FIG. 32:  The goal is to focus bladder-sparing surveillance at the beginning of the follow-up because that is when most events occur.  In addition, the NICE advocates adjusting frequency of surveillance to risk, so people who have high-risk NMI disease should be offered a cystoscopy 3-monthly for the first 2 years, followed by 6-monthly for 2 years, and then yearly thereafter.^[27]  However on-demand cystoscopy should be available in cases where symptoms significantly deteriorate or change, or recurrent difficult-to-treat infections or visible hematuria occur, or the patient’s bladder function deteriorates, as all these can be signs of recurrent disease. 

I would also consider enhancing surveillance with either cytology or a urinary biomarker such as nuclear matrix protein 22 (NMP-22), or using an augmented cystoscopy with blue-light fluorescence or narrow band imaging, to try to improve the ability to diagnose occult carcinoma in situ.  In my practice, many of these are rigid cystoscopies, since we want to take biopsies and washings to look at any shed urothelial cells in the bladder.  If outpatient office endoscopy is contemplated, I would advocate rigid cystoscopy for the first check, or after a new relapse, because these are the times when it is most likely that a biopsy will be required.  The disease will be mostly occult at this stage, and with the greatest risks for recurrence occur at this stage, I find it difficult to use only inspection in these high-risk situations.