Clinical significance of definite muscle layer in TUR specimen for evaluating progression rate in T1G3 bladder cancer: multicenter retrospective study by the Sapporo Medical University Urologic Oncology Consortium (SUOC)

Comparison of staging MRI to re-resection for localised bladder cancer: Narrative review

Introduction

Bladder cancer (BCa) is characterised by high prevalence, multifocality, and frequent recurrence, imposing significant clinical and economic burdens. Accurate staging, particularly distinguishing non-muscle-invasive bladder cancer (NMIBC) from muscle-invasive bladder cancer (MIBC) disease, is crucial for guiding treatment decisions. This narrative review explores the potential implications of incorporating multiparametric magnetic resonance imaging (mpMRI) and the Vesical Imaging Reporting Data System (VI-RADS) into BCa staging, focusing on repeat transurethral resection of bladder tumour (re-TURBT).

Methods

A comprehensive search of PubMed, EMBASE, and MEDLINE databases identified studies published from 2018 to 2023 discussing mpMRI or VI-RADS in the context of re-TURBT for BCa staging. Studies meeting inclusion criteria underwent qualitative analysis.

Results

Six recent studies met inclusion criteria. VI-RADS scoring, accurately predicted muscle invasion, aiding in NMIBC/MIBC differentiation. VI-RADS scores of ≥3 indicated MIBC with high sensitivity and specificity. VI-RADS potentially identified patients benefiting from re-TURBT and those for whom it could be safely omitted.

Discussion

mpMRI and VI-RADS offer promising prospects for BCa staging, potentially correlating more closely with re-TURBT and radical cystectomy histopathology than initial TURBT. However, validation and careful evaluation of clinical integration are needed. Future research should refine patient selection and optimise mpMRI's role in BCa management.

Conclusion

VI-RADS scoring could revolutionise BCa staging, especially regarding re-TURBT. There is potential that VI-RADS correlates more with the histopathology of re-TURBT and radical cystectomy than initial TURBT. While promising, ongoing research is essential to validate utility, refine selection criteria, and address economic considerations. Integration of VI-RADS into BCa staging holds potential benefits for patients and health care systems.

Bladder MRI with deep learning-based reconstruction: a prospective evaluation of muscle invasiveness using VI-RADS

PURPOSE

To investigate the influence of deep learning reconstruction (DLR) on bladder MRI, specifically examination time, image quality, and diagnostic performance of vesical imaging reporting and data system (VI-RADS) within a prospective clinical cohort.

METHODS

Seventy participants with bladder cancer who underwent MRI between August 2022 and February 2023 with a protocol containing standard T2-weighted imaging (T2WIS), standard diffusion-weighted imaging (DWIS), fast T2WI with DLR (T2WIDL), and fast DWI with DLR (DWIDL) were enrolled in this prospective study. Imaging quality was evaluated by measuring signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and qualitative image quality scoring. Additionally, the apparent diffusion coefficient (ADC) of bladder lesions derived from DWIS and DWIDL was measured and VI-RADS scoring was performed. Paired t-test or paired Wilcoxon signed-rank test were performed to compare image quality score, SNR, CNR, and ADC between standard sequences and fast sequences with DLR. The diagnostic performance for VI-RADS was assessed using the area under the receiver operating characteristic curve (AUC).

RESULTS

Compared to T2WIS and DWIS, T2WIDL and DWIDL reduced the acquisition time from 5:57 min to 3:13 min and showed significantly higher SNR, CNR, qualitative image quality score of overall image quality, image sharpness, and lesion conspicuity. There were no significant differences in ADC and AUC of VI-RADS between standard sequences and fast sequences with DLR.

CONCLUSIONS

The application of DLR to T2WI and DWI reduced examination time and significantly improved image quality, maintaining ADC and the diagnostic performance of VI-RADS for evaluating muscle invasion in bladder cancer.

Significance of Normalized Apparent Diffusion Coefficient in the Vesical Imaging-Reporting and Data System for Diagnosing Muscle-Invasive Bladder Cancer

BACKGROUND

Vesical Imaging-Reporting and Data System (VI-RADS) has been developed for assessing bladder cancer from multiparametric (mp) MRI but its performance in diagnosing muscle-invasive bladder cancer (MIBC) is suboptimal.

PURPOSE

To investigate associations between normalized apparent diffusion coefficient (NADC) and clinicopathological characteristics and to determine whether the inclusion of NADC can improve the performance of VI-RADS in diagnosing MIBC.

STUDY TYPE

Retrospective.

