EAU 2025 Guidelines: Non-muscle-invasive Bladder Cancer

What This Guideline Covers

The EAU 2025 Non-muscle-invasive Bladder Cancer guideline provides evidence-based recommendations across 7 topic areas. The key (Strong-rated) recommendations are summarised below; the complete recommendation tables — including Weak recommendations with their strength ratings — plus classification and evidence tables are in the Full Guidelines tab.

Key Recommendations at a Glance

Every Strong-rated EAU recommendation. Where the guideline labels its sections, they are used as sub-headings.

Bladder cancer classification

• Use the 2017 TNM (Tumour, Node, Metastasis Classification) system for classification of the depth of tumour invasion (staging).
• Do not use the term 'superficial bladder cancer'.

Primary assessment of NMIBC

• Take a patient history, focusing on urinary tract symptoms and haematuria.
• Use renal and bladder ultrasound and/ or computed tomography-intravenous urography (CT-IVU) during the initial work- up in patients with haematuria.
• Once a bladder tumour has been detected, perform a CT urography in selected cases (e.g., tumours located in the trigone, multiple- or high-risk tumours).
• If an MRI is performed for local staging of bladder cancer it should be done before TURB.
• Perform cystoscopy in patients with symptoms suggestive of bladder cancer or during surveillance. It cannot be replaced by cytology or by any other non-invasive test.
• Use a flexible cystoscope, if available, in both men and women. In men apply irrigation ‘bag squeeze’ to decrease procedural pain when passing the proximal urethra.
• Describe all macroscopic features of the tumour (site, size, number, and appearance) and mucosal abnormalities during cystoscopy. Use a bladder diagram.
• Use voided urine cytology as an adjunct to cystoscopy to detect high-grade tumour.
• Perform cytology on at least 25 mL fresh urine or urine with adequate fixation. First morning urine is not suitable because of the frequent presence of cytolysis.
• Use the Paris System 2nd Edn., for cytology reporting.

Transurethral resection of the bladder (TURB), biopsies and pathology report

• Perform a TURB followed by pathology investigation of the obtained specimen(s) as a diagnostic procedure and initial treatment step in patients suspected of having bladder cancer.
• Perform TURB systematically in individual steps: • bimanual palpation under anaesthesia before starting the procedure and at the end; • insertion of the resectoscope, under visual control with inspection of the whole urethra; • inspection of the whole urothelial lining of the bladder; • biopsy from the prostatic urethra (if indicated); • cold-cup bladder biopsies (if indicated); • resection of the tumour; • recording of findings in the surgery report/record including visual impression of grade/stage; • precise description of the specimen(s) for pathology evaluation.
• Perform en-bloc resection or resection in fractions (exophytic part of the tumour, the underlying bladder wall and the edges of the resection area).
• Avoid cauterisation as much as possible during TURB to avoid tissue deterioration.
• Take biopsies from abnormal-looking urothelium.
• Take multiple biopsies (mapping biopsies from the trigone, bladder dome, right, left, anterior and posterior bladder wall) or perform fluorescence-guided (PDD) biopsies, in case of normal looking urothelium and positive urine cytology.
• Take a sample of the prostatic urethra if there is positive urine cytology without evidence of tumour in the bladder, or if abnormalities of the prostatic urethra are visible.
• The TURB record must describe tumour location, appearance, size and multifocality, all steps of the procedure, extent, macroscopic completeness of resection as well as any complications.
• In patients with positive cytology, but negative cystoscopy, exclude an upper tract urothelial carcinoma, CIS in the bladder (by mapping biopsies or PDD- guided biopsies) and tumour in the prostatic urethra (by prostatic urethra biopsy).
• Perform a second TURB in the following situations: • after incomplete initial TURB, or in case of doubt about completeness of a TURB; • if there is no detrusor muscle in the specimen after initial resection, with the exception of Ta LG/G1 tumours and primary CIS; • in T1 tumours.
• Inform the pathologist of prior treatments (intravesical therapy, radiotherapy, etc.).
• The pathological report should specify tumour location, tumour grade and stage, lymphovascular invasion, subtypes of urothelial carcinoma, presence of CIS and detrusor muscle.

