Data support that BCG has a positive impact on tumor recurrence, disease progression, and survival. Proper attention to maintenance schedules, route of administration, dosing, strains, and viability is essential to obtain the maximum benefits of BCG immunotherapy. This review highlights and summarizes the recent advances concerning immunotherapy, with special emphasis on BCG therapy for transitional cell carcinoma.

[Progression and prognosis of in situ carcinoma of the bladder treated with BCG]

OBJECTIVES

In situ carcinoma (isT) of the bladder is a poor prognostic tumour with a natural progressive evolution. Treatment with BCG achieves a significant improvement in survival. This paper analyses our experience in the management of isT patients with endovesical BCG.

MATERIAL AND METHODS

Between 1983 and 1997 the Urology Unit in the Móstoles Hospital saw 636 patients with transitional carcinoma of the bladder. Of these, 498 (78%) were surface tumours, and 138 (22%) were infiltrant. isT: 80 patients (13%), 14 of which were primary (17%), 37 associated to a surface tumour (46%), and 29 to infiltrant tumours (36%). All surface tumours: isT was present in 51 patients (10%) 44 of which were managed with 2 courses of BCG Connaught (81 mg), for 6 weeks each followed by vesical reassessment. Quarterly follow-up was conducted during a 2-year period. Patients not managed with BCG were treated with radical cystectomy. An analysis was made of patients without complete response to BCG, as well as actuarial analysis of disease-free survival (DFS), survival until progression (SUP) and specific survival (SS). All possible prognostic factors are analyzed: sex, focal isT (a single focus) or diffuse isT (more than one focus). Primary or secondary isT and association to G1, G2 or G3 tumours.

RESULTS

In all 44 patients managed with BCG: males 37 (84%), females 7 (16%), primary 14 (32%), focal 22 (50%), diffuse 22 (50%). Six patients died (5 because of the tumour). Mean follow-up of living patients: 3.7 years (0.5-7.5 years). After the 2 BCG courses, 36 (82%) showed complete response. Thirteen patients (30%) had no complete response during follow-up, and 11 (85%) continued to progression. In total 7 patients underwent cystectomy. Of 5 patients directly cystectomized due to persistence of isT or T1G3 tumour at monitoring after BCG, 2 (40%) had infiltrant tumour and one (20%) nodular metastasis. Three patients with persistent isT or T1G3 after BCG were not initially cystectomized: two that were treated with other endovesical therapies because of their age progressed, and the third one underwent a third BCG course and required cystectomy due to tumour persistency. 5-year DFS: 56%, being diffuse isT vs. focal isT (p = 0.0206) was an unfavourable prognostic factor. 5-year SUP: 63%, no significant prognostic factor. 5-year SS: 79%, being a female was an unfavourable prognostic factor (p = 0.0201).

CONCLUSIONS

Based on our results and the analysis of the literature we recommend treatment with 2 BCG courses of all isTs of the bladder that present some of the following factors: Diffuse cancer associated to T1G3, involvement of prostatic urethra or overexpression of p53 over 20%. In the rest of vesical tumours, one BCG course followed by a second one if lack of response to the first. After failure of both BCG courses, cystectomy must be performed in both groups.

Bacille Calmette-Guérin in superficial transitional cell carcinoma

The mechanisms by which BCG exerts its antitumour activity remain unclear. Attachment of BCG to the bladder via FN has been shown to be an important step in initiating its antitumorigenic activity. The mechanism(s) by which BCG operates requires LAK cells, BCG-activated killer cells, T lymphocytes (CD4) helper cells and CD8 suppressor/cytotoxic cells) and monocytes. The optimal route of administration is intravesical. The efficacy of a BCG vaccine depends on the viability, dose and strain. Differences in efficacy and side-effects have not been shown between different strains. Low-dose regimens successfully protect from recurrences, with fewer side-effects. The initial schedule of BCG is a course of six instillations in 6 weeks; when the patient fails this course, two possibilities arise. The first is maintenance therapy; response rates improve but there is more local and systemic toxicity. The second is a further 6-week course, and this seems most useful in those with a sustained response to the initial treatment. The clinical response to BCG therapy can be monitored using cytokine measurements or p53 determinations. Toxicity remains a major problem in BCG treatment and triple antituberculosis combination therapy should be given for 3 months in those with severe systemic side-effects. The use of prophylactic isoniazid is not recommend to decrease side-effects. The clinical results of BCG have been good, with success rates of 58-100%, with a minimal follow-up of one year in prophylaxis. BCG seems superior to intravesical therapy, but at the cost of inducing more adverse effects. BCG is not indicated for low- and intermediate-risk patients, in whom chemotherapy is the first choice. BCG can also be used to eliminate tumour after an incomplete TUR, or in patients who are unfit for surgery, with a 60-70% success rate. The primary and best treatment for CIS is intravesical BCG; encouraging results have been reported, with success rate of 42-83% after a minimal follow-up of one year. Although currently BCG seems to be the choice for high-risk superficial TCC, many questions remain unanswered, especially about the mechanism(s) of action, the optimal dose and clinical schedule.