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New Italian Guidelines On Bladder Cancer, Based On The World Health Organization 2004 Classification

August 11, 2020

UroToday - The Association of Italian Urologists (formerly the Association of the Non Academic Urologists) was founded in 1993, and is now comprised of more than 500 urologists throughout Italy. The scientific and educational activities of the association rely on the annual national meeting, on a spring meeting based on live surgery demonstrations, on several other courses and, ultimately on the preparation, printing and distribution of guidelines. The complete guidelines, edited by, can be found and downloaded from our official website. The activity started in 1996 with the creation of guidelines on urinary stones. In the ensuing years, it has since covered nearly the entire field of urology and is now revisiting and reediting the oldest guidelines.

With respect to bladder cancer, the first guideline was published in 2001 on non-muscle invasive, and in 2002 on muscle-invasive bladder cancer. The distinction among non-muscle and muscle-invasive cancer regarded the historical concept that the so called "superficial" bladder cancer was a homogenous entity. Indeed it has emerged in the last 10 years that some forms of non-muscle invasive cancers carry an ominous biological behavior. However, they have been managed almost identically to G1 or papillary urothelial low potential neoplasm.

The primary reason is the existence of an intermediate grade of tumor classification, the WHO 1973, which led instinctively to the visualization of a gradual passage from low- to high-risk neoplasm. As a result, it is called "bladder cancer," a neoplasm with no metastatic potential whereas a T1G3 lesion is indeed "superficial." In the first case the patient has to cope with a "cancer" with all psychological implications, forcing the physician to mount an excessive and aggressive treatment. In the latter, the physician was driven by the term "superficial" to a less invasive treatment.

In 1998, the International Society of Urologic Pathology (ISUP) became aware of the misperception created by the WHO 1973 classification, but only in 2004 did the WHO adopt the new classification proposed by ISUP. The urological community today remains receptive to the revolutionary concept of the existence of 2 different entities, low- and high-grade bladder tumors. Low-grade tumors carry a very low likelihood of progression to metastatic disease while high-grade tumors, also in the "superficial" forms, carry a significant risk of progression to metastatic disease and of specific mortality. Therefore the revision of the 2001/2002 guidelines based on the distinction among superficial and invasive cancers was impossible and the AURO committee produced a completely new guideline based on the WHO 2004 classification. The guideline follows an ideal clinical pathway from symptoms to the first endoscopic treatment. The histological report defines the subsequent therapy and follow-up.

The new classification produces important changes in the management of non-muscle invasive bladder tumors. For instance, as the most updated evidence in the literature demonstrates, early single intravesical instillation may only benefit low-grade, low-risk tumors, reducing their recurrence rate by 12%, it was easy to conclude that the cost/benefit ratio of routine early single instillation was minimally advantageous and not to be recommended. The rigorous methodology adopted in the preparation of the guidelines warrants the validity of the evidence-based recommendations provided - notwithstanding the difficulties encountered during the literature examination, largely based on the old classification.

Recommendations on clinical queries characterized by lack of evidence were given according to the judge of a consensus conference comprised of a great number of specialists (urologists , oncologists , radiotherapists, pathologists) who had taken care of all aspects of bladder cancer patient care. To the best of our knowledge, the AUROit 2009 guidelines on bladder cancer are the first to introduce a more rational management of bladder cancer.

Paolo Puppo, MD (on behalf of the AURO committee on bladder cancer guidelines) as part of Beyond the Abstract on UroToday. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations, etc., of their research by referencing the published abstract.

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