POPULATION

Two hundred seventy-five patients with pathologically confirmed bladder cancer (101 MIBC and 174 non-MIBC [NMIBC]) underwent preoperative mpMRI (233 male, 42 female).

FIELD STRENGTH/SEQUENCE

3-T, T2-weighted imaging (turbo spin-echo), diffusion-weighted imaging (free-breathing spin-echo), and dynamic contrast-enhanced imaging (gradient-echo).

ASSESSMENT

NADC was the mean ADC of tumor divided by that of the iliopsoas muscles in trans caput femoris plane. Associations between NADC and clinicopathological characteristics were evaluated. Models were established for differentiating MIBC and NMIBC: VI-RADS model; VN model (VI-RADS and NADC), Images model (significant variables from imaging associated with MIBC), LN model (Images model without NADC), and Full model (all significant variables associated with MIBC).

STATISTICAL TESTS

Variables for model development were based on logistic regression. Models were evaluated by receiver operating characteristic (ROC) curve. Comparison of the area under the curves (AUCs) for the models used DeLong's test. A P value <0.05 was considered statistically significant.

RESULTS

NADC was significantly lower in lesions with diameter ≥ 3 cm, MIBC, histological high grade, lymph node metastasis, and lymphovascular invasion. Compared with VI-RADS model, the AUCs for VN model (VI-RADS score and NADC), Images model (VI-RADS score, NADC and tumor size) and Full model (VI-RADS score, NADC, tumor size and histological grade) were significantly higher. No significant differences were observed between the AUCs for VN model and Images model (P = 0.051).

DATA CONCLUSION

NADC reflects information about the aggressiveness of bladder cancer. Combining VI-RADS with NADC can improve performance in diagnosing MIBC.

EVIDENCE LEVEL

4 TECHNICAL EFFICACY: Stage 2.

Accuracy of Vesical Imaging-Reporting and Data System for muscle-invasive bladder cancer detection from multiparametric magnetic resonance imaging

PURPOSE

The Vesical Imaging-Reporting and Data System (VI-RADS) was used to distinguish the invasive nature of bladder masses before surgery. These imaging criteria can be used to carefully select patients who are candidates for repeat transurethral resection of bladder tumor (Re-TUR-BT). One-third of patients are understage at the time of Re-TUR-BT. This study aimed to evaluate the discrimination accuracy of VI-RADS between non-muscle-invasive bladder cancer and muscle-invasive bladder cancer.

MATERIALS AND METHODS

Patients with a bladder mass identified by cystoscopy who were assigned for TUR-BT were offered multiparametric magnetic resonance imaging (mpMRI) for VI-RADS. TUR-BT reports were compared with preoperative VI-RADS scores to evaluate the accuracy of discrimination of the muscle-invasive nature of the bladder mass.

RESULTS

A total of 58 bladder tumor lesions were included, 13 with muscle-invasive bladder cancer and 45 with non-muscle-invasive bladder cancer. Sensitivity and specificity were 92.3% and 86.7%, respectively, when a VI-RADS cutoff of 4 or more was used to define muscle-invasive bladder cancer. Positive predictive value and negative predictive value were 66.7% and 97.5%, with an accuracy of 87.9%. The area under the receiver operating characteristic curve was 0.932 (95% confidence interval, 0.874-0.989), and the empirical optimal cutpoint from the Youden method was 3.

CONCLUSIONS

VI-RADS is an accurate tool for correctly differentiating muscle-invasive bladder cancer from non-muscle-invasive bladder cancer. We found a cutpoint of VI-RADS 1-3 vs. 4-5 to have the highest specificity and accuracy for the discrimination of non-muscle-invasive from muscle-invasive bladder cancer.

Absence of detrusor muscle in TUR-BT specimen - can we predict who is at highest risk?

INTRODUCTION

As a high-quality TUR-BT is important to ensure adequate treatment for bladder cancer patients, the aim of the current study is to investigate the impact of patient-related, surgical and tumor-specific parameters on detrusor muscle (DM) absence (primary objective) and to assess the impact of DM on the prognosis after a TUR-BT (secondary objective).

PATIENTS AND METHODS

Transurethral resection of bladder tumors (TUR-BTs) between 2009 and 2021 were retrospectively screened (n = 3237). We included 2058 cases (1472 patients) for the primary and 472 patients for secondary objective. Clinicopathological variables including tumor size, localization, multifocality, configuration, operation time and skill-level of the urologist were assessed. We analyzed predictors for missing DM and prognostic factors for recurrence-free survival (RFS) for the complete cohort and subgroups.

