Risk stratification, intravesical/BCG scheduling, muscle-invasive decision-making, and post-cystectomy follow-up — built as sequential clinical algorithms.
Enter the TURBT pathology findings. This reproduces the EAU 2021/2024 four-tier prognostic risk grouping (Low / Intermediate / High / Very High), which drives every downstream decision (chemo vs BCG, BCG duration, surveillance intensity, and whether cystectomy should be discussed).
Fill in the form and select "Calculate risk group" to see the EAU risk category, the recommended adjuvant strategy, and the surveillance schedule.
Select the risk group (carried over from Step 1 if already calculated) to generate the exact induction/maintenance timetable, and check for BCG failure/unresponsiveness.
Ticking any of the first three defines BCG-unresponsive disease (EAU/FDA definition). This changes the recommended pathway from "continue/repeat BCG" to "reconsider strategy" below.
Select a risk group to generate the instillation schedule.
Applies once imaging/histology shows muscle invasion, or the NMIBC risk group is very-high-risk / BCG-unresponsive.
Select a disease category to see the recommended pathway.
Two independent questions: (A) cisplatin eligibility before surgery, using the Galsky criteria — this decides neoadjuvant chemotherapy; (B) final pathology after cystectomy — this decides adjuvant therapy.
Complete sections A and B to see neoadjuvant and adjuvant recommendations.
Follow-up intensity is risk-stratified by final pathology. Select the pathologic category and diversion type.
Select the pathologic category to generate the surveillance timetable (imaging, urethral cytology, metabolic monitoring).
Reference table: what the pathology report must contain, and how histologic subtype changes management independent of stage/grade.
| Element | Why it matters |
|---|---|
| Histologic type (urothelial vs variant/mixed, % of each component) | Even a minor variant component (e.g. >10% micropapillary) changes risk group and may mandate cystectomy even at NMIBC stage. |
| Grade — report both WHO 1973 (G1–G3) and WHO 2004/2016/2022 (LG/HG) | EAU risk tables and the 2021 EAU model use a hybrid of both systems; WHO1973 remains the stronger predictor of progression. |
| Depth of invasion / presence and substaging of T1 (T1a/b/c or micro- vs extensive) | T1 substaging refines risk within the T1 group and informs re-resection/cystectomy discussion. |
| Presence of muscularis propria (detrusor) in the specimen | Absence of detrusor muscle in a T1/HG specimen mandates re-resection (TURBT) before risk stratification is finalised. |
| Lymphovascular invasion (LVI) | Automatically upgrades NMIBC to the very-high-risk category. |
| Concurrent CIS, and CIS of the prostatic urethra in men | Prostatic urethral CIS defines very-high-risk NMIBC and changes diversion planning at cystectomy (orthotopic neobladder contraindicated if urethral margin positive). |
| At radical cystectomy: pT stage, pN stage (number examined/positive nodes), margin status, lymphovascular invasion, variant histology component | Directly drives the adjuvant therapy decision (Step 4) and follow-up intensity (Step 5). |
| Histology | Risk impact | Management note |
|---|---|---|
| Pure urothelial carcinoma (UC) | Standard stage/grade-based risk group applies | Follow the pathways in Steps 1–5 directly. |
| Micropapillary, plasmacytoid, sarcomatoid, or neuroendocrine (small cell) component | Very high risk even at Ta/T1 stage | Early/upfront radical cystectomy should be strongly discussed even without muscle invasion; BCG efficacy in these subtypes is poorly established and should not be relied on alone. |
| Small cell / neuroendocrine carcinoma (any stage) | Behaves like small-cell lung carcinoma | Treat with platinum-etoposide-based neoadjuvant chemotherapy, then cystectomy, regardless of clinical stage; consider prophylactic cranial irradiation discussion is not standard but systemic staging (brain/chest CT) is warranted. |
| Squamous cell carcinoma (pure) | Different chemosensitivity to urothelial carcinoma | Primary treatment is upfront radical cystectomy; conventional urothelial neoadjuvant chemotherapy regimens are not well validated — treat as a separate biological entity; consider referral to a specialist MDT, especially if schistosomiasis-associated. |
| Adenocarcinoma (primary bladder / urachal) | Different biology from UC | Upfront surgery (cystectomy ± en-bloc urachal/umbilical resection for urachal tumours); platinum/urothelial-type chemo not standard first line. |
| Nested, microcystic, lymphoepithelioma-like, plasmacytoid variants (isolated mention) | Nested/microcystic often under-graded on limited biopsy | Have a low threshold for re-resection and cross-sectional imaging; nested variant is frequently more aggressive than it appears histologically. |
| Divergent differentiation (squamous/glandular differentiation within UC, <50%) | Generally managed as UC of the dominant component | Still treated on the standard urothelial pathway provided urothelial carcinoma is the predominant (>50%) component; document the % clearly. |
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