EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder, the 2011 update | Actas Urológicas Españolas (English Edition)

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Actualización de 2011" ] ] "textoCompleto" => "IntroductionThe first European Association of Urology (EAU) guidelines on bladder cancer were published in 2002.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Since then the guidelines have been continuously updated, and the most recent version is available from the EAU Web site, <a href="http://www.uroweb.org/">www.uroweb.org</a>. An overview of the updated 2011 EAU guidelines on non-muscle-invasive bladder cancer (NMIBC) (Ta, T1, and carcinoma in situ [CIS]) is provided here.Evidence acquisitionThe panel members performed a systematic literature search for each section of the guidelines. Medline, Web of Science, and Embase databases were searched for original and review articles published between 2004 and 2010. Panel members selected records with the highest level of evidence according to a modified classification system from the Oxford Centre for Evidence-Based Medicine levels of evidence (LEs).<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Recommendations were graded to provide transparency regarding the underlying LE for each recommendation given.EpidemiologyBladder cancer is the most common malignancy of the urinary tract. The worldwide age standardised rate (ASR) is 10.1 per 100000 for men and 2.5 per 100000 for women. In Europe, the highest incidence of bladder cancer (ASR) has been reported in the western region (23.6 in men and 5.4 in women) and in the southern region (27.1 in men and 4.1 in women), followed by northern Europe (16.9 in men and 4.9 in women). The lowest incidence has been observed in eastern European regions (14.7 in men and 2.2 in women).<a class="elsevierStyleCrossRef" href="#bib0015">3</a>The global world mortality rate is 4 per 100000 among men and 1.1 per 100000 among women. In Europe, bladder cancer mortality rates have declined over the last decade to about 16% in men and 12% in women.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Approximately 75–85% of patients with bladder cancer present with disease that is confined to the mucosa (Ta or CIS) or submucosa (T1).Risk factorsUrologists should be aware of the various types of occupational exposures that may be related to urothelial carcinogens.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> Aromatic amines were recognised first. At-risk groups include workers in the following industries: printing, iron and aluminium processing, industrial painting, and gas- and tar manufacturing (LE: 3). Another prominent risk factor is cigarette smoking, which triples the risk of developing bladder cancer and leads to higher mortality rates<a class="elsevierStyleCrossRef" href="#bib0030">6</a> (LE: 3).ClassificationThe Tumour, Node, Metastasis (TNM) classification approved by the Union Internationale Contre le Cancer, which was updated in 2009, is used in these guidelines (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0035">7</a> The new classification for grading NMIBCs proposed by the World Health Organisation (WHO) and the International Society of Urological Pathology was published by the WHO in 2004 (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<a class="elsevierStyleCrossRef" href="#bib0040">8</a> New categories were defined among flat and papillary lesions. Among papillary lesions, they are papillary urothelial neoplasms of low malignant potential (PUNLMPs) and low-grade and high-grade urothelial carcinomas. PUNLMPs are lesions that do not have the cytologic features of malignancy but show normal urothelial cells in a papillary configuration. They have a negligible risk for progression but have a tendency to recur. The intermediate grade (grade 2), which was the subject of controversy in the 1973 WHO classification, was removed.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The prognostic value of both grading systems (WHO 1973 and 2004) has been confirmed. However, attempts to demonstrate better prognostic value of one system over another have yielded controversial results.<a class="elsevierStyleCrossRefs" href="#bib0045">9–11</a> Most clinical trials published to date on TaT1 bladder tumours used the 1973 WHO classification, and therefore these guidelines are based on this scheme. Both classifications can be used until more prospective trials validate the prognostic role of the WHO 2004.Despite well-defined criteria, there is interobserver variability in classifying dysplasia versus CIS, stage T1 versus Ta tumours, and grading of the tumours.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> Consequently, a review of slides is recommended, particularly for T1, CIS, and high-grade lesions.Specific characteristics of carcinoma in situ and its clinical classificationCIS is a flat, high-grade, noninvasive urothelial carcinoma. It can occur in the bladder, in the upper urinary tract, and in the prostatic ducts and urethra. Bladder CIS is classified into one of three different clinical types<a class="elsevierStyleCrossRef" href="#bib0065">13</a>: (1) primary, isolated CIS with no previous or concurrent exophytic tumours; (2) secondary, CIS detected during the follow-up of patients with a previous tumour; and (3) concurrent, CIS in the presence of exophytic tumours.DiagnosisHaematuria is the most common finding in NMIBC. Lower urinary tract symptoms may appear in patients with CIS.ImagingIntravenous urography (IVU) is used to detect filling defects and dilation in the upper urinary tract that can indicate the presence of urothelial tumour. Large exophytic tumours may be seen as filling defects in the bladder. The need to perform routine IVU is now questioned because of the low incidence of significant findings<a class="elsevierStyleCrossRefs" href="#bib0070">14,15</a> (LE: 3). The incidence of simultaneous upper urinary tract tumours is low (1.8%) but increases to 7.5% in tumours located in the trigone.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> The risk of tumour recurrence in the upper urinary tract during follow-up is increased in multiple and high-risk tumours.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>Computed tomography (CT) urography is used as an alternative to conventional IVU. In muscle-invasive tumours of the bladder and in upper urinary tract tumours, CT urography provides more information than IVU (LE: 4).Transabdominal ultrasound (US) allows the characterisation of renal masses, the detection of hydronephrosis, and the visualisation of intraluminal masses in the bladder. It can be a useful investigative tool in patients with haematuria to detect obstruction; however, it cannot exclude the presence of upper urinary tract tumours (LE: 3).Imaging (IVU, CT urography, or US) has no role in the diagnosis of CIS.Urinary cytologyExamining voided urine or bladder washing specimens for exfoliated cancer cells has high sensitivity in high-grade tumours but low sensitivity in low-grade tumours (LE: 2b).<a class="elsevierStyleCrossRef" href="#bib0080">16</a> Therefore, it is useful when a high-grade tumour or CIS is present; however, a negative result cannot exclude the presence of a low-grade cancer.Positive urinary cytology may indicate a urothelial tumour anywhere in the urinary tract. Cytologic interpretation is user-dependent.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> Cytology evaluation can be hampered by low cellular yield, urinary tract infections, stones, or intravesical instillations. With experienced cytologists, the specificity exceeds 90%<a class="elsevierStyleCrossRef" href="#bib0080">16</a> (LE: 2b). Cytology should be performed on fresh urine with adequate fixation. Morning urine is not suitable because cytolysis may be present.Urine molecular testsNumerous urinary tests for the diagnosis of bladder cancer based on the detection of soluble or cell-associated markers have been developed.<a class="elsevierStyleCrossRefs" href="#bib0080">16,18</a> Three tests are particularly promising, namely, NMP22, UroVysion, and ImmunoCyt.<a class="elsevierStyleCrossRefs" href="#bib0095">19–21</a> Although most of the tests have better sensitivity than urinary cytology, their specificity is lower (LE: 2b). None of them have been accepted as a standard diagnostic procedure in routine urology to date.The following objectives of application of urinary cytology or molecular tests must be considered.Screening of the population at risk of non-muscle-invasive bladder cancerUse of the haematuria dipstick, NMP22, or UroVysion for bladder cancer screening in high-risk populations has been reported.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> However, concerns about feasibility and cost effectiveness mean that the routine application of screening has not yet been established.Exploration of patients after haematuria or other symptoms suggestive of bladder cancerNone of the urinary tests can replace cystoscopy. However, urinary cytology or markers can be used as an adjunct to cystoscopy to detect invisible tumours, particularly CIS. In this setting, the method should have high sensitivity and specificity for high-grade tumours. Urinary cytology is highly specific and sensitive in this regard, and urinary markers are even more sensitive but less specific.<a class="elsevierStyleCrossRefs" href="#bib0080">16,18</a>Facilitate surveillance of non-muscle-invasive bladder cancer to reduce the number of cystoscopiesTo reduce the number of cystoscopies,<a class="elsevierStyleCrossRefs" href="#bib0080">16,23</a> tests should be able to detect recurrence before the tumours are large and numerous. The limitation of urinary cytology is its low sensitivity for low-grade recurrences. Several urinary markers have higher sensitivity, which is still not sufficient. Urinary cytology or markers cannot safely replace cystoscopy in this setting.CystoscopyThe diagnosis of bladder cancer depends on a cystoscopic examination and histologic evaluation of the resected tissue. The diagnosis of CIS is made using the combination of cystoscopy, urine cytology, and histologic evaluation of multiple bladder biopsies.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>Cystoscopy is initially performed in the office, using flexible instruments. If a bladder tumour has been visualised in earlier imaging studies, a diagnostic cystoscopy can be omitted.A careful description of the cystoscopy finding is necessary. It should include the site, size, number, and appearance (papillary or solid) of the tumours as well as a description of mucosal abnormalities.Transurethral resectionThe goal of transurethral resection (TUR) in TaT1 bladder tumours is to make the correct diagnosis and remove all visible lesions. Small tumours (<1cm) can be resected en bloc. The specimen should contain a part of the underlying bladder wall. Some experts believe that a deep resection is not necessary in small apparently low-grade lesions with a previous history of TaG1 tumour.Larger tumours should be resected separately in fractions, which include the exophytic part of the tumour, the underlying bladder wall with the detrusor muscle, and the edges of the resection area. The specimens from different fractions must be referred to the pathologist in separate containers. Cauterisation must be avoided as much as possible during the resection procedure to prevent tissue destruction.The pathologic report should specify the grade of the lesion, the depth of tumour invasion into the bladder wall, and whether the lamina propria and muscle are present in the specimen.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> A complete and correct TUR is essential for the prognosis of the patient.<a class="elsevierStyleCrossRef" href="#bib0125">25</a>Bladder and prostatic urethra biopsiesCIS can present as a velvet-like reddish area that is indistinguishable from inflammation, or it may not be visible at all. When abnormal areas of the urothelium are seen, it is advised to take “cold cup” biopsies or biopsies with a resection loop. Biopsies from normal-looking mucosa, so-called random biopsies (R-biopsies), should be performed in patients with positive urinary cytology in the absence of visible tumour in the bladder. In patients with TaT1 tumours, R-biopsies are not routinely recommended. The likelihood of detecting CIS in low-risk tumours is extremely low (<2%)<a class="elsevierStyleCrossRef" href="#bib0130">26</a> (LE: 2a). R-biopsies should be performed in TaT1 tumours when cytology is positive or when the exophytic tumour appears nonpapillary. It is recommended to take R-biopsies from the trigone, bladder dome, and from the right, left, anterior, and posterior bladder walls. Material obtained by random or directed biopsies must be sent for pathologic assessment in separate containers.The involvement of the prostatic urethra and ducts in male patients with NMIBC has been reported. The risk seems to be higher if the tumour is located on the trigone or bladder neck, in the presence of bladder CIS, and in multiple tumours<a class="elsevierStyleCrossRef" href="#bib0135">27</a> (LE: 3). In these cases and when cytology is positive with no evidence of tumour in the bladder or when abnormalities of prostatic urethra are visible, biopsies of the prostatic urethra are recommended. The biopsy is taken from abnormal areas and from the precollicular area between the 5 o’clock and 7 o’clock positions using a resection loop.Photodynamic diagnosis (fluorescence cystoscopy)Photodynamic diagnosis (PDD) is performed using violet light after intravesical instillation of 5-aminolaevulinic acid (5-ALA) or hexaminolevulinic acid (HAL). Fluorescence-guided biopsy and resection are more sensitive than conventional procedures for the detection of malignant tumours, particularly CIS. The additional detection rate of PDD was 20% for all tumours and 23% for CIS in a cumulative analysis of prospective trials<a class="elsevierStyleCrossRef" href="#bib0140">28</a> (LE: 2a). However, false positivity can be induced by inflammation, recent TUR, or bacillus Calmette-Guérin (BCG) intravesical instillation during the previous 3 mo.The benefit of 5-ALA fluorescence-guided TUR for recurrence-free survival has been considered. Cumulative analysis of three trials has shown that recurrence-free survival was 15.8–27% higher at 12 mo in the fluorescence-guided TUR groups compared with the white light cystoscopy alone groups<a class="elsevierStyleCrossRef" href="#bib0140">28</a> (LE: 2a). However, a large Swedish study could not detect any advantage in using 5-ALA fluorescence-guided TUR.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> A recent trial that compared HAL fluorescence-guided TUR with standard TUR reported an absolute reduction of no more than 9% in the recurrence rate within 9 mo in the HAL arm.<a class="elsevierStyleCrossRef" href="#bib0150">30</a>The value of fluorescence cystoscopy for improvement of the outcome in relation to progression rate or survival remains to be demonstrated.PDD should be restricted to those patients who are suspected of harbouring a high-grade tumour, particularly CIS (e.g., for biopsy guidance in patients with positive cytology or with a history of high-grade tumour).Second resectionA significant risk of residual tumour after the initial TUR of TaT1 lesions has been shown<a class="elsevierStyleCrossRefs" href="#bib0125">25,31</a> (LE:1b). Moreover, the tumour may be understaged by the initial resection.A second TUR should be considered if there is any suspicion that the initial resection was incomplete (e.g., when multiple or large tumours are present or when the pathologist reported no muscle tissue in the specimen). Furthermore, it should be performed when a high-grade non-muscle-invasive tumour or a T1 tumour was detected at the initial TUR. A second TUR can increase recurrence-free survival<a class="elsevierStyleCrossRef" href="#bib0160">32</a> (LE: 2a).Second resection should be performed 2–6 wk after the initial TUR. The procedure should include a resection of the primary tumour site.<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> summarises the recommendations for the diagnosis of NMIBC.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Predicting recurrence and progressionPrognosis of TaT1 tumoursThe classic way to categorise patients with TaT1 tumours is to divide them into risk groups based on prognostic factors derived from multivariate analyses. To predict separately the short- and long-term risks of both recurrence and progression in individual patients, a scoring system and risk tables were developed by the European Organisation for Research and Treatment of Cancer (EORTC).