Cystectomy without prior chemotherapy is most appropriate for this patient who has superficial bladder cancer. Superficial bladder cancer is the most common form of bladder cancer and is characterized by cancer cells confined to the mucosa, with no evidence of invasion into the muscle layer of the bladder. It is best managed by transurethral resection of the bladder tumor (TURBT), followed in most patients by either bacillus Calmette-Guérin (BCG) or mitomycin infused directly into the bladder. Although this treatment is effective in eradicating superficial bladder cancer, recurrences are common. Careful observation with serial cystoscopy is therefore essential. Many patients with recurrent superficial bladder cancer can be managed with repeat TURBT and additional intravesical infusion. However, patients who develop recurrence within 6 to 12 months of initial TURBT, or after one to two courses of BCG infusion (such as the patient described here), should undergo cystectomy. Cystectomy in this setting is associated with improved disease-specific survival. This procedure is not indicated in the initial management of superficial bladder cancer unless patients have ongoing tumor-related symptoms that cannot be managed with TURBT alone or if they are subsequently found to have muscle-invasive disease.

Systemic chemotherapy, although used prior to cystectomy for patients with muscle-invasive disease, has no role in the treatment of patients with superficial bladder cancer who are to undergo cystectomy.

External-beam radiation therapy has no established role in the treatment of superficial bladder cancer.

Repeat TURBT and BCG infusion is not indicated because this treatment has already been ineffective on two occasions.