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Unlabelled: Narrow-band imaging (NBI) cystoscopy detects more bladder tumors than standard white-light imaging (WLI) cystoscopy, but it is unclear whether NBI improves transurethral resection (TUR) of bladder tumors. This study compares 2-yr recurrence-free survival (RFS) of patients with non-muscle-invasive bladder tumors following restaging TUR using NBI or WLI cystoscopy. Patients were randomized 1:1 to undergo NBI-assisted TUR (NBI-TUR) or WLI-assisted TUR (WLI-TUR). The main outcome was number of patients free of tumor recurrence after 2-yr follow-up and 2-yr RFS times. Of 254 patients, 127 underwent NBI-TUR and 127 had WLI-TUR. Within 2 yr, 22% of the patients in the NBI-TUR group recurred compared with 33% after WLI-TUR (p=0.05). The mean RFS time was 22 mo (95% confidence interval [CI], 20-23) for the NBI-TUR group versus 19 mo (95% CI, 18-21) for the WLI-TUR group (p=0.02). Limitations are that this was a single-surgeon study and that a 20% difference in the number of patients free of recurrence was not achieved, suggesting the study was underpowered. In addition, observer bias may have contributed to results because NBI-TUR was performed after both WLI and NBI cystoscopy was used to inspect the bladder. Although the results suggest reduced recurrence rates and improved RFS times after restaging NBI-TUR compared with WLI-TUR, a larger study is needed., Patient Summary: Narrow-band imaging enhances visibility of bladder tumors over conventional white-light cystoscopy. This report compares transurethral resection of bladder tumors using narrow-band cystoscopy with white-light cystoscopy. The results show that narrow-band cystoscopy improves surgical removal of bladder tumors, which reduces the frequency of early and later tumor recurrences., (Copyright © 2014. Published by Elsevier B.V.)

Purpose: The frequency of febrile urinary tract infection was determined after outpatient flexible cystoscopy in antibiotic naïve patients with bladder tumor., Materials and Methods: A total of 3,108 outpatient cystoscopies were performed in 1,110 patients with bladder tumor. Immediately before cystoscopy patients submitted a voided urine sample for culture. Significant bacteriuria was defined as greater than 10(4) cfu/ml of a single organism. Patients received no antibiotics immediately before or after cystoscopy. They were followed for 30 days for onset of febrile urinary tract infection., Results: Of the 3,108 patient cystoscopies 673 (22%) had asymptomatic bacteriuria and 2,435 (78%) had sterile urine. A febrile urinary tract infection developed within 30 days of cystoscopy in 59 patients (1.9%), including in 3.7% of infected and 1.4% of uninfected patients (p = 0.01). All cases resolved within 12 to 24 hours with oral antibiotics. No patient was hospitalized for bacterial sepsis., Conclusions: Antibacterial therapy before outpatient flexible cystoscopy does not appear necessary in patients who have no clinical signs or symptoms of acute urinary tract infection, including bacteriuria., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the cost-effectiveness of endoscopic treatment of low-risk non-muscle-invasive bladder cancer (NMIBC) via office-based fulguration vs operating room-based transurethral resection of the bladder (TURB)., Methods: A Markov state-transition model was created to simulate and compare the economic burden of managing patients with office-based fulguration vs TURB. Direct procedural and hospitalization costs were queried from our institution. Patients were modeled as being followed up routinely with flexible cystoscopy, whereas tumor recurrences were treated with either fulguration or TURB., Results: A strategy of office-based fulguration was more cost-effective than TURB ($1171 per quality-adjusted life year [QALY] vs. $1208 per QALY) to treat recurrent NMIBC over a 5-year period. Fulguration was both more effective (14.94 vs. 14.91 QALYs) as well as less expensive ($17,494 vs. $18,005), thus dominating TURB. The incremental cost-effectiveness ratio was -$18,440 per QALY. Sensitivity analysis demonstrates that the relative costs of the procedures are more significant in determining cost-effectiveness than their respective utilities., Conclusion: Office-based cystoscopy and fulguration was more cost-effective than TURB for treating recurrent low-risk NMIBC. Adherence to an office-based treatment plan can lead to significant cost savings with a decreased therapeutic burden over the lifetime of a patient with NMIBC., (Copyright © 2015. Published by Elsevier Inc.)