<a class="elsevierStyleCrossRef" href="#bib0165">33</a> The EORTC database provided individual data for 2596 patients diagnosed with TaT1 tumours who did not have a second TUR or receive maintenance BCG therapy. The EORTC scoring system is based on the six most significant clinical and pathologic factors: number of tumours, tumour size, prior recurrence rate, T category, presence of concomitant CIS, and tumour grade.<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> illustrates the weights applied to various factors for calculating the total scores for recurrence and progression. <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> shows the total scores stratified into four categories reflecting the probabilities of recurrence and progression at 1 and 5 yr.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> With combining two of the four categories distinctly in recurrence and progression, the EAU working group suggests using a three-tier classification system defining low-, intermediate-, and high-risk groups (as shown in the right-most column in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia>A scoring model for BCG-treated patients that predicts the short- and long-term risks of recurrence and progression was recently developed by the Club Urológico Español de Tratamiento Oncológico (CUETO; Spanish Oncology Group). Using these tables, the calculated risk of recurrence is lower than that obtained by the EORTC tables. For progression probabilities, it is lower only in high-risk patients.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> The lower risks in the CUETO tables may be attributable to using a more effective instillation therapy in the individual studies on which the tables are based.Prognosis of carcinoma in situWithout any treatment, approximately 54% of patients with CIS progress to muscle-invasive disease.<a class="elsevierStyleCrossRefs" href="#bib0065">13,35</a> There are no reliable prognostic factors that can be used to predict the course of CIS. Some studies have reported a worse prognosis in patients with concurrent CIS and T1 tumours compared with primary CIS, extended CIS, and those who do not respond to BCG treatment<a class="elsevierStyleCrossRefs" href="#bib0065">13,36</a> (LE: 3).Adjuvant intravesical chemotherapyOne immediate postoperative intravesical instillationTaT1 tumours recur frequently and progress to muscle-invasive disease in a limited number of cases. It is therefore necessary to consider adjuvant therapy in all patients.The results of a meta-analysis of seven randomised trials demonstrated that one immediate instillation of chemotherapy after TUR significantly reduced recurrence compared with TUR alone (LE: 1a).<a class="elsevierStyleCrossRef" href="#bib0185">37</a> In absolute values, the reduction was 11.7%, which implies a 24.2% decrease in the corresponding relative risk. The efficacy of the single instillation has also been confirmed by two recently published studies.<a class="elsevierStyleCrossRefs" href="#bib0190">38,39</a> In one of these, the benefit was mainly seen in primary and single tumours. When stratified according to EORTC recurrence scores, the benefit was observed in patients with scores of 0–2 but not with scores ≥3. However, the study was not sufficiently powered for subgroup analyses.<a class="elsevierStyleCrossRef" href="#bib0195">39</a>No prospective data are available showing that the single instillation significantly reduces recurrence rates in patients with recurrent tumours. Nevertheless, there is significant evidence from one subgroup analysis that immediate instillation might have an impact on the repeat instillation regimens for the treatment of patients who have an intermediate and high risk of recurrence<a class="elsevierStyleCrossRef" href="#bib0200">40</a> (LE: 2a). There are no statistically relevant data that address the role of immediate chemotherapy instillation before further BCG intravesical treatment in tumours with a high risk of progression.In summary, one immediate instillation of chemotherapy significantly reduces the risk of recurrence of TaT1 bladder cancer. Further studies are required, however, to determine the definitive role of immediate chemotherapy before BCG or further chemotherapy instillations in intermediate- and high-risk groups.Adjuvant chemotherapy is thought to mediate its effect by destroying circulating tumour cells or having an ablative effect on residual tumour cells at the resection site. Prevention of tumour cell implantation should be initiated within the first hours after cell seeding. In all studies, the instillation was administered within 24h. Subgroup analysis of one study has shown that, if the first instillation was not given on the same day as TUR, there was a twofold increase in the relative risk of recurrence<a class="elsevierStyleCrossRef" href="#bib0200">40</a> (LE: 2a). A study in which the instillation was not given strictly on the same day did not find any advantage.<a class="elsevierStyleCrossRef" href="#bib0205">41</a>Mitomycin C (MMC), epirubicin, and doxorubicin have all shown comparable beneficial effects<a class="elsevierStyleCrossRef" href="#bib0185">37</a> (LE: 1a).Early immediate instillation of chemotherapy is recommended in tumours at low risk of recurrence and progression as the only intravesical treatment. A single instillation is considered as the initial stage of further intravesical therapy in those presumably at intermediate risk. In tumours that presumably have a high risk of progression (solid lesions, positive urinary cytology), immediate instillation is an option because it can have a positive impact on the recurrence rate through prevention of tumour cell implantation. However, there is no doubt that subsequent BCG intravesical immunotherapy is an essential treatment option in these patients.The instillation of chemotherapy should be omitted in any case of overt or suspected intra- or extraperitoneal perforation, which is most likely to appear in extensive TUR procedures and in situations with difficult bleeding requiring bladder irrigation. Severe complications have been reported in patients in whom extravasation of the drug occurs.<a class="elsevierStyleCrossRef" href="#bib0210">42</a> Clear instructions should be given to the nursing staff to control the free flow of the bladder catheter at the end of the instillation.Additional intravesical chemotherapy instillationsThe need for further adjuvant intravesical therapy depends on the patient's prognosis. In patients with a low risk of recurrence (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>), a single immediate instillation is considered to be sufficient treatment<a class="elsevierStyleCrossRef" href="#bib0185">37</a> (LE: 1a). For other patients, however, it remains an incomplete treatment because the likelihood of recurrence and/or progression is considerable.The choice between further chemotherapy or BCG immunotherapy largely depends on the risk that needs to be reduced: recurrence or progression. A meta-analysis comparing intravesical chemotherapy with TUR alone demonstrated that chemotherapy prevents recurrence but not progression<a class="elsevierStyleCrossRef" href="#bib0215">43</a> (LE: 1a). The efficacy of intravesical chemotherapy in reducing the risk of tumour recurrence was confirmed by two other meta-analyses in primary<a class="elsevierStyleCrossRef" href="#bib0220">44</a> and recurrent tumours.<a class="elsevierStyleCrossRef" href="#bib0225">45</a>It is still controversial how long and how frequently intravesical chemotherapy instillations should be given.<a class="elsevierStyleCrossRef" href="#bib0230">46</a> Nevertheless, the available evidence does not support any treatment schedule >1 yr.Optimising intravesical chemotherapyAdapting the urinary pH, decreasing urinary excretion, and buffering the intravesical solution can reduce the recurrence rate<a class="elsevierStyleCrossRef" href="#bib0235">47</a> (LE: 1b). Concentration was more important than treatment duration<a class="elsevierStyleCrossRef" href="#bib0240">48</a> (LE: 1b). In view of these data, it seems advisable to dissolve the drug in a buffered solution at optimal pH and to instruct the patient not to drink on the morning before instillation.Adjuvant intravesical bacillus Calmette-Guérin immunotherapyThe superiority of BCG after TUR compared with TUR alone or TUR and chemotherapy in preventing recurrences of TaT1 tumours has been confirmed<a class="elsevierStyleCrossRefs" href="#bib0245">49–56</a> (LE: 1a). The clinical effect is long lasting,<a class="elsevierStyleCrossRefs" href="#bib0270">54,55</a> and it was also observed in a separate analysis of patients with intermediate-risk tumours.<a class="elsevierStyleCrossRef" href="#bib0275">55</a>A recently published meta-analysis<a class="elsevierStyleCrossRef" href="#bib0280">56</a> evaluated individual data from 2820 patients who were enrolled in nine randomised studies that compared MMC with BCG. In the BCG maintenance trials, a 32% reduction in the risk of recurrence was found for BCG compared with MMC (p<0.0001), whereas BCG without maintenance was less effective than MMC.Data from two meta-analyses demonstrated that BCG therapy prevents, or at least delays, the risk of tumour progression<a class="elsevierStyleCrossRefs" href="#bib0285">57,58</a> (LE: 1a). The EORTC meta-analysis demonstrated a reduction of 27% in the odds of progression with BCG maintenance treatment (p=0.0001).<a class="elsevierStyleCrossRef" href="#bib0285">57</a> A recent randomised study with a long-term observation period demonstrated significantly fewer distant metastases and better overall and disease-specific survival in patients treated with BCG compared with epirubicin.<a class="elsevierStyleCrossRef" href="#bib0275">55</a> On the contrary, a meta-analysis of individual patient data was unable to confirm any statistically significant difference between MMC and BCG for progression, survival, and cause of death.<a class="elsevierStyleCrossRef" href="#bib0280">56</a>In summary, despite these conflicting results, most of the data were able to show a reduction in the risk of progression in tumours with high and intermediate risk if BCG including a maintenance schedule was used.The optimal bacillus Calmette-GuérinFor optimal efficacy, BCG should be given on a maintenance schedule<a class="elsevierStyleCrossRefs" href="#bib0260">52–58</a> (LE: 1a). The observations from the EORTC meta-analysis revealed that only patients receiving maintenance BCG benefitted. In the four trials where no maintenance BCG was given, no reduction in progression was observed. In the 20 trials in which some form of BCG maintenance was given, a reduction of 37% in the odds of progression was observed (p=0.00004). However, the meta-analysis was unable to determine which BCG maintenance schedule was the most effective.<a class="elsevierStyleCrossRef" href="#bib0285">57</a> The conclusions of other meta-analyses stated that at least 1 yr of maintenance BCG was required to show the superiority of BCG over MMC in preventing recurrence or progression.<a class="elsevierStyleCrossRefs" href="#bib0260">52,58</a>Induction BCG instillations are classically given according to the empirical 6-weekly induction schedule, and many different maintenance schedules have been used with up to 30 instillations given over 3 yr.<a class="elsevierStyleCrossRef" href="#bib0295">59</a> The optimal number of induction instillations and the optimal frequency and duration of maintenance instillations remain unknown.To reduce toxicity, one-third and one-quarter doses of BCG have been proposed. No overall difference in BCG efficacy was found when the one-third dose was compared with the full dose. However, there was a suggestion that a full dose of BCG may be more effective in multifocal disease<a class="elsevierStyleCrossRef" href="#bib0300">60</a> (LE: 1b). Although fewer patients reported toxicity with the reduced dose, the incidence of severe systemic toxicity was similar. A further reduction of BCG to one-sixth dose was associated with decreased efficacy but with equal toxicity.<a class="elsevierStyleCrossRef" href="#bib0305">61</a>Bacillus Calmette-Guérin toxicityThe use of BCG has been compromised because of tolerability issues, namely, deaths due to BCG sepsis and BCG-induced cystitis. However, with increased experience in using BCG, the side effects now appear to be less prominent. Fewer than 5% of patients experience serious side effects with BCG use<a class="elsevierStyleCrossRef" href="#bib0310">62</a> (LE: 1b). Major complications can appear after systemic absorption of the drug. BCG should not be administered during the first 2 wk after TUR, in patients with haematuria or urinary tract infection, after traumatic catheterisation, or in immunocompromised patients (LE: 2b). The management of side effects after BCG therapy should reflect their type and grade.<a class="elsevierStyleCrossRef" href="#bib0315">63</a>Indications for bacillus Calmette-GuérinThere is a consensus that not all patients with NMIBC should be treated with BCG due to the risk of toxicity. BCG use does not alter the natural course of tumours with a low risk of recurrence (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>) and may be considered overtreatment for this category of patients. In patients with tumours with a high risk of progression, BCG including a maintenance schedule is recommended. BCG with 1-yr maintenance is more effective than chemotherapy for preventing recurrence in patients with an intermediate or high risk of recurrence and intermediate risk of progression; however, BCG has more side effects than chemotherapy. For this reason both BCG with maintenance and intravesical chemotherapy remain a treatment option. The final choice should reflect the individual patient's risk and the efficacy and tolerability of each treatment modality. <a class="elsevierStyleCrossRefs" href="#tbl0030">Tables 6 and 7</a> summarise the recommendations for intravesical therapy in TaT1 tumours.<elsevierMultimedia ident="tbl0030"></elsevierMultimedia><elsevierMultimedia ident="tbl0035"></elsevierMultimedia>Specific aspects of treatment of carcinoma in situCIS cannot be resolved by endoscopic procedure alone. Histologic diagnosis of CIS must be followed by further treatment, either intravesical instillations or radical cystectomy (LE: 2). No consensus exists about whether conservative therapy (intravesical BCG instillations) or aggressive therapy (cystectomy) should be performed. Tumour-specific survival rates after early cystectomy for CIS are excellent, but up to 40–50% of patients may be overtreated.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>Intravesical treatment of bladder carcinoma in situRetrospective evaluations have reported a complete response rate of 48% with intravesical chemotherapy and 72–93% with BCG (LE: 2a). The results of a meta-analysis of clinical trials in CIS patients that compared intravesical BCG with chemotherapy showed a significantly increased response rate after BCG and a reduction of 59% in the odds of treatment failure with BCG (odds ratio [OR]: 0.41; p=0.0001). Clinical trials that compared BCG with MMC showed that the long-term benefit of BCG was smaller, but BCG was superior to MMC in BCG maintenance studies (OR: 0.57; p=0.04).<a class="elsevierStyleCrossRef" href="#bib0320">64</a>The EORTC meta-analysis of tumour progression in a subgroup of 403 CIS patients showed that BCG reduced the risk of progression by 35% compared with intravesical chemotherapy or different immunotherapy<a class="elsevierStyleCrossRef" href="#bib0285">57</a> (LE: 1a).In summary, when compared with chemotherapy, BCG treatment increases the complete response rate, the overall percentage of patients who remain disease-free, and reduces the risk of tumour progression in CIS patients (LE: 1a).Treatment of extravesical carcinoma in situPatients with CIS in the epithelial lining of the prostatic urethra can be treated with intravesical instillations of BCG. Previous TUR of the prostate can improve the contact of BCG with the prostatic urethra<a class="elsevierStyleCrossRef" href="#bib0325">65</a> (LE: 3). In patients with prostatic duct involvement, radical surgery should be considered<a class="elsevierStyleCrossRef" href="#bib0325">65</a> (LE: 3). <a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a> summarises the recommendations for therapy of CIS.Treatment of failures of intravesical therapyPatients with non-muscle-invasive recurrences after intravesical chemotherapy can benefit from BCG instillations (LE: 1a). Treatment with BCG is considered to have failed in the following situations: (1) where muscle-invasive tumour is detected during follow-up; (2) when high-grade non-muscle-invasive tumour is present at both 3 and 6 mo.