RESULTS

DM was present in 67.6% (n = 1371/2058). Surgery duration (continuous, minutes) was an independent predictor for absence of DM in the complete cohort (OR:0.98, r:0.012, 95%CI:0.98-0.99, p = 0.001). Other significant risk factors for missing DM were papillary tumors (OR:1.99, r:0.251, 95%CI:1.22-3.27, p = 0.006) in the complete cohort and bladder-roof and posterior-bladder-wall localization for re-resections. Absence of DM in high-grade BC correlated with reduced RFS (HR:1.96, 95%CI:1.0-3.79, p = 0.045).

CONCLUSION

Sufficient time for a TUR-BT is mandatory to assure DM in the TUR-BT specimen. Also, cases with more difficult locations of bladder tumors should be performed with utmost surgical diligence and endourological training should incorporate how to perform such operations. Of note, DM correlates with improved oncological prognosis in high-grade BC.

Biparametric magnetic resonance imaging assessment for detection of muscle-invasive bladder cancer: a systematic review and meta-analysis

OBJECTIVES

To investigate if removing DCE from the Vesical Imaging Reporting and Data System (VI-RADS) influences the diagnostic accuracy of muscle-invasive bladder cancer (MIBC). We also explored using different reference standards on the MRI diagnostic performance.

METHODS

We searched the Cochrane Library, Embase, and PubMed databases to June 26, 2021. Pooled biparametric MRI (bpMRI, T2WI+DWI) and multiparametric MRI (mpMRI, T2WI+DWI+DCE) sensitivities and specificities and the diagnostic performances of these methods for MIBC were compared using different reference standards.

RESULTS

Seventeen studies with 2344 patients were finally included, of which 7 studies, including 1041 patients, reported the diagnostic performance of bpMRI. VI-RADS showed sensitivities and specificities of 0.91 (95% CI 0.87-0.94) and 0.86 (95% CI 0.77-0.91) at cutoff scores of 3, and 0.85 (95% CI 0.77-0.90) and 0.93 (95% CI 0.89-0.96) at cutoff scores of 4. BpMRI showed sensitivities and specificities of 0.90 (95% CI 0.69-0.97) and 0.90 (95% CI 0.81-0.95), and 0.84 (95% CI 0.78-0.88) and 0.97 (95% CI 0.87-0.99), respectively, for cutoff scores of 3 and 4. The sensitivities of bpMRI vs mpMRI for MIBC were not significantly different, but bpMRI was more specific than mpMRI at cutoff scores of 3 (p = 0.02) and 4 (p = 0.02). The VI-RADS studies using primary transurethral resection of bladder tumors (TURBT) as the reference standard had significantly higher sensitivities (p < 0.001) than those using secondary TURBT or radical cystectomy as the reference.

DATA CONCLUSION

BpMRI and conventional VI-RADS had similar diagnostic efficacies for MIBC. Since MRI overestimated MIBC diagnoses using primary TURBT as the reference standard, we recommend using secondary TURBT as the reference standard.

KEY POINTS

• Biparametric MRI without DCE had similar diagnostic efficacies for MIBC compared with conventional VI-RADS. • The sensitivity of VI-RADS was overestimated when referring to the primary TURBT results. • Biparametric MRI comprised of T2WI and DWI could be used for detecting MIBC in clinical practice.

Closed-loop audit of muscle sampling in Trans-Urethral Resection of Bladder Tumour

Introduction:

Our experience with the presence of detrusor muscle (DM) following Trans-Urethral Resection of Bladder Tumour (TURBT).

Objectives:

To evaluate the presence of DM in primary TURBT specimens as a quality improvement exercise in Frimley Park Hospital, UK. And to assess if the level of the surgeon has impact on outcomes.

Methods:

Retrospective and prospective analysis of the electronic records from a single urology centre, servicing a group of urologists. Data collected over three consecutive audit loops between January 2014 and May 2018.

Results:

A total of 301 cases were performed under the care of seven consultant urologists. Analysis revealed a significant improvement in the overall quality of resections from 39% to 66% (50–84% for intermediate and high grade) after the introduction of the following interventions: (1) analysis and improved awareness of current practice; (2) introduction of European Association of Urology (EAU) guidelines by separating samples and sending a second specimen pot marked as bladder tumour base to look for DM; (3) dedicated urologists with an interest in bladder cancer performing en-bloc resection technique in appropriate cases.