Objective: To assess the ability of reflex UroVysion fluorescence in situ hybridization (FISH) testing to predict recurrence and progression in patients with non-muscle-invasive bladder cancer (NMIBC) with suspicious cytology but negative cystoscopy., Patients and Methods: Patients under NMIBC surveillance were followed with office cystoscopy and urinary cytology every 3-6 months. Between March 2007 and February 2012, 500 consecutive patients with suspicious cytology underwent reflex FISH analysis. Clinical and pathological data were reviewed retrospectively. Predictors for recurrence, progression and findings on subsequent cystoscopy (within 2-6 months after FISH) were evaluated using univariate and multivariate Cox regression., Results: In all, 243 patients with suspicious cytology also had negative surveillance cystoscopy. Positive FISH was a significant predictor of recurrence (hazard ratio [HR] = 2.35, 95% confidence interval [CI]: 1.42-3.90, P = 0.001) in multivariate analysis and for progression (HR = 3.01, 95% CI: 1.10-8.21, P = 0.03) in univariate analysis, compared with negative FISH. However, positive FISH was not significantly associated with evidence of tumour on subsequent surveillance cystoscopy compared with negative FISH (odds ratio = 0.8, 95% CI: 0.26-2.74, P = 1)., Conclusions: Positive FISH predicts recurrence and progression in patients under NMIBC surveillance with suspicious cytology but negative cystoscopy. However, there was no association between the FISH result and tumour recurrence in the immediate follow-up period. Reflex FISH testing for suspicious cytology might have limited ability to modify surveillance strategies in NMIBC., (© 2013 The Authors. BJU International © 2013 BJU International.)

Narrow-band imaging (NBI) is a novel optical method designed to enhance visual detection of bladder tumors over conventional white-light imaging (WLI) cystoscopy. Current experience with NBI cystoscopy in evaluating and treating non-muscle-invasive bladder tumors is reviewed. A comprehensive literature search was conducted including all published studies and abstracts investigating NBI cystoscopy in patients with bladder cancer. Comprehensive cystoscopic images are provided to illustrate differences between NBI and WLI cystoscopy. Early experience suggests that NBI cystoscopy detects more bladder tumors than does WLI cystoscopy, and NBI-assisted fulguration and transurethral resection (TUR) appear to result in fewer tumor recurrences. Questions remain, however, such as the following: Does NBI cystoscopy detect high-grade tumors, such as carcinoma in situ, that are missed by WLI cystoscopy? Would false positives lead to an unaccepted number of negative biopsies? And how might observer bias skew results? In addition, a major drawback of current studies is that the quality of cystoscopy and TUR by individual surgeons has not been addressed. Although clinical trials are just beginning, NBI cystoscopy holds promise that this new optical method may improve visualization of bladder tumors over conventional WLI cystoscopy. Further prospective and comparative trials are required to determine whether NBI will play a role in evaluating and treating urothelial tumors in individual patients.