<a class="elsevierStyleCrossRef" href="#bib0330">66</a> In patients with tumour present at 3 mo, an additional BCG course can achieve complete response in >50% of cases<a class="elsevierStyleCrossRefs" href="#bib0065">13,66</a> but increases the risk of progression<a class="elsevierStyleCrossRefs" href="#bib0335">67,68</a>; and (3) any deterioration of the disease under BCG treatment, such as a higher number of recurrences, higher T stage or higher grade, or the appearance of CIS, despite an initial response (LE: 3).Changing from BCG to intravesical chemotherapy, device-assisted chemotherapy instillations, or additional interferon α-2b can yield responses in selected cases with non-muscle-invasive BCG treatment failure. However, these strategies are considered experimental. Due to an increased risk of developing muscle-invasive tumour<a class="elsevierStyleCrossRefs" href="#bib0330">66,68</a> (LE: 3), cystectomy is strongly advocated following early BCG failure in fit patients.Patients with recurrence at >1 yr after completion of BCG therapy can be treated according to the risk classification defined in <a class="elsevierStyleCrossRefs" href="#tbl0020">Tables 4–6</a>.Cystectomy for non-muscle-invasive bladder cancerImmediate cystectomy can be considered for those patients who are at high risk of progression. According to the EORTC tables (<a class="elsevierStyleCrossRefs" href="#tbl0020">Tables 4 and 5</a>), these patients have multiple recurrent high-grade tumours, high-grade T1 tumours, and high-grade tumours with concurrent CIS. Cystectomy is advocated in patients with BCG failure. Delaying cystectomy in these patients may lead to decreased disease-specific survival.<a class="elsevierStyleCrossRef" href="#bib0345">69</a>Follow-upPatients need to be followed up because of the risk of recurrence and progression; however, the frequency and duration of cystoscopies and upper urinary tract investigations should reflect the degree of risk.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> When planning a follow-up schedule, the following aspects should be considered:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Prompt detection of muscle-invasive and high-grade non-muscle-invasive recurrence is crucial because a delay in diagnosis and therapy can be life threatening.</li><li class="elsevierStyleListItem" id="lsti0010">•Tumour recurrence in the low-risk group is nearly always low stage and low grade. Small non-invasive (Ta), low-grade papillary recurrences do not present an immediate danger to the patient, and early detection is not essential for successful therapy<a class="elsevierStyleCrossRef" href="#bib0350">70</a> (LE: 2b). In these patients, fulguration of small papillary recurrences on an outpatient basis is considered a safe treatment option<a class="elsevierStyleCrossRef" href="#bib0355">71</a> (LE: 3).</li><li class="elsevierStyleListItem" id="lsti0015">•The result of the first cystoscopy after TUR at 3 mo is a very important prognostic factor for recurrence and progression<a class="elsevierStyleCrossRefs" href="#bib0165">33,67,72</a> (LE: 1a). The first cystoscopy should always be performed 3 mo after TUR.</li><li class="elsevierStyleListItem" id="lsti0020">•The risk of upper urinary tract recurrence increases in patients with multiple and high-risk tumours<a class="elsevierStyleCrossRef" href="#bib0075">15</a> (LE: 3).</li></ul><a class="elsevierStyleCrossRef" href="#tbl0040">Table 8</a> lists the recommendations for the follow-up schedule of NMIBC.<elsevierMultimedia ident="tbl0040"></elsevierMultimedia>Author contributionsMarko Babjuk had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.Study concept and design: Babjuk, Oosterlinck.Acquisition of data: Babjuk, Oosterlinck, Sylvester, Kaasinen, Böhle, Palou-Redorta, Rouprêt.Analysis and interpretation of data: Babjuk, Oosterlinck.Drafting of the manuscript: Babjuk.Critical revision of the manuscript for important intellectual content: Babjuk, Oosterlinck, Sylvester, Kaasinen, Böhle, Palou, Rouprêt.Statistical analysis: Babjuk, Sylvester.Obtaining funding: None.Administrative, technical, or material support: None.Supervision: Babjuk, Oosterlinck.Other (specify): None.Conflict of interestI certify that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (e.g., employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: Marko Babjuk receives speaker honoraria from GE Healthcare and GSK. Willem Oosterlinck is a company consultant and receives fellowship and travel grants from GSK, receives speaker honoraria from Pfizer, participates in trials for Amgen, Astra Zeneca, and Astellas, and receives fellowships and travel and research grants from Astra Zeneca. Morgan Rouprêt has nothing to disclose. Juan Palou-Redorta is a consultant and receives speaker honoraria from Sanofi-Pasteur and General Electric. He also participates in trials for General Electric. Andreas Böhle receives speaker honoraria from Sanofi-Aventis, Medac, Bard, and Fresenius. Eero Kaasinen receives research grants from the Pfizer Foundation and for a research group at Pfizer. Richard Sylvester is a consultant for Bioniche, Allergan, and Astra Zeneca, and he received speaker honoraria from the Kyowa 2008 EAU Satellite Symposium.Funding/Support and role of the sponsor: None." "textoCompletoSecciones" => array:1 [ "secciones" => array:17 [ 0 => array:2 [ "identificador" => "xres101710" "titulo" => array:5 [ 0 => "Abstract" 1 => "Context and objective" 2 => "Evidence acquisition" 3 => "Evidence synthesis" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec88877" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres101711" "titulo" => array:5 [ 0 => "Resumen" 1 => "Contexto y objetivo" 2 => "Adquisición de la evidencia" 3 => "Síntesis de la evidencia" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec88878" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Evidence acquisition" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Epidemiology" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Risk factors" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Classification" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Specific characteristics of carcinoma in situ and its clinical classification" ] ] ] 9 => array:3 [ "identificador" => "sec0035" "titulo" => "Diagnosis" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Imaging" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Urinary cytology" ] 2 => array:3 [ "identificador" => "sec0050" "titulo" => "Urine molecular tests" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Screening of the population at risk of non-muscle-invasive bladder cancer" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Exploration of patients after haematuria or other symptoms suggestive of bladder cancer" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Facilitate surveillance of non-muscle-invasive bladder cancer to reduce the number of cystoscopies" ] ] ] 3 => array:2 [ "identificador" => "sec0070" "titulo" => "Cystoscopy" ] 4 => array:2 [ "identificador" => "sec0075" "titulo" => "Transurethral resection" ] 5 => array:2 [ "identificador" => "sec0085" "titulo" => "Photodynamic diagnosis (fluorescence cystoscopy)" ] 6 => array:2 [ "identificador" => "sec0090" "titulo" => "Second resection" ] ] ] 10 => array:3 [ "identificador" => "sec0095" "titulo" => "Predicting recurrence and progression" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0100" "titulo" => "Prognosis of TaT1 tumours" ] 1 => array:2 [ "identificador" => "sec0105" "titulo" => "Prognosis of carcinoma in situ" ] ] ] 11 => array:3 [ "identificador" => "sec0110" "titulo" => "Adjuvant intravesical chemotherapy" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0115" "titulo" => "One immediate postoperative intravesical instillation" ] 1 => array:2 [ "identificador" => "sec0120" "titulo" => "Additional intravesical chemotherapy instillations" ] 2 => array:2 [ "identificador" => "sec0125" "titulo" => "Optimising intravesical chemotherapy" ] 3 => array:2 [ "identificador" => "sec0130" "titulo" => "Adjuvant intravesical bacillus Calmette-Guérin immunotherapy" ] 4 => array:2 [ "identificador" => "sec0140" "titulo" => "Bacillus Calmette-Guérin toxicity" ] 5 => array:3 [ "identificador" => "sec0145" "titulo" => "Indications for bacillus Calmette-Guérin" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0150" "titulo" => "Specific aspects of treatment of carcinoma in situ" ] 1 => array:2 [ "identificador" => "sec0155" "titulo" => "Intravesical treatment of bladder carcinoma in situ" ] 2 => array:2 [ "identificador" => "sec0160" "titulo" => "Treatment of extravesical carcinoma in situ" ] ] ] 6 => array:2 [ "identificador" => "sec0165" "titulo" => "Treatment of failures of intravesical therapy" ] ] ] 12 => array:2 [ "identificador" => "sec0170" "titulo" => "Cystectomy for non-muscle-invasive bladder cancer" ] 13 => array:2 [ "identificador" => "sec0175" "titulo" => "Follow-up" ] 14 => array:2 [ "identificador" => "sec0180" "titulo" => "Author contributions" ] 15 => array:2 [ "identificador" => "sec0185" "titulo" => "Conflict of interest" ] 16 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-12-12" "fechaAceptado" => "2011-12-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec88877" "palabras" => array:11 [ 0 => "Bacillus Calmette-Guérin (BCG)" 1 => "Bladder cancer" 2 => "Cystectomy" 3 => "Cystoscopy" 4 => "Diagnosis" 5 => "European Association of Urology Guidelines" 6 => "Follow-up" 7 => "Intravesical chemotherapy" 8 => "Prognosis" 9 => "Transurethral resection (TUR)" 10 => "Urothelial carcinoma" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec88878" "palabras" => array:11 [ 0 => "Bacilo de Calmette-Guérin (BCG)" 1 => "Cáncer de vejiga" 2 => "Cistectomía" 3 => "Cistoscopia" 4 => "Diagnóstico" 5 => "Guía clínica de la Asociación Europea de Urología" 6 => "Seguimiento" 7 => "Quimioterapia intravesical" 8 => "Pronóstico" 9 => "Resección transuretral (RTU)" 10 => "Carcinoma urotelial" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Context and objectiveTo present the 2011 European Association of Urology (EAU) guidelines on non-muscle-invasive bladder cancer (NMIBC). Evidence acquisitionLiterature published between 2004 and 2010 on the diagnosis and treatment of NMIBC was systematically reviewed. Previous guidelines were updated, and the level of evidence and grade of recommendation were assigned. Evidence synthesisTumours staged as Ta, T1, or carcinoma in situ (CIS) are grouped as NMIBC. Diagnosis depends on cystoscopy and histologic evaluation of the tissue obtained by transurethral resection (TUR) in papillary tumours or by multiple bladder biopsies in CIS. In papillary lesions, a complete TUR is essential for the patient's prognosis. Where the initial resection is incomplete or where a high-grade or T1 tumour is detected, a second TUR should be performed within 2–6 wk. In papillary tumours, the risks of both recurrence and progression may be estimated for individual patients using the scoring system and risk tables. The stratification of patients into low-, intermediate-, and high-risk groups (separately for recurrence and progression) is pivotal to recommending adjuvant treatment. For patients with a low risk of tumour recurrence and progression, one immediate instillation of chemotherapy is recommended. Patients with an intermediate or high risk of recurrence and an intermediate risk of progression should receive one immediate instillation of chemotherapy followed by a minimum of 1 yr of bacillus Calmette-Guérin (BCG) intravesical immunotherapy or further instillations of chemotherapy. Papillary tumours with a high risk of progression and CIS should receive intravesical BCG for 1 yr. Cystectomy may be offered to the highest risk patients, and it is at least recommended in BCG failure patients. ConclusionsThese abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Contexto y objetivoPresentar la guía clínica de la Asociación Europea de Urología (EAU) de 2011 del carcinoma de vejiga no músculo-invasivo (CVNMI). Adquisición de la evidenciaSe ha realizado una revisión sistemática de la literatura publicada entre 2004 y 2010 acerca del diagnóstico y el tratamiento del CVNMI. Se actualizaron las guías clínicas previas, y se asignó un nivel de evidencia (NE) y un grado de recomendación (GR). Síntesis de la evidenciaLos tumores en estadio Ta, T1 o carcinoma in situ (CIS) se agrupan como CVNMI. El diagnóstico depende de la cistoscopia y de la evaluación histológica del tejido obtenido por resección transuretral (RTU) en los tumores papilares o por biopsias de vejiga múltiples en el CIS. En las lesiones papilares, una completa RTU es esencial para el pronóstico del paciente. Cuando la primera resección es incompleta o cuando se detecta un tumor de alto grado o T1, se debe realizar una segunda RTU a las 2-6 semanas. En los tumores papilares, el riesgo tanto de recurrencia como de progresión se puede calcular de manera individual mediante los sistemas de puntuación y tablas de riesgo. La estratificación de los pacientes en grupos de riesgo bajo, intermedio y alto (separando la recidiva y la progresión) es fundamental para recomendar un tratamiento adyuvante. Para los pacientes con bajo riesgo de recurrencia y progresión se recomienda una instilación inmediata de quimioterapia. Los pacientes con riesgo intermedio o alto de recurrencia y riesgo intermedio de progresión deben recibir una instilación inmediata de quimioterapia seguida de un mínimo de un añno con inmunoterapia intravesical con bacilo de Calmette-Guérin (BCG) o más instilaciones de quimioterapia. Los tumores papilares con alto riesgo de progresión y CIS deben recibir BCG intravesical durante un año. Se puede ofrecer una cistectomía a los pacientes de más alto riesgo, y por lo menos se recomienda a los pacientes en los que ha fallado la BCG. ConclusionesLa versión reducida de esta guía clínica de la EAU presenta una información actualizada sobre el diagnóstico y el tratamiento del CVNMI para la incorporación a la práctica clínica." ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Badjuk M, et al. Guía clínica del carcinoma urotelial de vejiga no músculo-invasivo de la Asociación Europea de Urología. Actualización de 2011. Actas Urol Esp. 2012;36:389–402." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "The translation of this article was carried out with the permission of the European Association of Urology." ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T Primary tumour</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Primary tumour cannot be assessed \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No evidence of primary tumour \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ta \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Noninvasive papillary carcinoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Carcinoma in situ: ‘flat tumour’ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tumour invades subepithelial connective tissue \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tumour invades muscle \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T2a Tumour invades superficial muscle (inner half) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T2b Tumour invades deep muscle (outer half) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tumour invades perivesical tissue: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T3a Microscopically \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T3b Macroscopically (extravesical mass) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tumour invades any of the following: prostate, uterus, vagina, pelvic wall, abdominal wall \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T4a Tumour invades prostate, uterus, or vagina \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T4b Tumour invades pelvic wall or abdominal wall \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">N Lymph nodes</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Regional lymph nodes cannot be assessed \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">N0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No regional lymph node metastasis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">N1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Metastasis in a single lymph node in the true pelvis (hypogastric, obturator, external iliac, or presacral) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">N2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Metastasis in multiple lymph nodes in the true pelvis (hypogastric, obturator, external iliac, or presacral) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">N3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Metastasis in a common iliac lymph node(s) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M Distant metastasis</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Distant metastasis cannot be assessed \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No distant metastasis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Distant metastasis \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab184251.png" ] ] ] ] "descripcion" => array:1 [ "en" => "2009 TNM classification of urinary bladder cancer." