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INTRODUCTION AND OBJECTIVES: Risk stratification into low-, intermediate-and high-risk groups has been widely used for the management of patients with non-muscle-invasive bladder cancer (NMIBC). Although low-and high-risk groups have been clearly classified, the intermediate-risk group has traditionally included heterogeneous patients which do not fit into either of these groups, resulting in uncertainty regarding its prognosis and adjuvant therapy. Whereas small, Ta low-grade recurrence does not present an immediate danger to the patient, recurrence of high-risk tumors should be early detected during the follow-up of intermediate-risk NMIBC patients. Here, we aimed to substratify intermediate-risk NMIBC patients based on the prediction of high-risk recurrence (HRR).METHODS: This study included 645 primary NMIBC patients who underwent TURBT at a single institution from 2010 to 2018. Risk stratification was according to the EAU guidelines. Of the 645 patients, 330 patients with intermediate-risk NMIBC were in analysis. HRR was defined as high-risk non-muscle-invasive, muscle-invasive, or metastatic recurrences. Factors predicting HRR were explored using the Cox proportional hazards model. RESULTS: Of the total patients, 146 (44%) patients recurred. HRR was developed in 37 (11%) patients, which included 34 (10%) with high-risk non-muscle-invasive recurrence and three (1%) with muscle invasive recurrence. On multivariate analysis, bladder neck involvement (BNI) (HR 2.84, p [ 0.020) and positive urine cytology (PUC) (HR 3.82, p <0.001) were independent predictors for HRR. The 5-yr HRRfree survival (HRRFS) rate was 71% in 82 (25%) patients with either BNI or PUC. Meanwhile, in 248 (75%) patients without BNI and PUC, the 5-yr HRRFS rate was 93% (p <0.001), and no patient eventually progressed to muscle-invasive disease and died of the disease.CONCLUSIONS: In intermediate-risk NMIBC, most of the patients without bladder neck involvement and positive urine cytology were free from high-risk recurrence. Thus, they may safely avoid adjuvant intravesical therapy and intensive follow-up by cystoscopy.

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