T1HG Bladder Tumours: So Many Papers, Do We Need Them? Yes, We Do!

“How many roads a man must walk on….” and how many papers we must read and write… to put down the final word on the appropriate management of high risk NMI-BC. Although it is more than 20 years that we take notice of promises on biological markers predictive of the behaviour of NMI-BC, till today we can only base our decisions on clinical and pathological data. Consequently, we need exchange of experiences and reports on the outcome of these patients. The aim of the treatment of T1 bladder tumours is to minimize mortality while assuring reduced morbidity and good quality of life. A conservative approach is, obviously, not applicable to all T1HG tumours. We need to identify unequivocal selection criteria to choose the proper treatment. Therefore, we must appreciate the Authors’ effort in retrospectively analysing the outcome of 523 patients submitted to re-TUR for T1HG bladder cancer (1). The prognosis of T1HG seems to be extremely variable, with a 5-year’s progression rate raging between 20% to 75%. This wide range probably depends on our partial incapability or reluctance in distinguishing different risk subgroups. Many studies refer to unselected T1HG tumours with associated untoward risk factors. We know that concomitant Tis is a factor worsening the fate of these patients (2). A single and primary TaG1 tumour has a better prognosis than recurrent and multiple ones. Likewise, in T1HG tumours several Authors have outlined the prognostic role of numerous clinical and pathological features as multiplicity, size, previous history, response to BCG, growth pattern, level of lamina propria infiltration and presence of lymphovascular invasion (3-7). A negative re-TUR has been proposed by some Authors as the prerequisite for a conservative approach in highly selected T1HG tumours that should be single, less than 1.5 cm in size, without involvement of the muscularis mucosae, in absence of Tis, and with no recurrence at 1 year after BCG (4,7). Following these criteria, conservative treatment should be reserved to a very small proportion of T1HG tumours. The study of Dalbagni and coll (1) starts from two important considerations: 1. The management of T1 bladder cancer is a dynamic process that should be tailored for each individual patient; 2. there are no definite guidelines for selecting patient’s initial treatment. Many praises and some objections can be attributed to this paper that raises several important issues.