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "WHO=World Health Organisation; CIS=carcinoma in situ." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1973 WHO grading \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urothelial papilloma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grade 1: well differentiated \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grade 2: moderately differentiated \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grade 3: poorly differentiated \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2004 WHO grading \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Flat lesions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hyperplasia (flat lesion without atypia or papillary) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reactive atypia (flat lesion with atypia) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Atypia of unknown significance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urothelial dysplasia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urothelial CIS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Papillary lesions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urothelial papilloma (which is a completely benign lesion) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Papillary urothelial neoplasm of low malignant potential \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low-grade papillary urothelial carcinoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High-grade papillary urothelial carcinoma \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab184256.png" ] ] ] ] "descripcion" => array:1 [ "en" => "World Health Organisation grading in 1973 and in 2004." ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "GR=grade; US=ultrasound; CT=computed tomography; IVU=intravenous urography; TUR=transurethral resection; CIS=carcinoma in situ." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Recommendations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">GR \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The renal and bladder US may be used during initial workup in patients with haematuria. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">At the time of initial diagnosis of bladder cancer, CT urography or IVU should be performed only in selected cases (e.g., tumours located in the trigone). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cystoscopy is recommended in all patients with symptoms suggestive of bladder cancer. It cannot be replaced by cytology or by any other noninvasive test. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cystoscopy should describe all macroscopic features of the tumour (site, size, number, and appearance) and mucosal abnormalities. A bladder diagram is recommended. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Voided urine cytology or urinary markers are advocated to predict high-grade tumour before TUR. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">It is recommended to perform TUR in one piece for small papillary tumours (<1cm), including part of the underlying bladder wall. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">It is recommended to perform TUR in fractions (including muscle tissue) for tumours >1cm in diameter. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">It is recommended to take biopsies from abnormal-looking urothelium. Biopsies from normal-looking mucosa (trigone, bladder dome, and from right, left, anterior, and posterior bladder walls) are recommended only when cytology is positive or when exophytic tumour has a nonpapillary appearance. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Biopsy of the prostatic urethra is recommended for cases of bladder neck tumour, when bladder CIS is present or suspected, when there is positive cytology without evidence of tumour in the bladder, or when abnormalities of prostatic urethra are visible. If biopsy is not performed during the initial procedure, it should be completed at the time of the second resection. The biopsy should be taken from the precollicular area between 5 and 7 o’clock positions using a resection loop. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">If equipment is available, fluorescence-guided biopsy when bladder CIS is suspected (e.g., positive cytology, recurrent tumour with previous history of a high-grade lesion). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A second TUR should be performed 2–6 wk after the initial resection when the latter is incomplete (in large and multiple tumours, no muscle in the specimen) or when an exophytic high-grade and/or T1 tumour is detected. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The pathologic report should specify the grade, the depth of tumour invasion, and whether the lamina propria and muscle are present in the specimen. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab184252.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Recommendations for the diagnosis of non-muscle-invasive bladder cancer." ] ] 3 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "CIS=carcinoma in situ; WHO=World Health Organisation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Factor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Recurrence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Progression \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No. of tumours</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Single \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2–7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tumour diameter</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><3cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥3cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prior recurrence rate</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Primary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤1 recurrence per year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>1 recurrence per year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Category</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ta \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Concomitant CIS</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grade (1973 WHO)</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">G1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">G2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">G3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0–17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0–23 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab184254.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Electronic calculator for Table 4 is available at http://www.eortc.be/tools/bladdercalculator/." ] ] ] "descripcion" => array:1 [ "en" => "Weighting used to calculate recurrence and progression scores.<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a>" ] ] 4 => array:7 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "CI=confidence interval." "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recurrence score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Probability of recurrence at 1 yr</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Probability of recurrence at 5 yr</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recurrence risk group \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">(95% CI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">(95% CI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(10–19) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(24–37) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low risk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1–4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(21–26) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(42–49) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intermediate risk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5–9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(35–41) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(58–65) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10–17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(55–67) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(73–84) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High risk \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab184253.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Progression score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Probability of progression at 1 yr</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Probability of progression at 5 yr</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Progression risk group \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">(95% CI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">(95% CI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(0–0.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(0–1.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low risk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2–6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(0.4–1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(5–8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intermediate risk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7–13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(4–7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(14–20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High risk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14–23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(10–24) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(35–55) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab184255.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "Electronic calculator for Table 5 is available at http://www.eortc.be/tools/bladdercalculator/." ] ] ] "descripcion" => array:1 [ "en" => "Probability of recurrence and progression according to total score.<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a>" ] ] 5 => array:7 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "BCG=bacillus Calmette-Guérin." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Risk category \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Intermediate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">High \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recurrence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">One immediate instillation of chemotherapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">One immediate instillation of chemotherapy, followed by further instillations, either chemotherapy or a minimum 1 yr of BCG (the final choice is determined by the risk of tumour progression) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">One immediate instillation of chemotherapy, followed by further instillations, either chemotherapy or a minimum of 1 yr of BCG (the final choice is determined by the risk of tumour progression) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Progression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">One immediate instillation of chemotherapy (it can be followed by further chemotherapy instillations if the patient has an intermediate risk of recurrence at the same time) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">One immediate instillation of chemotherapy, followed by a minimum of 1 yr of BCG or further chemotherapy instillations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intravesical BCG for at least 1 yr or immediate cystectomy \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab184249.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Treatment recommendations in TaT1 tumours according to risk stratification." ] ] 6 => array:7 [ "identificador" => "tbl0035" "etiqueta" => "Table 7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "GR=grade; BCG=bacillus Calmette-Guérin; CIS=carcinoma in situ; TUR=transurethral resection." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Recommendations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">GR \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The type of adjuvant therapy should be based on the risk groups specified in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In patients at low risk of tumour recurrence and progression, one immediate instillation of chemotherapy is recommended as the complete adjuvant treatment. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In patients with TaT1 tumours at intermediate or high risk of recurrence and intermediate risk of progression, one immediate instillation of chemotherapy should be followed by a minimum 1 yr of BCG treatment or by further instillations of chemotherapy. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">If chemotherapy is given, it is advised to use the drug at its optimal pH and to maintain the concentration of the drug during instillation by reducing fluid intake. The optimal schedule and the duration of the chemotherapy instillations remain unclear, but it should probably be given for no more than 1 yr. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In patients at high risk of tumour progression, intravesical BCG for at least 1 yr is recommended. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In patients with bladder CIS, intravesical BCG is recommended for at least 1 yr. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In patients with CIS in the epithelial lining of the prostatic urethra, TUR of the prostate followed by intravesical instillations of BCG may be a suitable option. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">For patients at high risk of tumour progression, immediate cystectomy may be offered. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cystectomy is recommended for patients with BCG failure. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab184257.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Recommendations for adjuvant therapy in TaT1 tumours and for treatment of carcinoma in situ." ] ] 7 => array:7 [ "identificador" => "tbl0040" "etiqueta" => "Table 8" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "GR=grade; CIS=carcinoma in situ; PDD=photodynamic diagnosis; CT=computed tomography." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Recommendations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">GR \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients with TaT1 tumours at low risk of recurrence and progression should have a cystoscopy at 3 mo. If negative, the following cystoscopy is advised 9 mo later and then yearly for 5 yr. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients with TaT1 tumours at high risk of progression and those with CIS should have a cystoscopy and urinary cytology at 3 mo. If negative, the following cystoscopy and cytology should be repeated every 3 mo for a period of 2 yr, every 6 mo thereafter until 5 yr, and then yearly. Yearly imaging of the upper tract is recommended. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients with TaT1 tumours at intermediate risk of progression (about a third of all patients) should have an intervening follow-up scheme using cystoscopy and cytology, which is adapted according to personal and subjective factors. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">During follow-up in patients with positive cytology and no visible tumour in the bladder, R-biopsies or biopsies with PDD (if equipment is available) and investigation of extravesical locations (CT urography, prostatic urethra biopsy) are recommended. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab184250.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Recommendations for follow-up of non-muscle-invasive bladder cancer in patients after transurethral resection." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:72 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines on bladder cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "W. 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EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder, the 2011 update