Background: Antimicrobial resistance is a major health problem, caused primarily by overuse of antibiotics in clinical situations in which they are not necessary. Practice guidelines recommend that antibiotics be given before outpatient cystoscopy to prevent symptomatic urinary tract infection (UTI)., Objective: To determine the frequency of febrile UTI after outpatient flexible cystoscopy in antibiotic-naive bladder tumor patients., Design, Setting, and Participants: A total of 2010 consecutive outpatients with bladder tumors were entered into a prospective registry study. All patients underwent cystoscopy after they submitted a voided urine sample for culture. Significant bacteriuria was defined as >10(4) colony-forming units per milliliter with a single organism. Patients were stratified for known risk factors for UTI., Intervention: Patients underwent flexible cystoscopy and received no antibiotics immediately before or after cystoscopy. They were followed for 30 d for onset of febrile UTI., Outcome Measurements and Statistical Analysis: The end point was incidence of febrile UTI within 30 d of cystoscopy. Febrile UTI was defined as temperature >38°C and dysuria, or having received antibiotics from an outside physician for urinary symptoms., Results and Limitations: Of the 2010 patient cystoscopies, 489 (24%) had asymptomatic bacteriuria, and 1521 (76%) had sterile urine. Thirty-nine patients (1.9%) developed febrile UTI ≤30 d after cystoscopy-4.5% in colonized patients and 1.1% in uninfected patients (p=0.02). All UTIs resolved in ≤12-24h with oral antibiotics. None of the patients was admitted for bacterial sepsis. Limitations of the study are that it is a single-surgeon experience in one institution, and results may not apply to other patient populations., Conclusions: Antibacterial therapy before outpatient flexible cystoscopy does not appear necessary in bladder tumor patients who have no clinical signs or symptoms of acute UTI, including asymptomatic bacteriuria. Antibiotic stewardship is the responsibility of all urologists., (Copyright © 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To evaluate frequency of recurrences among patients with papillary bladder tumours followed sequentially with conventional white-light (WLI) cystoscopy and narrow-band imaging (NBI) cystoscopy., Patients and Methods: A cohort of 126 patients with recurrent low-grade papillary bladder tumours were followed every 6 months for 3 years by conventional WLI cystoscopy, and then over the next 3 consecutive years by NBI cystoscopy. Recurrent tumours detected were treated by outpatient fulguration or transurethral resection. We compared the tumour recurrence rate during follow-up with WLI and NBI cystoscopy, using patients as their own controls., Results: Of the 126 patients, 94% had tumour recurrences during WLI cystoscopy vs 62% during NBI cystoscopy. The mean number of recurrent tumours was 5.2 with WLI cystoscopy vs 2.8 with NBI cystoscopy, and the median recurrence-free survival time was 13 vs 29 months (P= 0.001)., Conclusion: Compared with follow-up with WLI cystoscopy, NBI cystoscopy was associated with fewer patients having tumour recurrences, fewer numbers of recurrent tumours, and a longer recurrence-free survival time., (© 2010 THE AUTHORS. JOURNAL COMPILATION © 2010 BJU INTERNATIONAL.)

Objective: To test the frequency of malignancy in normal-appearing urothelium in patients with high-risk bladder cancer, as biopsy of normal-appearing mucosa using standard white-light cystoscopy (WLC) reportedly shows carcinoma in situ (CIS) in some patients with bladder tumours., Patients and Methods: Cold-cup biopsies of normal-appearing mucosa were obtained by two experienced oncological urologists from 63 patients during transurethral resection of bladder cancers. Each biopsy labelled as 'normal' was interpreted by two expert uropathologists., Results: Each of the biopsies in all 63 patients was interpreted by both urological pathologists as showing normal or benign histology, except that one showed focal CIS., Conclusions: Bladder urothelium appearing normal to expert urological oncologists using standard WLC rarely shows CIS when biopsies are evaluated by experienced uropathologists., (© 2010 THE AUTHORS. JOURNAL COMPILATION © 2010 BJU INTERNATIONAL.)

Study Type: Diagnostic (exploratory cohort)., Level of Evidence: 2b., Objective: To evaluate whether narrow-band imaging cystoscopy (NBIC) can identify bladder tumour suspected on follow-up white-light cystoscopy (WLC) after intravesical bacille Calmette-Guérin (BCG) therapy, as BCG causes an intense reaction in the bladder, appearing as red lesions on WLC, which might be residual tumour or BCG-induced inflammation., Patients and Methods: Sixty-one patients with high-risk non-muscle-invasive bladder tumours were evaluated 3 months after starting induction BCG therapy. All patients had abnormal erythematous lesions on WLC, suspected to be residual carcinoma in situ. After WLC, they were evaluated by NBIC, urine cytology and biopsy, followed by transurethral resection of all visible lesions., Results: Of the 61 patients, 22 (36%) had residual tumour. NBIC correctly identified tumour in 21 patients, but another 10 had unnecessary biopsy (NBIC positive, negative biopsy). Only one of 30 patients who had negative NBIC findings had tumour. NBIC outperformed urine cytology in detecting residual tumour after BCG therapy., Conclusion: NBIC appears to better identify patients who have suspected residual tumour on follow-up WLC at 3 months after BCG therapy.