Conclusion:

Through our closed-loop audits, we have demonstrated a considerable improvement in the quality of resections, resulting in accurate staging from the initial resection. This could in turn lead to improved over all prognoses and negating the need for re-resection in all cases of high-risk non-muscle invasive bladder cancer (NMIBC).

Level of evidence:

3

Development of a New Recurrence-Free Survival Prediction Nomogram for Patients with Primary Non-Muscle-Invasive Bladder Cancer Based on Preoperative Controlling Nutritional Status Score

Background

Bladder cancer is the second most prevalent neoplasm in the urogenital system in terms of morbidity and mortality, and there is an urgent need for a more accurate assessment of individual prognosis in patients with primary non-muscle-invasive bladder cancer (NMIBC). The Controlling Nutritional Status (CONUT) score is an emerging biomarker score which has been confirmed to have prognostic value in various malignant tumors. The study attempted to systematically identify the prognostic role of preoperative CONUT score on posttreatment recurrence-free survival (RFS) in patients with NMIBC, and determine the predictive value and feasibility of the new prognostic prediction model.

Methods

A total of 94 patients with NMIBC were analyzed retrospectively between January 2011 and December 2015. Statistical analysis was conducted using the nonparametric method. The Kaplan-–Meier method was used to assess recurrence-free survival (RFS), and Log rank tests was used to analyze the equivalences of survival curves. We used univariate and multivariate Cox proportional hazards regression model to identify important predictors of RFS. Discrimination of nomogram was measured by the concordance index. Predictive accuracy of the model was evaluated using the internal validation.

Results

In univariate analysis, age, history of smoking, pathological T stage, tumor grade, tumor size, and CONUT score were significantly correlated with RFS. Multivariate analysis indicated that CONUT score (HR =3.855, 95% CI 1.242–11.970, p=0.020) was an independent predictor of RFS in patients with NMIBC. Based on significant parameters in multivariate analysis and reliable recurrence predictors determined in predictive models and relevant guidelines, a new age-, history of smoking-, pathologic factors- and the CONUT score-based scoring model was developed to predict recurrence of NMBIC. In addition, we internally validated the nomogram using the consistency index and calibration plots, which demonstrated that the model has high prediction accuracy (c-index= 0.851).

Conclusion

The development of a new nomogram based on CONUT score could increase the accuracy of recurrence prediction and improve individualized treatment plans for patients with NMIBC.

Efficacy of three BCG strains (Connaught, TICE and RIVM) with or without secondary resection (re-TUR) for intermediate/high-risk non-muscle-invasive bladder cancers: results from a retrospective single-institution cohort analysis

Purpose

(I) To evaluate the clinical efficacy of three different BCG strains in patients with intermediate-/high-risk non-muscle-invasive bladder cancer (NMIBC). (II) To determine the importance of performing routine secondary resection (re-TUR) in the setting of BCG maintenance protocol for the three strains.

Methods

NMIBCs who received an adjuvant induction followed by a maintenance schedule of intravesical immunotherapy with BCG Connaught, TICE and RIVM. Only BCG-naïve and those treated with the same strain over the course of follow-up were included. Cox proportional hazards model was developed according to prognostic factors by the Spanish Urological Oncology Group (CUETO) as well as by adjusting for the implementation of re-TUR.

Results

n = 422 Ta-T1 patients (Connaught, n = 146; TICE, n = 112 and RIVM, n = 164) with a median (IQR) follow-up of 72 (60–85) were reviewed. Re-TUR was associated with improved recurrence and progression outcomes (HR_RFS: 0.63; 95% CI 0.46–0.86; HR_PFS: 0.55; 95% CI 0.31–0.86). Adjusting for CUETO risk factors and re-TUR, BGC TICE and RIVM provided longer RFS compared to Connaught (HR_TICE: 0.58, 95% CI 0.39–0.86; HR_RIVM: 0.61, 95% CI 0.42–0.87) while no differences were identified between strains for PFS and CSS. Sub-analysis of only re-TUR cases (n = 190, 45%) showed TICE the sole to achieve longer RFS compared to both Connaught and RIVM.

Conclusion

Re-TUR was confirmed to ensure longer RFS and PFS in intermediate-/high-risk NMIBCs but did not influence the relative single BCG strain efficacy. When routinely performing re-TUR followed by a maintenance BCG schedule, TICE was superior to the other strains for RFS outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00432-021-03571-0.