Guía clínica del carcinoma urotelial de vejiga no músculo-invasivo de la Asociación Europea de Urología. Actualización de 2011

M. Babjuka,

Corresponding author

Marek.badjuk@lfmotol.cuni.cz

Corresponding author.

, W. Oosterlinckb, R. Sylvesterc, E. Kaasinend, A. Böhlee, J. Palou-Redortaf, M. Rouprêtg

a Servicio de Urología, Hospital Motol, Segunda Facultad de Medicina, Universidad Carolina, Praga, Czech Republic

b Servicio de Urología, Hospital Universitario de Gante, Gante, Belgium

c Oficina central de la Organización Europea para la Investigación y el Tratamiento del Cáncer, Departamento de Bioestadística, Bruselas, Belgium

d Servicio de Urología, Hospital Hyvinkää, Hyvinkää, Finland

e Servicio de Urología, Hospital HELIOS Agnes Karll, Bad Schwartau, Germany

f Servicio de Urología, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain

g Servicio de Urología del Hospital Pitié-Salpétrière, GHU Est, Hospitales Públicos de París; Facultad de Medicina de Pierre y Marie Curie, Universidad de París VI, París, France

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        "titulo" => "Gu&#237;a cl&#237;nica del carcinoma urotelial de vejiga no m&#250;sculo-invasivo de la Asociaci&#243;n Europea de Urolog&#237;a&#46; Actualizaci&#243;n de 2011"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The first European Association of Urology &#40;EAU&#41; guidelines on bladder cancer were published in 2002&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Since then the guidelines have been continuously updated&#44; and the most recent version is available from the EAU Web site&#44; <a href="http://www.uroweb.org/">www&#46;uroweb&#46;org</a>&#46; An overview of the updated 2011 EAU guidelines on non-muscle-invasive bladder cancer &#40;NMIBC&#41; &#40;Ta&#44; T1&#44; and carcinoma in situ &#91;CIS&#93;&#41; is provided here&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Evidence acquisition</span><p id="par0010" class="elsevierStylePara elsevierViewall">The panel members performed a systematic literature search for each section of the guidelines&#46; Medline&#44; Web of Science&#44; and Embase databases were searched for original and review articles published between 2004 and 2010&#46; Panel members selected records with the highest level of evidence according to a modified classification system from the Oxford Centre for Evidence-Based Medicine levels of evidence &#40;LEs&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Recommendations were graded to provide transparency regarding the underlying LE for each recommendation given&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Epidemiology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Bladder cancer is the most common malignancy of the urinary tract&#46; The worldwide age standardised rate &#40;ASR&#41; is 10&#46;1 per 100<span class="elsevierStyleHsp" style=""></span>000 for men and 2&#46;5 per 100<span class="elsevierStyleHsp" style=""></span>000 for women&#46; In Europe&#44; the highest incidence of bladder cancer &#40;ASR&#41; has been reported in the western region &#40;23&#46;6 in men and 5&#46;4 in women&#41; and in the southern region &#40;27&#46;1 in men and 4&#46;1 in women&#41;&#44; followed by northern Europe &#40;16&#46;9 in men and 4&#46;9 in women&#41;&#46; The lowest incidence has been observed in eastern European regions &#40;14&#46;7 in men and 2&#46;2 in women&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The global world mortality rate is 4 per 100<span class="elsevierStyleHsp" style=""></span>000 among men and 1&#46;1 per 100<span class="elsevierStyleHsp" style=""></span>000 among women&#46; In Europe&#44; bladder cancer mortality rates have declined over the last decade to about 16&#37; in men and 12&#37; in women&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Approximately 75&#8211;85&#37; of patients with bladder cancer present with disease that is confined to the mucosa &#40;Ta or CIS&#41; or submucosa &#40;T1&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Risk factors</span><p id="par0025" class="elsevierStylePara elsevierViewall">Urologists should be aware of the various types of occupational exposures that may be related to urothelial carcinogens&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Aromatic amines were recognised first&#46; At-risk groups include workers in the following industries&#58; printing&#44; iron and aluminium processing&#44; industrial painting&#44; and gas- and tar manufacturing &#40;LE&#58; 3&#41;&#46; Another prominent risk factor is cigarette smoking&#44; which triples the risk of developing bladder cancer and leads to higher mortality rates<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> &#40;LE&#58; 3&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Classification</span><p id="par0030" class="elsevierStylePara elsevierViewall">The Tumour&#44; Node&#44; Metastasis &#40;TNM&#41; classification approved by the Union Internationale Contre le Cancer&#44; which was updated in 2009&#44; is used in these guidelines &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The new classification for grading NMIBCs proposed by the World Health Organisation &#40;WHO&#41; and the International Society of Urological Pathology was published by the WHO in 2004 &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> New categories were defined among flat and papillary lesions&#46; Among papillary lesions&#44; they are papillary urothelial neoplasms of low malignant potential &#40;PUNLMPs&#41; and low-grade and high-grade urothelial carcinomas&#46; PUNLMPs are lesions that do not have the cytologic features of malignancy but show normal urothelial cells in a papillary configuration&#46; They have a negligible risk for progression but have a tendency to recur&#46; The intermediate grade &#40;grade 2&#41;&#44; which was the subject of controversy in the 1973 WHO classification&#44; was removed&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The prognostic value of both grading systems &#40;WHO 1973 and 2004&#41; has been confirmed&#46; However&#44; attempts to demonstrate better prognostic value of one system over another have yielded controversial results&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;11</span></a> Most clinical trials published to date on TaT1 bladder tumours used the 1973 WHO classification&#44; and therefore these guidelines are based on this scheme&#46; Both classifications can be used until more prospective trials validate the prognostic role of the WHO 2004&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Despite well-defined criteria&#44; there is interobserver variability in classifying dysplasia versus CIS&#44; stage T1 versus Ta tumours&#44; and grading of the tumours&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Consequently&#44; a review of slides is recommended&#44; particularly for T1&#44; CIS&#44; and high-grade lesions&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Specific characteristics of carcinoma in situ and its clinical classification</span><p id="par0045" class="elsevierStylePara elsevierViewall">CIS is a flat&#44; high-grade&#44; noninvasive urothelial carcinoma&#46; It can occur in the bladder&#44; in the upper urinary tract&#44; and in the prostatic ducts and urethra&#46; Bladder CIS is classified into one of three different clinical types<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#58; &#40;1&#41; primary&#44; isolated CIS with no previous or concurrent exophytic tumours&#59; &#40;2&#41; secondary&#44; CIS detected during the follow-up of patients with a previous tumour&#59; and &#40;3&#41; concurrent&#44; CIS in the presence of exophytic tumours&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis</span><p id="par0050" class="elsevierStylePara elsevierViewall">Haematuria is the most common finding in NMIBC&#46; Lower urinary tract symptoms may appear in patients with CIS&#46;</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Imaging</span><p id="par0055" class="elsevierStylePara elsevierViewall">Intravenous urography &#40;IVU&#41; is used to detect filling defects and dilation in the upper urinary tract that can indicate the presence of urothelial tumour&#46; Large exophytic tumours may be seen as filling defects in the bladder&#46; The need to perform routine IVU is now questioned because of the low incidence of significant findings<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> &#40;LE&#58; 3&#41;&#46; The incidence of simultaneous upper urinary tract tumours is low &#40;1&#46;8&#37;&#41; but increases to 7&#46;5&#37; in tumours located in the trigone&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The risk of tumour recurrence in the upper urinary tract during follow-up is increased in multiple and high-risk tumours&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Computed tomography &#40;CT&#41; urography is used as an alternative to conventional IVU&#46; In muscle-invasive tumours of the bladder and in upper urinary tract tumours&#44; CT urography provides more information than IVU &#40;LE&#58; 4&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Transabdominal ultrasound &#40;US&#41; allows the characterisation of renal masses&#44; the detection of hydronephrosis&#44; and the visualisation of intraluminal masses in the bladder&#46; It can be a useful investigative tool in patients with haematuria to detect obstruction&#59; however&#44; it cannot exclude the presence of upper urinary tract tumours &#40;LE&#58; 3&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Imaging &#40;IVU&#44; CT urography&#44; or US&#41; has no role in the diagnosis of CIS&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Urinary cytology</span><p id="par0075" class="elsevierStylePara elsevierViewall">Examining voided urine or bladder washing specimens for exfoliated cancer cells has high sensitivity in high-grade tumours but low sensitivity in low-grade tumours &#40;LE&#58; 2b&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Therefore&#44; it is useful when a high-grade tumour or CIS is present&#59; however&#44; a negative result cannot exclude the presence of a low-grade cancer&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Positive urinary cytology may indicate a urothelial tumour anywhere in the urinary tract&#46; Cytologic interpretation is user-dependent&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Cytology evaluation can be hampered by low cellular yield&#44; urinary tract infections&#44; stones&#44; or intravesical instillations&#46; With experienced cytologists&#44; the specificity exceeds 90&#37;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> &#40;LE&#58; 2b&#41;&#46; Cytology should be performed on fresh urine with adequate fixation&#46; Morning urine is not suitable because cytolysis may be present&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Urine molecular tests</span><p id="par0085" class="elsevierStylePara elsevierViewall">Numerous urinary tests for the diagnosis of bladder cancer based on the detection of soluble or cell-associated markers have been developed&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;18</span></a> Three tests are particularly promising&#44; namely&#44; NMP22&#44; UroVysion&#44; and ImmunoCyt&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#8211;21</span></a> Although most of the tests have better sensitivity than urinary cytology&#44; their specificity is lower &#40;LE&#58; 2b&#41;&#46; None of them have been accepted as a standard diagnostic procedure in routine urology to date&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The following objectives of application of urinary cytology or molecular tests must be considered&#46;</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Screening of the population at risk of non-muscle-invasive bladder cancer</span><p id="par0095" class="elsevierStylePara elsevierViewall">Use of the haematuria dipstick&#44; NMP22&#44; or UroVysion for bladder cancer screening in high-risk populations has been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> However&#44; concerns about feasibility and cost effectiveness mean that the routine application of screening has not yet been established&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Exploration of patients after haematuria or other symptoms suggestive of bladder cancer</span><p id="par0100" class="elsevierStylePara elsevierViewall">None of the urinary tests can replace cystoscopy&#46; However&#44; urinary cytology or markers can be used as an adjunct to cystoscopy to detect invisible tumours&#44; particularly CIS&#46; In this setting&#44; the method should have high sensitivity and specificity for high-grade tumours&#46; Urinary cytology is highly specific and sensitive in this regard&#44; and urinary markers are even more sensitive but less specific&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;18</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Facilitate surveillance of non-muscle-invasive bladder cancer to reduce the number of cystoscopies</span><p id="par0105" class="elsevierStylePara elsevierViewall">To reduce the number of cystoscopies&#44;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;23</span></a> tests should be able to detect recurrence before the tumours are large and numerous&#46; The limitation of urinary cytology is its low sensitivity for low-grade recurrences&#46; Several urinary markers have higher sensitivity&#44; which is still not sufficient&#46; Urinary cytology or markers cannot safely replace cystoscopy in this setting&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Cystoscopy</span><p id="par0110" class="elsevierStylePara elsevierViewall">The diagnosis of bladder cancer depends on a cystoscopic examination and histologic evaluation of the resected tissue&#46; The diagnosis of CIS is made using the combination of cystoscopy&#44; urine cytology&#44; and histologic evaluation of multiple bladder biopsies&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Cystoscopy is initially performed in the office&#44; using flexible instruments&#46; If a bladder tumour has been visualised in earlier imaging studies&#44; a diagnostic cystoscopy can be omitted&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">A careful description of the cystoscopy finding is necessary&#46; It should include the site&#44; size&#44; number&#44; and appearance &#40;papillary or solid&#41; of the tumours as well as a description of mucosal abnormalities&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Transurethral resection</span><p id="par0125" class="elsevierStylePara elsevierViewall">The goal of transurethral resection &#40;TUR&#41; in TaT1 bladder tumours is to make the correct diagnosis and remove all visible lesions&#46; Small tumours &#40;&#60;1<span class="elsevierStyleHsp" style=""></span>cm&#41; can be resected en bloc&#46; The specimen should contain a part of the underlying bladder wall&#46; Some experts believe that a deep resection is not necessary in small apparently low-grade lesions with a previous history of TaG1 tumour&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Larger tumours should be resected separately in fractions&#44; which include the exophytic part of the tumour&#44; the underlying bladder wall with the detrusor muscle&#44; and the edges of the resection area&#46; The specimens from different fractions must be referred to the pathologist in separate containers&#46; Cauterisation must be avoided as much as possible during the resection procedure to prevent tissue destruction&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The pathologic report should specify the grade of the lesion&#44; the depth of tumour invasion into the bladder wall&#44; and whether the lamina propria and muscle are present in the specimen&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> A complete and correct TUR is essential for the prognosis of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>Bladder and prostatic urethra biopsies</p><p id="par0140" class="elsevierStylePara elsevierViewall">CIS can present as a velvet-like reddish area that is indistinguishable from inflammation&#44; or it may not be visible at all&#46; When abnormal areas of the urothelium are seen&#44; it is advised to take &#8220;cold cup&#8221; biopsies or biopsies with a resection loop&#46; Biopsies from normal-looking mucosa&#44; so-called random biopsies &#40;R-biopsies&#41;&#44; should be performed in patients with positive urinary cytology in the absence of visible tumour in the bladder&#46; In patients with TaT1 tumours&#44; R-biopsies are not routinely recommended&#46; The likelihood of detecting CIS in low-risk tumours is extremely low &#40;&#60;2&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> &#40;LE&#58; 2a&#41;&#46; R-biopsies should be performed in TaT1 tumours when cytology is positive or when the exophytic tumour appears nonpapillary&#46; It is recommended to take R-biopsies from the trigone&#44; bladder dome&#44; and from the right&#44; left&#44; anterior&#44; and posterior bladder walls&#46; Material obtained by random or directed biopsies must be sent for pathologic assessment in separate containers&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The involvement of the prostatic urethra and ducts in male patients with NMIBC has been reported&#46; The risk seems to be higher if the tumour is located on the trigone or bladder neck&#44; in the presence of bladder CIS&#44; and in multiple tumours<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> &#40;LE&#58; 3&#41;&#46; In these cases and when cytology is positive with no evidence of tumour in the bladder or when abnormalities of prostatic urethra are visible&#44; biopsies of the prostatic urethra are recommended&#46; The biopsy is taken from abnormal areas and from the precollicular area between the 5 o&#8217;clock and 7 o&#8217;clock positions using a resection loop&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Photodynamic diagnosis &#40;fluorescence cystoscopy&#41;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Photodynamic diagnosis &#40;PDD&#41; is performed using violet light after intravesical instillation of 5-aminolaevulinic acid &#40;5-ALA&#41; or hexaminolevulinic acid &#40;HAL&#41;&#46; Fluorescence-guided biopsy and resection are more sensitive than conventional procedures for the detection of malignant tumours&#44; particularly CIS&#46; The additional detection rate of PDD was 20&#37; for all tumours and 23&#37; for CIS in a cumulative analysis of prospective trials<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> &#40;LE&#58; 2a&#41;&#46; However&#44; false positivity can be induced by inflammation&#44; recent TUR&#44; or bacillus Calmette-Gu&#233;rin &#40;BCG&#41; intravesical instillation during the previous 3 mo&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The benefit of 5-ALA fluorescence-guided TUR for recurrence-free survival has been considered&#46; Cumulative analysis of three trials has shown that recurrence-free survival was 15&#46;8&#8211;27&#37; higher at 12 mo in the fluorescence-guided TUR groups compared with the white light cystoscopy alone groups<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> &#40;LE&#58; 2a&#41;&#46; However&#44; a large Swedish study could not detect any advantage in using 5-ALA fluorescence-guided TUR&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> A recent trial that compared HAL fluorescence-guided TUR with standard TUR reported an absolute reduction of no more than 9&#37; in the recurrence rate within 9 mo in the HAL arm&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">The value of fluorescence cystoscopy for improvement of the outcome in relation to progression rate or survival remains to be demonstrated&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">PDD should be restricted to those patients who are suspected of harbouring a high-grade tumour&#44; particularly CIS &#40;e&#46;g&#46;&#44; for biopsy