Transurethral laser ablation for recurrent non-muscle-invasive bladder cancer

Evidence-based recommendations on transurethral laser ablation for recurrent non-muscle-invasive bladder cancer in adults. This involves using a laser inserted into the bladder to destroy the cancer cells.

# Recommendations
The evidence on the safety of transurethral laser ablation for recurrent non-muscle-invasive bladder cancer shows that there are no major safety concerns. However, current evidence on its efficacy is limited in quality and quantity. Therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research. Find out what special arrangements mean on the NICE interventional procedures guidance page.
Clinicians wishing to do transurethral laser ablation for recurrent non-muscle-invasive bladder cancer should:
Inform the clinical governance leads in their NHS trusts.
Ensure that patients and their carers understand the uncertainty about the procedure's safety and efficacy, and provide them with clear written information to support shared decision making. In addition, the use of NICE's information for the public is recommended.
Audit and review clinical outcomes of all patients having transurethral laser ablation for recurrent non-muscle-invasive bladder cancer. NICE has identified relevant audit criteria and has developed an audit tool (which is for use at local discretion).
Patient selection should be done by a specialist bladder cancer multidisciplinary team.
NICE encourages further research and prospective data collection into transurethral laser ablation for recurrent non-muscle-invasive bladder cancer. Studies should investigate patient selection, types of laser used, tumour recurrence and long-term follow up.# The condition, current treatments and procedure

# The condition
The most common form of bladder cancer is transitional cell carcinoma. Non-muscle-invasive transitional cell carcinoma is classified as stage Ta when it is confined to the uroepithelium and stage T1 when it has spread into the connective tissue layer between the urothelium and the muscle wall. Non-muscle-invasive transitional cell carcinomas usually appear as small growths from the bladder lining. They can be graded from G1 (low grade, least aggressive) to G3 (high grade, most aggressive). Carcinoma in situ consists of aggressive cancer cells that spread within the surface lining of the bladder and appear flat. It is more likely to recur after treatment.

# Current treatments
NICE's guideline on bladder cancer describes its diagnosis and management. Surgical interventions for non-muscle-invasive transitional cell carcinoma include transurethral resection, in which malignant tissue is removed with an electrocautery device during cystoscopy. Bacillus CalmetteGuerin (BCG) vaccine or chemotherapy drugs may be put directly into the bladder, either as treatments in themselves or as adjuvant therapy after transurethral resection. Cystectomy may also be necessary in some patients.

# The procedure
This procedure is most often used for very small, recurrent bladder tumours. It is usually done as day surgery using local anaesthesia. A flexible cystoscope is passed through the urethra into the bladder. The tumours are then ablated using a laser fibre contained in the cystoscope.
If there is a lot of bleeding after the procedure, a urinary catheter may be inserted to allow bladder irrigation.
Adjuvant intravesical chemotherapy may be offered after the procedure.
The aim is to destroy the tumour with less morbidity than is seen with conventional treatments. The suggested benefits over cystodiathermy include less bleeding and reduced pain.