FIG. 36:  In conclusion, this Figure is a repeat of Figure 6, illustrating what I believe – that the solution to improving survival in bladder cancer, certainly in the short-term, should come from re-focusing our energy and efforts to spend more effort on managing aggressive disease and less effort on cystoscopy and follow-up for patients with low-risk disease. 

If a patient has true low-risk disease, ie, low-grade non-muscle invasive non-recurrent disease, they can be discharged at 1 year and re-referred when/if they experience a change in symptoms. 

If a patient has true high- or very high-risk disease, then the patient should probably have a radical cystectomy, or at least careful follow-up after BCG immunotherapy. 

Both intermediate- and high-risk disease patients require more frequent cystoscopy in the first year to 2 years after diagnosis, but this could be decreased to once-yearly thereafter. 

For intermediate-risk disease, I believe 5 years of follow-up is sufficient unless the patient experiences a change in symptoms or in circumstances, and likewise for high-risk disease, where I believe follow-up should continue for longer, because these patients have a much higher risk of progression and subsequent mortality.  In my practice, we would probably follow them indefinitely, certainly while they remain fit for radical treatment should they develop a recurrence.