guidance in patients with positive cytology or with a history of high-grade tumour&#41;&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Second resection</span><p id="par0170" class="elsevierStylePara elsevierViewall">A significant risk of residual tumour after the initial TUR of TaT1 lesions has been shown<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;31</span></a> &#40;LE&#58;1b&#41;&#46; Moreover&#44; the tumour may be understaged by the initial resection&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">A second TUR should be considered if there is any suspicion that the initial resection was incomplete &#40;e&#46;g&#46;&#44; when multiple or large tumours are present or when the pathologist reported no muscle tissue in the specimen&#41;&#46; Furthermore&#44; it should be performed when a high-grade non-muscle-invasive tumour or a T1 tumour was detected at the initial TUR&#46; A second TUR can increase recurrence-free survival<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> &#40;LE&#58; 2a&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Second resection should be performed 2&#8211;6 wk after the initial TUR&#46; The procedure should include a resection of the primary tumour site&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> summarises the recommendations for the diagnosis of NMIBC&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Predicting recurrence and progression</span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Prognosis of TaT1 tumours</span><p id="par0190" class="elsevierStylePara elsevierViewall">The classic way to categorise patients with TaT1 tumours is to divide them into risk groups based on prognostic factors derived from multivariate analyses&#46; To predict separately the short- and long-term risks of both recurrence and progression in individual patients&#44; a scoring system and risk tables were developed by the European Organisation for Research and Treatment of Cancer &#40;EORTC&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> The EORTC database provided individual data for 2596 patients diagnosed with TaT1 tumours who did not have a second TUR or receive maintenance BCG therapy&#46; The EORTC scoring system is based on the six most significant clinical and pathologic factors&#58; number of tumours&#44; tumour size&#44; prior recurrence rate&#44; T category&#44; presence of concomitant CIS&#44; and tumour grade&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> illustrates the weights applied to various factors for calculating the total scores for recurrence and progression&#46; <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> shows the total scores stratified into four categories reflecting the probabilities of recurrence and progression at 1 and 5 yr&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> With combining two of the four categories distinctly in recurrence and progression&#44; the EAU working group suggests using a three-tier classification system defining low-&#44; intermediate-&#44; and high-risk groups &#40;as shown in the right-most column in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">A scoring model for BCG-treated patients that predicts the short- and long-term risks of recurrence and progression was recently developed by the Club Urol&#243;gico Espa&#241;ol de Tratamiento Oncol&#243;gico &#40;CUETO&#59; Spanish Oncology Group&#41;&#46; Using these tables&#44; the calculated risk of recurrence is lower than that obtained by the EORTC tables&#46; For progression probabilities&#44; it is lower only in high-risk patients&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> The lower risks in the CUETO tables may be attributable to using a more effective instillation therapy in the individual studies on which the tables are based&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Prognosis of carcinoma in situ</span><p id="par0205" class="elsevierStylePara elsevierViewall">Without any treatment&#44; approximately 54&#37; of patients with CIS progress to muscle-invasive disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;35</span></a> There are no reliable prognostic factors that can be used to predict the course of CIS&#46; Some studies have reported a worse prognosis in patients with concurrent CIS and T1 tumours compared with primary CIS&#44; extended CIS&#44; and those who do not respond to BCG treatment<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;36</span></a> &#40;LE&#58; 3&#41;&#46;</p></span></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Adjuvant intravesical chemotherapy</span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">One immediate postoperative intravesical instillation</span><p id="par0210" class="elsevierStylePara elsevierViewall">TaT1 tumours recur frequently and progress to muscle-invasive disease in a limited number of cases&#46; It is therefore necessary to consider adjuvant therapy in all patients&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">The results of a meta-analysis of seven randomised trials demonstrated that one immediate instillation of chemotherapy after TUR significantly reduced recurrence compared with TUR alone &#40;LE&#58; 1a&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> In absolute values&#44; the reduction was 11&#46;7&#37;&#44; which implies a 24&#46;2&#37; decrease in the corresponding relative risk&#46; The efficacy of the single instillation has also been confirmed by two recently published studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#44;39</span></a> In one of these&#44; the benefit was mainly seen in primary and single tumours&#46; When stratified according to EORTC recurrence scores&#44; the benefit was observed in patients with scores of 0&#8211;2 but not with scores &#8805;3&#46; However&#44; the study was not sufficiently powered for subgroup analyses&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">No prospective data are available showing that the single instillation significantly reduces recurrence rates in patients with recurrent tumours&#46; Nevertheless&#44; there is significant evidence from one subgroup analysis that immediate instillation might have an impact on the repeat instillation regimens for the treatment of patients who have an intermediate and high risk of recurrence<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> &#40;LE&#58; 2a&#41;&#46; There are no statistically relevant data that address the role of immediate chemotherapy instillation before further BCG intravesical treatment in tumours with a high risk of progression&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">In summary&#44; one immediate instillation of chemotherapy significantly reduces the risk of recurrence of TaT1 bladder cancer&#46; Further studies are required&#44; however&#44; to determine the definitive role of immediate chemotherapy before BCG or further chemotherapy instillations in intermediate- and high-risk groups&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Adjuvant chemotherapy is thought to mediate its effect by destroying circulating tumour cells or having an ablative effect on residual tumour cells at the resection site&#46; Prevention of tumour cell implantation should be initiated within the first hours after cell seeding&#46; In all studies&#44; the instillation was administered within 24<span class="elsevierStyleHsp" style=""></span>h&#46; Subgroup analysis of one study has shown that&#44; if the first instillation was not given on the same day as TUR&#44; there was a twofold increase in the relative risk of recurrence<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> &#40;LE&#58; 2a&#41;&#46; A study in which the instillation was not given strictly on the same day did not find any advantage&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Mitomycin C &#40;MMC&#41;&#44; epirubicin&#44; and doxorubicin have all shown comparable beneficial effects<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> &#40;LE&#58; 1a&#41;&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Early immediate instillation of chemotherapy is recommended in tumours at low risk of recurrence and progression as the only intravesical treatment&#46; A single instillation is considered as the initial stage of further intravesical therapy in those presumably at intermediate risk&#46; In tumours that presumably have a high risk of progression &#40;solid lesions&#44; positive urinary cytology&#41;&#44; immediate instillation is an option because it can have a positive impact on the recurrence rate through prevention of tumour cell implantation&#46; However&#44; there is no doubt that subsequent BCG intravesical immunotherapy is an essential treatment option in these patients&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">The instillation of chemotherapy should be omitted in any case of overt or suspected intra- or extraperitoneal perforation&#44; which is most likely to appear in extensive TUR procedures and in situations with difficult bleeding requiring bladder irrigation&#46; Severe complications have been reported in patients in whom extravasation of the drug occurs&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> Clear instructions should be given to the nursing staff to control the free flow of the bladder catheter at the end of the instillation&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Additional intravesical chemotherapy instillations</span><p id="par0250" class="elsevierStylePara elsevierViewall">The need for further adjuvant intravesical therapy depends on the patient&#39;s prognosis&#46; In patients with a low risk of recurrence &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#44; a single immediate instillation is considered to be sufficient treatment<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> &#40;LE&#58; 1a&#41;&#46; For other patients&#44; however&#44; it remains an incomplete treatment because the likelihood of recurrence and&#47;or progression is considerable&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">The choice between further chemotherapy or BCG immunotherapy largely depends on the risk that needs to be reduced&#58; recurrence or progression&#46; A meta-analysis comparing intravesical chemotherapy with TUR alone demonstrated that chemotherapy prevents recurrence but not progression<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> &#40;LE&#58; 1a&#41;&#46; The efficacy of intravesical chemotherapy in reducing the risk of tumour recurrence was confirmed by two other meta-analyses in primary<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> and recurrent tumours&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">It is still controversial how long and how frequently intravesical chemotherapy instillations should be given&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> Nevertheless&#44; the available evidence does not support any treatment schedule &#62;1 yr&#46;</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Optimising intravesical chemotherapy</span><p id="par0265" class="elsevierStylePara elsevierViewall">Adapting the urinary pH&#44; decreasing urinary excretion&#44; and buffering the intravesical solution can reduce the recurrence rate<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> &#40;LE&#58; 1b&#41;&#46; Concentration was more important than treatment duration<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> &#40;LE&#58; 1b&#41;&#46; In view of these data&#44; it seems advisable to dissolve the drug in a buffered solution at optimal pH and to instruct the patient not to drink on the morning before instillation&#46;</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Adjuvant intravesical bacillus Calmette-Gu&#233;rin immunotherapy</span><p id="par0270" class="elsevierStylePara elsevierViewall">The superiority of BCG after TUR compared with TUR alone or TUR and chemotherapy in preventing recurrences of TaT1 tumours has been confirmed<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#8211;56</span></a> &#40;LE&#58; 1a&#41;&#46; The clinical effect is long lasting&#44;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54&#44;55</span></a> and it was also observed in a separate analysis of patients with intermediate-risk tumours&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">A recently published meta-analysis<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> evaluated individual data from 2820 patients who were enrolled in nine randomised studies that compared MMC with BCG&#46; In the BCG maintenance trials&#44; a 32&#37; reduction in the risk of recurrence was found for BCG compared with MMC &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#44; whereas BCG without maintenance was less effective than MMC&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Data from two meta-analyses demonstrated that BCG therapy prevents&#44; or at least delays&#44; the risk of tumour progression<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">57&#44;58</span></a> &#40;LE&#58; 1a&#41;&#46; The EORTC meta-analysis demonstrated a reduction of 27&#37; in the odds of progression with BCG maintenance treatment &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> A recent randomised study with a long-term observation period demonstrated significantly fewer distant metastases and better overall and disease-specific survival in patients treated with BCG compared with epirubicin&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> On the contrary&#44; a meta-analysis of individual patient data was unable to confirm any statistically significant difference between MMC and BCG for progression&#44; survival&#44; and cause of death&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">In summary&#44; despite these conflicting results&#44; most of the data were able to show a reduction in the risk of progression in tumours with high and intermediate risk if BCG including a maintenance schedule was used&#46;The optimal bacillus Calmette-Gu&#233;rin</p><p id="par0290" class="elsevierStylePara elsevierViewall">For optimal efficacy&#44; BCG should be given on a maintenance schedule<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">52&#8211;58</span></a> &#40;LE&#58; 1a&#41;&#46; The observations from the EORTC meta-analysis revealed that only patients receiving maintenance BCG benefitted&#46; In the four trials where no maintenance BCG was given&#44; no reduction in progression was observed&#46; In the 20 trials in which some form of BCG maintenance was given&#44; a reduction of 37&#37; in the odds of progression was observed &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;00004&#41;&#46; However&#44; the meta-analysis was unable to determine which BCG maintenance schedule was the most effective&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> The conclusions of other meta-analyses stated that at least 1 yr of maintenance BCG was required to show the superiority of BCG over MMC in preventing recurrence or progression&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">52&#44;58</span></a></p><p id="par0295" class="elsevierStylePara elsevierViewall">Induction BCG instillations are classically given according to the empirical 6-weekly induction schedule&#44; and many different maintenance schedules have been used with up to 30 instillations given over 3 yr&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> The optimal number of induction instillations and the optimal frequency and duration of maintenance instillations remain unknown&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">To reduce toxicity&#44; one-third and one-quarter doses of BCG have been proposed&#46; No overall difference in BCG efficacy was found when the one-third dose was compared with the full dose&#46; However&#44; there was a suggestion that a full dose of BCG may be more effective in multifocal disease<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> &#40;LE&#58; 1b&#41;&#46; Although fewer patients reported toxicity with the reduced dose&#44; the incidence of severe systemic toxicity was similar&#46; A further reduction of BCG to one-sixth dose was associated with decreased efficacy but with equal toxicity&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a></p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Bacillus Calmette-Gu&#233;rin toxicity</span><p id="par0305" class="elsevierStylePara elsevierViewall">The use of BCG has been compromised because of tolerability issues&#44; namely&#44; deaths due to BCG sepsis and BCG-induced cystitis&#46; However&#44; with increased experience in using BCG&#44; the side effects now appear to be less prominent&#46; Fewer than 5&#37; of patients experience serious side effects with BCG use<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a> &#40;LE&#58; 1b&#41;&#46; Major complications can appear after systemic absorption of the drug&#46; BCG should not be administered during the first 2 wk after TUR&#44; in patients with haematuria or urinary tract infection&#44; after traumatic catheterisation&#44; or in immunocompromised patients &#40;LE&#58; 2b&#41;&#46; The management of side effects after BCG therapy should reflect their type and grade&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a></p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Indications for bacillus Calmette-Gu&#233;rin</span><p id="par0310" class="elsevierStylePara elsevierViewall">There is a consensus that not all patients with NMIBC should be treated with BCG due to the risk of toxicity&#46; BCG use does not alter the natural course of tumours with a low risk of recurrence &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41; and may be considered overtreatment for this category of patients&#46; In patients with tumours with a high risk of progression&#44; BCG including a maintenance schedule is recommended&#46; BCG with 1-yr maintenance is more effective than chemotherapy for preventing recurrence in patients with an intermediate or high risk of recurrence and intermediate risk of progression&#59; however&#44; BCG has more side effects than chemotherapy&#46; For this reason both BCG with maintenance and intravesical chemotherapy remain a treatment option&#46; The final choice should reflect the individual patient&#39;s risk and the efficacy and tolerability of each treatment modality&#46; <a class="elsevierStyleCrossRefs" href="#tbl0030">Tables 6 and 7</a> summarise the recommendations for intravesical therapy in TaT1 tumours&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><elsevierMultimedia ident="tbl0035"></elsevierMultimedia><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Specific aspects of treatment of carcinoma in situ</span><p id="par0315" class="elsevierStylePara elsevierViewall">CIS cannot be resolved by endoscopic procedure alone&#46; Histologic diagnosis of CIS must be followed by further treatment&#44; either intravesical instillations or radical cystectomy &#40;LE&#58; 2&#41;&#46; No consensus exists about whether conservative therapy &#40;intravesical BCG instillations&#41; or aggressive therapy &#40;cystectomy&#41; should be performed&#46; Tumour-specific survival rates after early cystectomy for CIS are excellent&#44; but up to 40&#8211;50&#37; of patients may be overtreated&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Intravesical treatment of bladder carcinoma in situ</span><p id="par0320" class="elsevierStylePara elsevierViewall">Retrospective evaluations have reported a complete response rate of 48&#37; with intravesical chemotherapy and 72&#8211;93&#37; with BCG &#40;LE&#58; 2a&#41;&#46; The results of a meta-analysis of clinical trials in CIS patients that compared intravesical BCG with chemotherapy showed a significantly increased response rate after BCG and a reduction of 59&#37; in the odds of treatment failure with BCG &#40;odds ratio &#91;OR&#93;&#58; 0&#46;41&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; Clinical trials that compared BCG with MMC showed that the long-term benefit of BCG