Stratification of non-muscle invasive bladder cancer

• Stratify patients into four risk groups to predict progression groups according to Table 2. A patient’s risk group can be determined by using the 2021 EAU risk group calculator available at www.nmibc.net.
• For information about the risk of disease progression in a patient with primary TaT1 tumours not treated with bacillus Calmette-Guerin (BCG), use the data from Table 3.
• Use the 2006 EORTC scoring model to predict the risk of tumour recurrence in individual patients not treated with BCG.
• Use the 2016 EORTC scoring model or the CUETO risk scoring model to predict the risk of tumour recurrence in individual patients treated with BCG intravesical immunotherapy (the 2016 EORTC model is calculated for one to three year of maintenance, the CUETO model for five to six months).

General recommendations for adjuvant therapy in TaT1 tumours and for therapy of carcinoma in situ (CIS)

• Counsel smokers to stop smoking.
• The type of further therapy after transurethral resection of the bladder (TURB) should be based on the risk groups shown in Table 2. For determination of a patient’s risk group use the 2021 EAU risk group calculator available at www.nmibc.net.
• In patients with tumours presumed to be at low risk and in those with small papillary recurrences (presumably Ta LG/ G1) detected more than one year after previous TURB, offer one immediate single chemotherapy instillation.
• Offer post-operative saline or water continuous irrigation of the bladder to patients who cannot receive a single instillation of chemotherapy.
• Patients with small recurrent low grade Ta tumours can be effectively and safely offered office fulguration.
• In patients with high-risk tumours, full-dose intravesical bacillus Calmette-Guérin (BCG) for one to three years (induction plus three- weekly instillations at 3, 6, 12, 18, 24, 30 and 36 months), is indicated. The additional beneficial effect of the second and third years of maintenance should be weighed against its added costs, side effects and access to BCG. Immediate radical cystectomy (RC) may also be discussed with the patient.
• Discuss immediate RC in patients with very high-risk tumours. Intravesical full-dose BCG instillations for one to three years remains an option for selected patients, particularly those who decline or are unfit for RC.
• The definition of ‘BCG unresponsive’ should be respected as it most precisely defines the patients who are unlikely to respond to further BCG instillations.
• Offer a RC to patients with BCG unresponsive tumours.
• Omit a single immediate instillation of chemotherapy in any case of overt or suspected bladder perforation or bleeding requiring bladder irrigation.
• If intravesical chemotherapy is given, use the drug at its optimal pH and maintain the concentration of the drug by reducing fluid intake before and during instillation.
• Absolute contraindications of BCG intravesical instillation are: • during the first two weeks after TURB; • in patients with visible haematuria; • after traumatic catheterisation; • in patients with symptomatic urinary tract infection.

Treatment of TaT1 tumours and carcinoma in situ according to risk stratification

• Offer one immediate instillation of intravesical chemotherapy after transurethral resection of the bladder (TURB).
• In general, chemotherapy (the optimal schedule is unknown) is a reasonable first-line option in the majority of patients. One-year full-dose BCG treatment (induction plus three-weekly instillations at 3, 6 and 12 months), is an alternative option. The final choice should reflect the individual patient’s risk of recurrence and progression as well as the efficacy and side effects of each treatment modality. Offer one immediate chemotherapy instillation to patients with small papillary recurrences detected more than one year after previous TURB.
• Offer intravesical full-dose BCG instillations for one to three years but discuss immediate radical cystectomy (RC).
• Offer RC or intravesical full-dose bacillus Calmette-Guérin (BCG) instillations for one to three years, particularly to those who decline or are unfit for RC.

Follow-up of patients after transurethral resection of the bladder for NMIBC

• Base follow-up of TaT1 tumours and carcinoma in situ (CIS) on regular cystoscopy.
• Perform endoscopy under anaesthesia and bladder biopsies when office cystoscopy shows suspicious findings or if urinary cytology is positive.
• During follow-up in patients with positive cytology and no visible tumour in the bladder, mapping biopsies or PDD-guided biopsies (if equipment is available) and investigation of extravesical locations (CT urography, prostatic urethra biopsy) are recommended.