It has been shown that active surveillance (AS) is an effective approach in managing selected low-risk urological tumors. These include low-risk prostate cancer, small renal tumors, and clinical stage I germ cell tumors. In 2003, Soloway et al [1] first proposed AS as a management option for patients diagnosed with low-grade (LG) non–muscle-invasive bladder cancer (NMIBC) who experience LG-appearing recurrence during follow-up. This approach involves closely monitoring the patient rather than immediately proceeding with invasive treatments such as surgery or fulguration.

The aim with AS is to deintensify treatment without compromising oncological outcomes. However, although early reports suggested the safety and efficacy of this option, AS in urothelial carcinoma of the bladder (BC) remains a widely controversial and debated issue [2]. In 75% of cases, BC presents as NMIBC, the majority of which are LG tumors that do not invade the lamina propria (Ta). While high-grade (HG) NMIBC is characterized by a risk of progression of up to 40%, which could affect survival, LG NMIBC has excellent prognosis, with a high recurrence rate but a low risk of progression and cancer-specific mortality of <1% [3].

Once the initial tumor has been removed, patients are likely to experience recurrence during follow-up. The gold-standard treatment for LG recurrent tumors is transurethral resection of bladder tumor (TURBT), regardless of the tumor size and number of recurrences [3]. TURBT is usually associated with hospitalization, access to the operating room, and anesthesia. BC has the highest lifetime treatment cost per patient of all cancers, and the annual cost of care for patients with low-risk disease has increased over the years, imposing a large resource burden on health care systems [4]. In this context, it was shown that AS reduces direct resource consumption that can be reinvested in the management of other patients [5].

Finally, although considered a “minor” surgical procedure, TURBT carries risks of complications such as bladder perforations, bleeding, and urethral injury. Most patients with NMIBC also have several comorbidities, which increases the risk of surgical and anesthesiology complications [1].

Alternative approaches to TURBT for patients with LG tumors have attracted increasing interest in recent years. For example, it has been proven that office fulguration is a safe and effective procedure with comparable recurrence rates and lower complication rates in comparison to TURBT [6]. Some studies have demonstrated the efficacy of chemoresection in this patient setting [7]. Overall, seven studies have reported outcomes for patients on AS. These studies lack homogeneity and consistency regarding inclusion criteria and follow-up, making it difficult to draw definitive conclusions [2], [8], [9], [10].