was smaller&#44; but BCG was superior to MMC in BCG maintenance studies &#40;OR&#58; 0&#46;57&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a></p><p id="par0325" class="elsevierStylePara elsevierViewall">The EORTC meta-analysis of tumour progression in a subgroup of 403 CIS patients showed that BCG reduced the risk of progression by 35&#37; compared with intravesical chemotherapy or different immunotherapy<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> &#40;LE&#58; 1a&#41;&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">In summary&#44; when compared with chemotherapy&#44; BCG treatment increases the complete response rate&#44; the overall percentage of patients who remain disease-free&#44; and reduces the risk of tumour progression in CIS patients &#40;LE&#58; 1a&#41;&#46;</p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Treatment of extravesical carcinoma in situ</span><p id="par0335" class="elsevierStylePara elsevierViewall">Patients with CIS in the epithelial lining of the prostatic urethra can be treated with intravesical instillations of BCG&#46; Previous TUR of the prostate can improve the contact of BCG with the prostatic urethra<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> &#40;LE&#58; 3&#41;&#46; In patients with prostatic duct involvement&#44; radical surgery should be considered<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> &#40;LE&#58; 3&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a> summarises the recommendations for therapy of CIS&#46;</p></span></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Treatment of failures of intravesical therapy</span><p id="par0340" class="elsevierStylePara elsevierViewall">Patients with non-muscle-invasive recurrences after intravesical chemotherapy can benefit from BCG instillations &#40;LE&#58; 1a&#41;&#46; Treatment with BCG is considered to have failed in the following situations&#58; &#40;1&#41; where muscle-invasive tumour is detected during follow-up&#59; &#40;2&#41; when high-grade non-muscle-invasive tumour is present at both 3 and 6 mo&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> In patients with tumour present at 3 mo&#44; an additional BCG course can achieve complete response in &#62;50&#37; of cases<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;66</span></a> but increases the risk of progression<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">67&#44;68</span></a>&#59; and &#40;3&#41; any deterioration of the disease under BCG treatment&#44; such as a higher number of recurrences&#44; higher T stage or higher grade&#44; or the appearance of CIS&#44; despite an initial response &#40;LE&#58; 3&#41;&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">Changing from BCG to intravesical chemotherapy&#44; device-assisted chemotherapy instillations&#44; or additional interferon &#945;-2b can yield responses in selected cases with non-muscle-invasive BCG treatment failure&#46; However&#44; these strategies are considered experimental&#46; Due to an increased risk of developing muscle-invasive tumour<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">66&#44;68</span></a> &#40;LE&#58; 3&#41;&#44; cystectomy is strongly advocated following early BCG failure in fit patients&#46;</p><p id="par0350" class="elsevierStylePara elsevierViewall">Patients with recurrence at &#62;1 yr after completion of BCG therapy can be treated according to the risk classification defined in <a class="elsevierStyleCrossRefs" href="#tbl0020">Tables 4&#8211;6</a>&#46;</p></span></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Cystectomy for non-muscle-invasive bladder cancer</span><p id="par0355" class="elsevierStylePara elsevierViewall">Immediate cystectomy can be considered for those patients who are at high risk of progression&#46; According to the EORTC tables &#40;<a class="elsevierStyleCrossRefs" href="#tbl0020">Tables 4 and 5</a>&#41;&#44; these patients have multiple recurrent high-grade tumours&#44; high-grade T1 tumours&#44; and high-grade tumours with concurrent CIS&#46; Cystectomy is advocated in patients with BCG failure&#46; Delaying cystectomy in these patients may lead to decreased disease-specific survival&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a></p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Follow-up</span><p id="par0360" class="elsevierStylePara elsevierViewall">Patients need to be followed up because of the risk of recurrence and progression&#59; however&#44; the frequency and duration of cystoscopies and upper urinary tract investigations should reflect the degree of risk&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> When planning a follow-up schedule&#44; the following aspects should be considered&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0365" class="elsevierStylePara elsevierViewall">Prompt detection of muscle-invasive and high-grade non-muscle-invasive recurrence is crucial because a delay in diagnosis and therapy can be life threatening&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0370" class="elsevierStylePara elsevierViewall">Tumour recurrence in the low-risk group is nearly always low stage and low grade&#46; Small non-invasive &#40;Ta&#41;&#44; low-grade papillary recurrences do not present an immediate danger to the patient&#44; and early detection is not essential for successful therapy<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> &#40;LE&#58; 2b&#41;&#46; In these patients&#44; fulguration of small papillary recurrences on an outpatient basis is considered a safe treatment option<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a> &#40;LE&#58; 3&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0375" class="elsevierStylePara elsevierViewall">The result of the first cystoscopy after TUR at 3 mo is a very important prognostic factor for recurrence and progression<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;67&#44;72</span></a> &#40;LE&#58; 1a&#41;&#46; The first cystoscopy should always be performed 3 mo after TUR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0380" class="elsevierStylePara elsevierViewall">The risk of upper urinary tract recurrence increases in patients with multiple and high-risk tumours<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> &#40;LE&#58; 3&#41;&#46;</p></li></ul></p><p id="par0385" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0040">Table 8</a> lists the recommendations for the follow-up schedule of NMIBC&#46;</p><elsevierMultimedia ident="tbl0040"></elsevierMultimedia></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Author contributions</span><p id="par0390" class="elsevierStylePara elsevierViewall">Marko Babjuk had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis&#46;</p><p id="par0395" class="elsevierStylePara elsevierViewall">Study concept and design&#58; Babjuk&#44; Oosterlinck&#46;</p><p id="par0400" class="elsevierStylePara elsevierViewall">Acquisition of data&#58; Babjuk&#44; Oosterlinck&#44; Sylvester&#44; Kaasinen&#44; B&#246;hle&#44; Palou-Redorta&#44; Roupr&#234;t&#46;</p><p id="par0405" class="elsevierStylePara elsevierViewall">Analysis and interpretation of data&#58; Babjuk&#44; Oosterlinck&#46;</p><p id="par0410" class="elsevierStylePara elsevierViewall">Drafting of the manuscript&#58; Babjuk&#46;</p><p id="par0415" class="elsevierStylePara elsevierViewall">Critical revision of the manuscript for important intellectual content&#58; Babjuk&#44; Oosterlinck&#44; Sylvester&#44; Kaasinen&#44; B&#246;hle&#44; Palou&#44; Roupr&#234;t&#46;</p><p id="par0420" class="elsevierStylePara elsevierViewall">Statistical analysis&#58; Babjuk&#44; Sylvester&#46;</p><p id="par0425" class="elsevierStylePara elsevierViewall">Obtaining funding&#58; None&#46;</p><p id="par0430" class="elsevierStylePara elsevierViewall">Administrative&#44; technical&#44; or material support&#58; None&#46;</p><p id="par0435" class="elsevierStylePara elsevierViewall">Supervision&#58; Babjuk&#44; Oosterlinck&#46;</p><p id="par0440" class="elsevierStylePara elsevierViewall">Other &#40;specify&#41;&#58; None&#46;</p></span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0445" class="elsevierStylePara elsevierViewall">I certify that all conflicts of interest&#44; including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript &#40;e&#46;g&#46;&#44; employment&#47;affiliation&#44; grants or funding&#44; consultancies&#44; honoraria&#44; stock ownership or options&#44; expert testimony&#44; royalties&#44; or patents filed&#44; received&#44; or pending&#41;&#44; are the following&#58; Marko Babjuk receives speaker honoraria from GE Healthcare and GSK&#46; Willem Oosterlinck is a company consultant and receives fellowship and travel grants from GSK&#44; receives speaker honoraria from Pfizer&#44; participates in trials for Amgen&#44; Astra Zeneca&#44; and Astellas&#44; and receives fellowships and travel and research grants from Astra Zeneca&#46; Morgan Roupr&#234;t has nothing to disclose&#46; Juan Palou-Redorta is a consultant and receives speaker honoraria from Sanofi-Pasteur and General Electric&#46; He also participates in trials for General Electric&#46; Andreas B&#246;hle receives speaker honoraria from Sanofi-Aventis&#44; Medac&#44; Bard&#44; and Fresenius&#46; Eero Kaasinen receives research grants from the Pfizer Foundation and for a research group at Pfizer&#46; Richard Sylvester is a consultant for Bioniche&#44; Allergan&#44; and Astra Zeneca&#44; and he received speaker honoraria from the Kyowa 2008 EAU Satellite Symposium&#46;</p><p id="par0450" class="elsevierStylePara elsevierViewall">Funding&#47;Support and role of the sponsor&#58; None&#46;</p></span></span>"
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              "titulo" => "Adjuvant intravesical bacillus Calmette-Gu&#233;rin immunotherapy"
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              "titulo" => "Bacillus Calmette-Gu&#233;rin toxicity"
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          "titulo" => "Cystectomy for non-muscle-invasive bladder cancer"
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            0 => "Bacillus Calmette-Gu&#233;rin &#40;BCG&#41;"
            1 => "Bladder cancer"
            2 => "Cystectomy"
            3 => "Cystoscopy"
            4 => "Diagnosis"
            5 => "European Association of Urology Guidelines"
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            1 => "C&#225;ncer de vejiga"
            2 => "Cistectom&#237;a"
            3 => "Cistoscopia"
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            5 => "Gu&#237;a cl&#237;nica de la Asociaci&#243;n Europea de Urolog&#237;a"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Context and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To present the 2011 European Association of Urology &#40;EAU&#41; guidelines on non-muscle-invasive bladder cancer &#40;NMIBC&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Evidence acquisition</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Literature published between 2004 and 2010 on the diagnosis and treatment of NMIBC was systematically reviewed&#46; Previous guidelines were updated&#44; and the level of evidence and grade of recommendation were assigned&#46;</p> <span class="elsevierStyleSectionTitle">Evidence synthesis</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Tumours staged as Ta&#44; T1&#44; or carcinoma in situ &#40;CIS&#41; are grouped as NMIBC&#46; Diagnosis depends on cystoscopy and histologic evaluation of the tissue obtained by transurethral resection &#40;TUR&#41; in papillary tumours or by multiple bladder biopsies in CIS&#46; In papillary lesions&#44; a complete TUR is essential for the patient&#39;s prognosis&#46; Where the initial resection is incomplete or where a high-grade or T1 tumour is detected&#44; a second TUR should be performed within 2&#8211;6 wk&#46; In papillary tumours&#44; the risks of both recurrence and progression may be estimated for individual patients using the scoring system and risk tables&#46; The stratification of patients into low-&#44; intermediate-&#44; and high-risk groups &#40;separately for recurrence and progression&#41; is pivotal to recommending adjuvant treatment&#46; For patients with a low risk of tumour recurrence and progression&#44; one immediate instillation of chemotherapy is recommended&#46; Patients with an intermediate or high risk of recurrence and an intermediate risk of progression should receive one immediate instillation of chemotherapy followed by a minimum of 1 yr of bacillus Calmette-Gu&#233;rin &#40;BCG&#41; intravesical immunotherapy or further instillations of chemotherapy&#46; Papillary tumours with a high risk of progression and CIS should receive intravesical BCG for 1 yr&#46; Cystectomy may be offered to the highest risk patients&#44; and it is at least recommended in BCG failure patients&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">These abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Contexto y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Presentar la gu&#237;a cl&#237;nica de la Asociaci&#243;n Europea de Urolog&#237;a &#40;EAU&#41; de 2011 del carcinoma de vejiga no m&#250;sculo-invasivo &#40;CVNMI&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Adquisici&#243;n de la evidencia</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se ha realizado una revisi&#243;n sistem&#225;tica de la literatura publicada entre 2004 y 2010 acerca del diagn&#243;stico y el tratamiento del CVNMI&#46; Se actualizaron las gu&#237;as cl&#237;nicas previas&#44; y se asign&#243; un nivel de evidencia &#40;NE&#41; y un grado de recomendaci&#243;n &#40;GR&#41;&#46;</p> <span class="elsevierStyleSectionTitle">S&#237;ntesis de la evidencia</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Los tumores en estadio Ta&#44; T1 o carcinoma in situ &#40;CIS&#41; se agrupan como CVNMI&#46; El diagn&#243;stico depende de la cistoscopia y de la evaluaci&#243;n histol&#243;gica del tejido obtenido por resecci&#243;n transuretral &#40;RTU&#41; en los tumores papilares o por biopsias de vejiga m&#250;ltiples en el CIS&#46; En las lesiones papilares&#44; una completa RTU es esencial para el pron&#243;stico del paciente&#46; Cuando la primera resecci&#243;n es incompleta o cuando se detecta un tumor de alto grado o T1&#44; se debe realizar una segunda RTU a las 2-6 semanas&#46; En los tumores papilares&#44; el riesgo tanto de recurrencia como de progresi&#243;n se puede calcular de manera individual mediante los sistemas de puntuaci&#243;n y tablas de riesgo&#46; La estratificaci&#243;n de los pacientes en grupos de riesgo bajo&#44; intermedio y alto &#40;separando la recidiva y la progresi&#243;n&#41; es fundamental para recomendar un tratamiento adyuvante&#46; Para los pacientes con bajo riesgo de recurrencia y progresi&#243;n se recomienda una instilaci&#243;n inmediata de quimioterapia&#46; Los pacientes con riesgo intermedio o alto de recurrencia y riesgo intermedio de progresi&#243;n deben recibir una instilaci&#243;n inmediata de quimioterapia seguida de un m&#237;nimo de un a&#241;no con inmunoterapia intravesical con bacilo de Calmette-Gu&#233;rin &#40;BCG&#41; o m&#225;s instilaciones de quimioterapia&#46; Los tumores papilares con alto riesgo de progresi&#243;n y CIS deben recibir BCG intravesical durante un a&#241;o&#46; Se puede ofrecer una cistectom&#237;a a los pacientes de m&#225;s alto riesgo&#44; y por lo menos se recomienda a los pacientes en los que ha fallado la BCG&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La versi&#243;n reducida de esta gu&#237;a cl&#237;nica de la EAU presenta una informaci&#243;n actualizada sobre el diagn&#243;stico y el tratamiento del CVNMI para la incorporaci&#243;n a la pr&#225;ctica cl&#237;nica&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Badjuk M&#44; et al&#46; Gu&#237;a cl&#237;nica del carcinoma urotelial de vejiga no m&#250;sculo-invasivo de la Asociaci&#243;n Europea de Urolog&#237;a&#46; Actualizaci&#243;n de 2011&#46; Actas Urol Esp&#46; 2012&#59;36&#58;389&#8211;402&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">The translation of this article was carried out with the permission of the European Association of Urology&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No evidence of primary tumour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ta&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Noninvasive papillary carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Carcinoma in situ&#58; &#8216;flat tumour&#8217;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>T1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tumour invades subepithelial connective tissue&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>T2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tumour invades muscle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">T2a Tumour invades superficial muscle &#40;inner half&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">T2b Tumour invades deep muscle &#40;outer half&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>T3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tumour invades perivesical tissue&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">T3a Microscopically&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">T3b Macroscopically &#40;extravesical mass&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>T4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tumour invades any of the following&#58; prostate&#44; uterus&#44; vagina&#44; pelvic wall&#44; abdominal wall&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">T4a Tumour invades prostate&#44; uterus&#44; or vagina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">T4b Tumour invades pelvic wall or abdominal wall&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">N Lymph nodes</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>NX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Regional lymph nodes cannot be assessed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No regional lymph node metastasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metastasis in a single lymph node in the true pelvis &#40;hypogastric&#44; obturator&#44; external iliac&#44; or presacral&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metastasis in multiple lymph nodes in the true pelvis &#40;hypogastric&#44; obturator&#44; external iliac&#44; or presacral&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metastasis in a common iliac lymph node&#40;s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">M Distant metastasis</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>MX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Distant metastasis cannot be assessed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>M0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No distant metastasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>M1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Distant metastasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">2009 TNM classification of urinary bladder cancer&#46;</p>"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">WHO<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>World Health Organisation&#59; CIS<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>carcinoma in situ&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">1973 WHO grading</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Urothelial papilloma</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Grade 1&#58; well differentiated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Grade 2&#58; moderately differentiated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Grade 3&#58; poorly differentiated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">2004 WHO grading</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Flat lesions</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Hyperplasia &#40;flat lesion without atypia or papillary&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Reactive atypia &#40;flat lesion with atypia&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Atypia of unknown significance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Urothelial dysplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Urothelial CIS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Papillary lesions</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Urothelial papilloma &#40;which is a completely benign lesion&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Papillary urothelial neoplasm of low malignant potential&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Low-grade papillary urothelial carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>High-grade papillary urothelial carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab184256.