Clinical Evaluation of a Novel Deintensified Surveillance Protocol for Low-risk Non-muscle-invasive Bladder Cancer: A Prospective Study in 250 Patients

Recent Edinburgh-based research demonstrated high negative predictive value (NPV) for urinary dipstick testing for haematuria (UDH) in low-risk bladder cancer surveillance. This enabled a new protocol where flexible cystoscopy in surveillance years 2 and 4 is performed only if UDH is positive. Adopted across Scotland and included as aspirational in European Association of Urology guidelines, this protocol has yet to be validated in real-world settings. This study aims to evaluate the clinical outcomes of low-risk bladder cancer with the implementation of the new surveillance protocol.

The protocol began in December 2018. All patients with low-risk bladder cancer on initial transurethral resection of bladder tumour were included from January 2019 to February 2025. General practitioners conducted UDH in surveillance years 2 and 4; cystoscopy followed if positive. Patient and clinical data were prospectively recorded using a standardised institutional pro forma. This study performed the first clinical evaluation of the deintensified low-risk protocol. The study evaluated the recurrence and progression rates, NPV of UDH throughout surveillance, and number of check cystoscopies performed. The statistical analysis used Stata-BE version 19.0 for Mac.

A total of 250 patients were observed with a recurrence rate of 14.4% and a progression rate of 1.6%, similar to preprotocol outcomes. The NPV of UDH remained above 94% throughout surveillance. Flexible cystoscopy use declined by 18.2%, saving at least £51 000. Limitations included a lack of randomisation, modest cohort sizes at 4 and 5 yr of surveillance, and absence of patient-reported outcomes.

The deintensified protocol appears safe, maintaining clinical outcomes whilst reducing procedural use and costs in low-risk bladder cancer.