Objective: To determine whether narrow-band imaging (NBI) cystoscopy enhances the detection of non-muscle-invasive bladder tumours over standard white-light imaging (WLI) cystoscopy, as surveillance WLI is the standard method used to diagnose patients with recurrent bladder tumours, but they can be missed by WLI cystoscopy, possibly accounting for early recurrences., Patients and Methods: We evaluated 427 patients for recurrent bladder tumours by WLI cystoscopy, followed by NBI cystoscopy as a further procedure, using the same video-cystoscope. Recurrent tumours visualized by WLI or NBI cystoscopy were mapped, imaged, biopsied and subsequently treated by transurethral resection (TUR) or fulguration. Biopsies or TUR specimens obtained by WLI and NBI were examined separately for presence of tumour., Results: In all, 103 patients (24%) had tumour recurrences; 90 (87%) were detected by both WLI and NBI and another 13 (100%) only by NBI cystoscopy. NBI detected extra papillary tumours or more extensive carcinoma in situ in 58 (56%) patients found to have recurrences. The mean number of recurrent tumours visualized on WLI cystoscopy was 2.3, vs to 3.4 seen on NBI cystoscopy (P = 0.01)., Conclusion: NBI cystoscopy improved the detection of recurrent non-muscle-invasive bladder tumours over standard WLI cystoscopy.

Purpose: We evaluated the management and treatment outcomes of low grade papillary bladder tumors., Materials and Methods: We evaluated 215 patients diagnosed with low grade and noninvasive papillary bladder tumors, and followed them every 6 months with flexible cystoscopy for 6 to 10 or more years. Tumor recurrence was treated with transurethral resection or outpatient cystoscopic fulguration., Results: Of the 215 patients 143 (67%) had at least 1 recurrence (positive cystoscopy). With a median followup of 8 years tumor recurrences averaged 6.2 (range 1 to 19) requiring 0.34 transurethral resections per year or 1 transurethral resection every 3 years, or 0.61 fulgurations or 1 fulguration approximately every 2 years. There were 17 patients (8%) who had progression in grade or stage and 1 patient (0.5%) died of bladder cancer. Patients most likely to have recurrence had multiple tumors, low grade (TaLG) carcinoma or tumor at first followup cystoscopy., Conclusions: Surveillance cystoscopy at 6-month intervals coupled with outpatient fulguration controls recurrent tumors and reduces the therapeutic burden for patients diagnosed with low grade papillary bladder tumors.

Purpose: Interest has emerged in urinary biomarkers to replace or alternate with followup cystoscopies for routine bladder cancer surveillance. We assessed whether patients would accept a urine biomarker assay over flexible cystoscopy for monitoring bladder cancer., Materials and Methods: We enrolled 200 consecutive patients previously diagnosed with superficial bladder tumors who were undergoing outpatient flexible cystoscopy as followup. Immediately after cystoscopy each patient completed a pain intensity numerical rating and was interviewed. The standard gamble method was applied to determine the minimal accepted diagnostic accuracy at which a urine test would be favored over cystoscopy for bladder surveillance. Clinical and demographic data with potential to affect patient preferences were analyzed., Results: Of the 200 patients 75% would accept the results of a urine test as a replacement for cystoscopy only if it was capable of detecting more than 95% of recurrent bladder tumors and an additional 21% would accept it if the urine test was at least 90% to 95% accurate. Anxiety associated with the possibility of missing cancer was the major determinant of the minimal accepted accuracy. While male gender and higher pain intensity at cystoscopy were associated with willingness to accept a small level of uncertainty on univariate and multivariate analyses, the risk of progression to muscle invasion and the convenience of followup did not appear to affect patient preferences., Conclusions: From the patient perspective a urinary biomarker would likely require 95% or greater diagnostic accuracy to supplant cystoscopies for routine bladder surveillance. Inadequate sensitivity may be the major impediment to general acceptance of urinary biomarkers in this setting.

Objective: To correlate urine cytology findings before and after flexible cystoscopy., Patients and Methods: A total of 153 patients undergoing surveillance for bladder tumour provided voided urine for cytology before and immediately after flexible cystoscopy., Results: Of the 153 patients, 116 had negative urine cytology before and after (96%) a visibly normal cystoscopy and 37 had positive urine cytology before and after cystoscopy that showed recurrent tumour., Conclusions: Urine cytology immediately after flexible cystoscopy correlates well with results of urine cytology before cystoscopy.

