Controversies in the management of T1 urothelial bladder cancer

T1 urothelial bladder cancers are in majority high-grade and seem to grow rapidly with the potential not only to recur, but also to progress to muscle invasion. Therefore, management discussions for patients with a high-grade T1 urothelial bladder cancer are critical. In this review, we aim to give an overview of the controversies encountered in the management of these tumors. Relevant information on T1 urothelial cell bladder cancer was identified through a literature search of published studies and review articles. Establishing an accurate diagnosis is of utmost importance in T1 bladder cancer; particularly understaging can adversely impact the survival of the patient. Therefore, a standard re-TUR is highly recommended in all T1 bladder cancer patients. On the other hand overtreatment affects the quality of life and can lead to unnecessary morbidity. The available treatment options range widely: they include transurethral resection alone with or without re-resection, adding intravesical therapy, radical cystectomy, and bladder sparing techniques using radiotherapy or combined chemoradiation. The choice and timing of the decision whether to pursue with conservative management (TUR and BCG) or to proceed with cystectomy (selected cases with adverse prognostic factors) should be continuously reconsidered on an individual patient basis. This is why the decision making is so difficult, and although we have come along a way in understanding the biological behavior of these tumors, both the choice and timing of treatment remain controversial. After ensuring that accurate staging has been done, the therapeutic options for T1 bladder tumors vary widely (from bladder sparing approaches to cystectomy) and a choice should be made based on individual patient basis.