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">World Health Organisation grading in 1973 and in 2004&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">GR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>grade&#59; US<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>ultrasound&#59; CT<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>computed tomography&#59; IVU<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>intravenous urography&#59; TUR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>transurethral resection&#59; CIS<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>carcinoma in situ&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">GR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The renal and bladder US may be used during initial workup in patients with haematuria&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">At the time of initial diagnosis of bladder cancer&#44; CT urography or IVU should be performed only in selected cases &#40;e&#46;g&#46;&#44; tumours located in the trigone&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cystoscopy is recommended in all patients with symptoms suggestive of bladder cancer&#46; It cannot be replaced by cytology or by any other noninvasive test&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cystoscopy should describe all macroscopic features of the tumour &#40;site&#44; size&#44; number&#44; and appearance&#41; and mucosal abnormalities&#46; A bladder diagram is recommended&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Voided urine cytology or urinary markers are advocated to predict high-grade tumour before TUR&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">It is recommended to perform TUR in one piece for small papillary tumours &#40;&#60;1<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; including part of the underlying bladder wall&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">It is recommended to perform TUR in fractions &#40;including muscle tissue&#41; for tumours &#62;1<span class="elsevierStyleHsp" style=""></span>cm in diameter&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">It is recommended to take biopsies from abnormal-looking urothelium&#46; Biopsies from normal-looking mucosa &#40;trigone&#44; bladder dome&#44; and from right&#44; left&#44; anterior&#44; and posterior bladder walls&#41; are recommended only when cytology is positive or when exophytic tumour has a nonpapillary appearance&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Biopsy of the prostatic urethra is recommended for cases of bladder neck tumour&#44; when bladder CIS is present or suspected&#44; when there is positive cytology without evidence of tumour in the bladder&#44; or when abnormalities of prostatic urethra are visible&#46; If biopsy is not performed during the initial procedure&#44; it should be completed at the time of the second resection&#46; The biopsy should be taken from the precollicular area between 5 and 7 o&#8217;clock positions using a resection loop&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">If equipment is available&#44; fluorescence-guided biopsy when bladder CIS is suspected &#40;e&#46;g&#46;&#44; positive cytology&#44; recurrent tumour with previous history of a high-grade lesion&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A second TUR should be performed 2&#8211;6 wk after the initial resection when the latter is incomplete &#40;in large and multiple tumours&#44; no muscle in the specimen&#41; or when an exophytic high-grade and&#47;or T1 tumour is detected&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The pathologic report should specify the grade&#44; the depth of tumour invasion&#44; and whether the lamina propria and muscle are present in the specimen&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab184252.png"
              ]
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Recommendations for the diagnosis of non-muscle-invasive bladder cancer&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">CIS<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>carcinoma in situ&#59; WHO<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>World Health Organisation&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Factor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Recurrence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Progression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">No&#46; of tumours</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Single&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#8211;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8805;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Tumour diameter</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;3<span class="elsevierStyleHsp" style=""></span>cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8805;3<span class="elsevierStyleVsp" style="height:0.5px"></span>cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Prior recurrence rate</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Primary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8804;1 recurrence per year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;1 recurrence per year&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ta&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Grade &#40;1973 WHO&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>G1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>G2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>G3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#8211;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#8211;23&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Weighting used to calculate recurrence and progression scores&#46;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t">Recurrence score&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;10&#8211;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Low risk&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#8211;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;21&#8211;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;42&#8211;49&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intermediate risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#8211;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;35&#8211;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;58&#8211;65&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#8211;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;55&#8211;67&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;73&#8211;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            1 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Progression score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Probability of progression at 1 yr</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Probability of progression at 5 yr</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Progression risk group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#8211;0&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#8211;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Low risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#8211;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;0&#46;4&#8211;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;5&#8211;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intermediate risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#8211;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;4&#8211;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;14&#8211;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#8211;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;10&#8211;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;35&#8211;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab184255.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara">Electronic calculator for Table 5 is available at <span class="elsevierStyleInterRef" href="http://www.eortc.be/tools/bladdercalculator/">http&#58;&#47;&#47;www&#46;eortc&#46;be&#47;tools&#47;bladdercalculator&#47;</span>&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Probability of recurrence and progression according to total score&#46;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a></p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0030"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">BCG<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>bacillus Calmette-Gu&#233;rin&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Risk category&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Intermediate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Recurrence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">One immediate instillation of chemotherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">One immediate instillation of chemotherapy&#44; followed by further instillations&#44; either chemotherapy or a minimum 1 yr of BCG &#40;the final choice is determined by the risk of tumour progression&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">One immediate instillation of chemotherapy&#44; followed by further instillations&#44; either chemotherapy or a minimum of 1 yr of BCG &#40;the final choice is determined by the risk of tumour progression&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Progression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">One immediate instillation of chemotherapy &#40;it can be followed by further chemotherapy instillations if the patient has an intermediate risk of recurrence at the same time&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">One immediate instillation of chemotherapy&#44; followed by a minimum of 1 yr of BCG or further chemotherapy instillations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intravesical BCG for at least 1 yr or immediate cystectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab184249.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Treatment recommendations in TaT1 tumours according to risk stratification&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "tbl0035"
        "etiqueta" => "Table 7"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">GR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>grade&#59; BCG<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>bacillus Calmette-Gu&#233;rin&#59; CIS<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>carcinoma in situ&#59; TUR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>transurethral resection&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">GR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The type of adjuvant therapy should be based on the risk groups specified in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In patients at low risk of tumour recurrence and progression&#44; one immediate instillation of chemotherapy is recommended as the complete adjuvant treatment&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In patients with TaT1 tumours at intermediate or high risk of recurrence and intermediate risk of progression&#44; one immediate instillation of chemotherapy should be followed by a minimum 1 yr of BCG treatment or by further instillations of chemotherapy&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">If chemotherapy is given&#44; it is advised to use the drug at its optimal pH and to maintain the concentration of the drug during instillation by reducing fluid intake&#46; The optimal schedule and the duration of the chemotherapy instillations remain unclear&#44; but it should probably be given for no more than 1 yr&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In patients at high risk of tumour progression&#44; intravesical BCG for at least 1 yr is recommended&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In patients with bladder CIS&#44; intravesical BCG is recommended for at least 1 yr&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In patients with CIS in the epithelial lining of the prostatic urethra&#44; TUR of the prostate followed by intravesical instillations of BCG may be a suitable option&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">For patients at high risk of tumour progression&#44; immediate cystectomy may be offered&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cystectomy is recommended for patients with BCG failure&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Recommendations for adjuvant therapy in TaT1 tumours and for treatment of carcinoma in situ&#46;</p>"
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          "leyenda" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">GR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>grade&#59; CIS<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>carcinoma in situ&#59; PDD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>photodynamic diagnosis&#59; CT<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>computed tomography&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Recommendations&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">GR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Patients with TaT1 tumours at low risk of recurrence and progression should have a cystoscopy at 3 mo&#46; If negative&#44; the following cystoscopy is advised 9 mo later and then yearly for 5 yr&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">Patients with TaT1 tumours at high risk of progression and those with CIS should have a cystoscopy and urinary cytology at 3 mo&#46; If negative&#44; the following cystoscopy and cytology should be repeated every 3 mo for a period of 2 yr&#44; every 6 mo thereafter until 5 yr&#44; and then yearly&#46; Yearly imaging of the upper tract is recommended&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">Patients with TaT1 tumours at intermediate risk of progression &#40;about a third of all patients&#41; should have an intervening follow-up scheme using cystoscopy and cytology&#44; which is adapted according to personal and subjective factors&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">During follow-up in patients with positive cytology and no visible tumour in the bladder&#44; R-biopsies or biopsies with PDD &#40;if equipment is available&#41; and investigation of extravesical locations &#40;CT urography&#44; prostatic urethra biopsy&#41; are recommended&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Recommendations for follow-up of non-muscle-invasive bladder cancer in patients after transurethral resection&#46;</p>"
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      "titulo" => "References"
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                            1 => "G&#46;M&#46;H&#46; Swaen"
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                            0 => "M&#46;P&#46; Zeegers"
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                      "Revista" => array:6 [
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                        "edicion" => "7th ed&#46;"
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            7 => array:3 [
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                            0 => "G&#46; Sauter"
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Burger"
                            1 => "M&#46;N&#46;M&#46; van der Aa"
                            2 => "J&#46;M&#46;M&#46; van Oers"
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                      "autores" => array:1 [
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                          "autores" => array:6 [
                            0 => "C&#46;C&#46; Pan"
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                            2 => "K&#46;K&#46; Chen"
                            3 => "H&#46;J&#46; Yu"
                            4 => "C&#46;H&#46; Sun"
                            5 => "D&#46;M&#46; Ho"
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                      ]
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                  ]
                  "host" => array:1 [
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            10 => array:3 [
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; May"
                            1 => "S&#46; Brookman-Amissah"
                            2 => "J&#46; Roigas"
                            3 => "A&#46; Hartmann"
                            4 => "S&#46; St&#246;rkel"
                            5 => "G&#46; Kristiansen"
                          ]
                        ]
                      ]
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                  ]
                  "host" => array:1 [
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
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                          "etal" => false
                          "autores" => array:5 [
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                            1 => "R&#46; Sylvester"
                            2 => "L&#46; Collette"
                            3 => "A&#46; Bono"
                            4 => "F&#46; Ten Kate"
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                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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            12 => array:3 [
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46; Sylvester"
                            1 => "A&#46; van der Meijden"
                            2 => "J&#46;A&#46; Witjes"
                            3 => "G&#46; Jakse"
                            4 => "N&#46; Nonomura"
                            5 => "C&#46; Cheng"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.urology.2005.06.135"
                      "Revista" => array:7 [
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                        "fecha" => "2005"
                        "volumen" => "66"
                        "numero" => "Suppl&#46; 1"
                        "paginaInicial" => "90"
                        "paginaFinal" => "107"
                        "link" => array:1 [
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Article information

ISSN: 21735786
Original language: English

DOI:10.1016/j.acuroe.2011.12.007

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2017 February	16	4	20
2017 January	0	9	9
2016 December	14	8	22
2016 November	18	8	26
2016 October	38	9	47
2016 September	13	6	19
2016 August	18	7	25
2016 July	17	5	22
2016 June	16	12	28
2016 May	26	5	31
2016 April	37	7	44
2016 March	31	7	38
2016 February	23	12	35
2016 January	25	9	34
2015 December	17	10	27
2015 November	20	8	28
2015 October	16	5	21
2015 September	13	3	16
2015 August	20	5	25
2015 July	22	2	24
2015 June	5	0	5
2015 May	14	6	20
2015 April	25	8	33
2015 March	20	7	27
2015 February	15	4	19
2015 January	21	3	24
2014 December	36	8	44
2014 November	13	3	16
2014 October	39	11	50
2014 September	35	7	42
2014 August	38	7	45
2014 July	44	14	58
2014 June	3	0	3
2014 May	5	1	6
2014 January	4	2	6
2013 December	12	3	15
2013 November	9	5	14
2013 October	23	6	29
2013 September	10	8	18

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