Purpose: We correlated individual urologist impressions of tumor stage and grade of recurrent papillary bladder tumors at cystoscopy with histological findings after transurethral resection to determine whether cystoscopy can reliably identify low grade, noninvasive papillary tumor for outpatient fulguration., Materials and Methods: A total of 144 recurrent papillary bladder tumors identified on outpatient flexible cystoscopy were classified as low grade and noninvasive (stage Ta grade 1), high grade and noninvasive (stage Ta grade 3) or invasive (stage T1). Voided urine cytology was also performed. The cystoscopic impression of each tumor was correlated with the final histological findings of tumor stage and grade after transurethral resection., Results: Cystoscopy classified 97 tumors as stage Ta grade 1 and 47 as stage Ta grade 3 or stage T1. Cystoscopy correctly predicted the tumor stage and grade of 93% of stage Ta grade 1 and 99% of stage Ta grade 1 lesions associated with negative urine cytology., Conclusions: Urologists can usually identify noninvasive, low grade recurrent papillary tumors on followup cystoscopy that may be treated safely with outpatient fulguration.

Purpose: Our goal was to determine the association between biochemically verified post-diagnosis smoking exposure and nonmuscle-invasive bladder cancer (NMIBC) recurrence risk. Materials and Methods: We conducted a prospective study of 354 NMIBC patients with a smoking history undergoing care between 2015 and 2018. Patients contributed at least 2 biospecimens during followup which were tested for cotinine to determine biochemically verified post-diagnosis smoking exposure (yes/no). Our primary endpoint was time to first recurrence after study start date. We examined whether post-diagnosis smoking exposure was associated with recurrence risk in multivariable Cox proportional hazards models that accounted for demographics, clinicopathological variables, time since diagnosis and pack-years. Results: Patients were predominantly White, male and had a median age of 68 years. Most patients had Ta disease (62%) and tumors of high grade (68%). Intravesical bacillus Calmette-Guerin was given to 63% of the cohort. Patients were followed for a median of 3.6 years since study start. Post-diagnosis smoking exposure was detected in 22% of patients, and 38.7% (137) of patients experienced a recurrence during followup. In multivariable models, only bacillus Calmette-Guerin treatment and prior recurrence rate were significantly associated with recurrence. There was no association between post-diagnosis smoking exposure and recurrence risk (HR: 0.73, 95% CI: 0.45e1.20). Conclusions: In a cohort of patients with predominantly high risk NMIBC, postdiagnosis smoking exposure was not associated with NMIBC recurrence. However, smoking cessation support remains a critical component of cancer care given that the benefits of quitting extend far beyond NMIBC recurrence. [ABSTRACT FROM AUTHOR]

Purpose Malignant voided cytology with normal endoscopic evaluation represents a diagnostic and therapeutic challenge in many patients with a history of nonmuscle invasive bladder cancer. Bladder biopsy is often advised but its efficacy is unclear. We evaluated the usefulness of bladder biopsy in patients with unexplained positive cytology and describe recurrence patterns in this unique patient subset. Materials and Methods From an institutional database we retrospectively identified patients with a history of nonmuscle invasive bladder cancer and surveillance cystoscopy from 2008 to 2012 who had malignant voided urine cytology but normal cystoscopy. Patients underwent systematic bladder biopsy or cystoscopic surveillance and were followed for recurrence and progression. Results Of 444 patients 343 were followed with surveillance only and 101 underwent a total of 118 biopsies of normal-appearing bladder mucosa. Three biopsies (2.5%) showed carcinoma in situ and none revealed invasive carcinoma. During the median 32-month followup recurrence developed in the bladder in 194 patients (44%), in the upper tract in 24 (5%) and in the prostatic urethra in 5 (1%) while 219 (49%) had no recurrence. A previous diagnosis of upper tract urothelial carcinoma and a history of bacillus Calmette-Guérin treatment were associated with an increased recurrence risk on multivariate analysis. Recurrence rates and patterns were similar in the biopsy and surveillance groups. Conclusions Patients with malignant cytology despite normal cystoscopy have a high recurrence rate. Biopsy of normal-appearing bladder mucosa in this setting is rarely positive and does not alter the recurrence pattern. [ABSTRACT FROM AUTHOR]

Urologists often insist on sterile urine before invasive outpatient urological procedures, and urine culture and antibiotics are usually given before cystoscopy or instillation of bacille Calmette–Guérin (BCG) therapy, especially in patients who have positive urine cultures. Our experience suggests that cystoscopy and induction BCG therapy can be performed safely, even in patients with asymptomatic bacteriuria, without pretreatment or prophylactic antibiotics. The rate of subsequent febrile urinary tract infection is <4% in both infected and uninfected patients. Pretreatment antibacterial therapy does not appear to be necessary before these two outpatient urological procedures in patients with bladder cancer. Such strategy facilitates timely interventions and reduces the possibility of antibiotic resistance. [ABSTRACT FROM AUTHOR]

