Recently, the European Association of Urology (EAU) utilized a larger cohort of patients (2596) with NMIBC randomized who received all kinds of postoperative intravesical chemotherapy. Three risk groups were identified (low risk: single lesion, Ta, grade 1 and ≤3 cm), intermediate risk (Ta–T1, grade 1–2, multifocal, > 3 cm) and high risk (any T1, grade 3, multifocal or highly recurrent, CIS). Unfortunately, the outcomes generated from this risk stratification tool are difficult to interpret in the present situation. Only 200 patients received bacillus Calmette–Guerin (BCG) as an immediate postoperative treatment (gold standard in the treatment of NMIBC), no standard second TURBT was performed, and less than 20 % of patients actually received an additional intravesical treatment. Several authors have tried to externally validate this cohort showing an overestimation of the recurrence and progression rates [3]. The software for this model is available on line at http://​www.​eortc.​be/​tools/​bladdercalculato​r.

In 2008, the Spanish Urological Club for Oncological Treatment published a similar stratification model. A total of 1062 patients treated with intravesical BCG were included in the study. Recurrence and progression scores were created. The BCG maintenance protocol was standardized among the different institutions; however, treatments lasted only up to 6 months. Furthermore, the series was graded according to 1987 TNM classification and the WHO 1973 grading system. Neither second transurethral resection (TUR) nor immediate instillation was performed. Approximately 20 % of the patients had high-grade (HG) T1 disease and less than 10 % had CIS at biopsy, the population where this kind of predictive model is mostly needed [3].

The first nomogram in bladder cancer was published in 2005 [4]. It was a multi-institutional collaboration were the authors estimated the risk of recurrence and progression in 2861 patients with NMIBC using a urine marker NMP22 (nuclear matrix protein 22) and urine cytology. The performance of the nomogram was increased by adding the urine marker for the three endpoints evaluated: any transitional cell carcinoma (TCC) recurrence, recurrence of HG Ta/T1, and recurrence higher than T2. The main clinical application in this setting for NMP22 is that it could provide a means to individualize the cystoscopy follow-up in patients with Ta or T1 TCC or CIS by determining the best timing for repeated cystoscopy (delay in cystoscopy follow-up if negative test). The limitations of the study are that it does not consider relevant factors such as previous history of TCC (recurrences and grades) and previous history of intravesical therapy. Moreover, the performance of the nomogram varied significantly among the participant institutions, emphasizing the need for external validation of all tools.