Purpose: Maximilian Carl-Friedrich Nitze (1848 to 1906) designed the modern cystoscope, providing a foundation for urology. Materials and Methods: The historical literature, including the original writings of Nitze, was reviewed. Results: The invention of the cystoscope by Nitze revolutionized endoscopy but his true genius lay in his lifelong pursuit of better methods to diagnose and treat patients with urological diseases and in teaching others the practical use and value of cystoscopy. He also designed the first operating cystoscope, took the first endoscopic photographs and published the first textbook in urology. Conclusions: The legacy of discovery of Max Nitze established the specialty of urology and a legitimate claim as the father of urology. [Copyright &y& Elsevier]

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Urine culture and antibiotics are usually given before outpatient urological procedures, namely cystoscopy or intravesical BCG therapy. Injudicious use of antibiotics promotes multidrug bacterial resistance. Pretreatment antibacterial therapy may not be necessary before outpatient urological procedures in patients with bladder cancer. Such strategy facilitates timely intervention and avoids antibiotic resistance. OBJECTIVES To investigate the frequency of infectious complications after intravesical BCG therapy or cystoscopy in antibiotic-naive patients with bladder tumours who have asymptomatic bacteriuria., The aim was to avoid antibiotics in infected patients undergoing these common outpatient urological procedures., METHODS A total of 354 patients received induction BCG therapy and another 663 patients underwent cystoscopy after submitting a voided urine sample for culture. They received no antibiotics before or after the procedure., Significant bacteriuria was defined as >104 or >105 colony-forming units per millilitre with a single organism., The patients were followed for 3 months for onset of febrile UTI, defined as dysuria and fever >38 °C requiring antibiotics., RESULTS Ninety BCG-treated patients (25%) and 114 cystoscopy patients (17%) had bacteriuria., After BCG therapy, two patients with infected urine (2.2%) and three with sterile cultures (1.1%) had febrile UTIs ( P= 0.17)., After cystoscopy, four infected patients (3.5%) and five uninfected patients (1%) had febrile UTIs ( P= 0.08)., All UTIs resolved within 24 h with oral antibiotics, and none of the patients was admitted for bacterial sepsis., CONCLUSIONS Antibacterial prophylaxis before intravesical BCG therapy or outpatient cystoscopy does not appear to be necessary in patients with asymptomatic bacteriuria., Such strategy avoids overuse of antibiotics, reducing drug-resistant bacterial infections. [ABSTRACT FROM AUTHOR]

Purpose Patients with recurrent or persistent high-grade non–muscle-invasive bladder cancer after bacille Calmette-Guérin (BCG) therapy are termed “BCG failures.” We hypothesize that BCG-refractory patients who fail to respond to BCG have worse outcomes after bladder-sparing treatments compared with BCG-relapsing patients whose tumors recur after at least a 6-month disease-free interval. Materials and methods We screened 32 patients who had failed BCG therapy for eligibility in a multicenter investigational trial. BCG-refractory patients received instillations of a mycobacterial cell wall–DNA complex extract. BCG-relapsing patients were treated with additional BCG or other intravesical agents. Both groups of patients were followed prospectively with transurethral biopsy after 6 months, and cystoscopy every 3 to 6 months for more than 2 years. Median follow-up time for all patients was 53 months (range: 24–72 mo). Results Seventeen patients were classified as BCG refractory and 15 patients defined BCG relapsing. Recurrence-free median survival time was 10 months for BCG-refractory patients receiving mycobacterial cell wall–DNA complex vs. 23 months for BCG-relapsing patients who received another induction course of BCG therapy ( P = 0.002). Progression-free survival time was 18 months for BCG-refractory vs. 52 months for BCG-relapsing patients ( P = 0.001). Of the 17 BCG-refractory patients, 8 (47%) have died vs. 3 (20%) of the 15 BCG-relapsing patients. Conclusions BCG-refractory and BCG-relapsing categories differentiate BCG-failed patients into high-and lower-risk prognostic groups that may be useful in guiding treatment strategies. [ABSTRACT FROM AUTHOR]