Systematic Review and Meta-Analysis of Vesical Imaging-Reporting and Data System (VI-RADS) Inter-Observer Reliability: An Added Value for Muscle Invasive Bladder Cancer Detection

Simple Summary

In our systematic review and meta-analysis of eight observational studies including a total of 1016 patients, we demonstrated excellent pooled inter-observer agreement among Genito-Urinary radiologists when adopting the novel Vesical Imaging-Reporting and Data System (VI-RADS) criteria in the pre-trans-urethral resection of bladder tumor (TURBT) assessment for non-muscle (NMIBC) vs. muscle-invasive bladder cancer (MIBC) detection.

Abstract

The Vesical Imaging-Reporting and Data System (VI-RADS) has been introduced to provide preoperative bladder cancer staging and has proved to be reliable in assessing the presence of muscle invasion in the pre-TURBT (trans-urethral resection of bladder tumor). We aimed to assess through a systematic review and meta-analysis the inter-reader variability of VI-RADS criteria for discriminating non-muscle vs. muscle invasive bladder cancer (NMIBC, MIBC). PubMed, Web of Science, Cochrane, and Embase were searched up until 30 July 2020. The Quality Appraisal of Diagnostic Reliability (QAREL) checklist was utilized to assess the quality of included studies and a pooled measure of inter-rater reliability (Cohen’s Kappa [κ] and/or Intraclass correlation coefficients (ICCs)) was calculated. Further sensitivity analysis, subgroup analysis, and meta-regression were conducted to investigate the contribution of moderators to heterogeneity. In total, eight studies between 2018 and 2020, which evaluated a total of 1016 patients via 21 interpreting genitourinary (GU) radiologists, met inclusion criteria and were critically examined. No study was considered to be significantly flawed with publication bias. The pooled weighted mean κ estimate was 0.83 (95%CI: 0.78–0.88). Heterogeneity was present among the studies (Q = 185.92, d.f. = 7, p < 0.001; I2 = 92.7%). Meta-regression analyses showed that the relative % of MIBC diagnosis and cumulative reader’s experience to influence the estimated outcome (Coeff: 0.019, SE: 0.007; p= 0.003 and 0.036, SE: 0.009; p = 0.001). In the present study, we confirm excellent pooled inter-reader agreement of VI-RADS to discriminate NMIBC from MIBC underlying the importance that standardization and reproducibility of VI-RADS may confer to multiparametric magnetic resonance (mpMRI) for preoperative BCa staging.

Overview of VI-RADS in Bladder Cancer

OBJECTIVE. The purpose of this article is to review the natural history and management of bladder cancer, with insight into MRI applications for the assessment of muscle invasiveness of bladder cancer using the newly developed Vesical Imaging Reporting and Data System (VI-RADS) score. CONCLUSION. Multiparametric MRI and the VI-RADS score have been consistently validated across several different institutions as appropriate tools for local staging of bladder cancer and have been proven to contribute to the diagnostic workup and management of urinary bladder cancer.

[Is a routine second transurethral resection of the bladder still necessary after hexaminolévulinate photodynamic diagnosis-assisted TURBT?]

OBJECTIVES

The aim of our study was to assess the impact of blue light cystoscopy with hexaminolevulinate on residual tumor rates at second-look transurethral resection of the bladder (TURB).

MATERIAL AND METHODS

Among all patients undergoing TURB in our center between 2012 and 2017, 52 patients had a second-look after a first complete TURB with a delay<3months. We compare patients with standard white light cystoscopy/TURB then second-look blue light cystoscopy/re-TURB (group A, n=30) and patients with blue light cystoscopy/TURB at the initial procedure then white light cystoscopy/re-TURB (group B, n=22). The residual tumor rates at second-look, restaging and changing in therapeutic strategy, as well as recurrence free survival and progression rate were compared.

RESULTS

Residual tumor at the time of second-look cystoscopy was detected in 42.3% of cases in our cohort, with a significant difference between the two groups (63.3% in group A versus 0% in group B, <0.001). In group A, 16.7% (5/30) of patients had upstaging and/or upgrading at second-look cystoscopy, resulting in a change in therapeutic strategy in most cases (4/5) while none upstaging was observed in group B. In multivariate analysis, the use of luminofluorescence at the first TURB was the only independent predictive factor of residual tumor (P=0.0031).

CONCLUSION

The quality of the initial TURB, when performed by using blue light cystoscopy, had a significant impact on the rate of residual tumor at the second-look resection and could modify therapeutic strategy of NMIBC.

LEVEL OF EVIDENCE

4.

Does restaging transurethral resection of bladder tumour influence outcomes in patients treated with BCG immunotherapy? 491 cases in 20 years' experience

Introduction

Bladder cancer is one of the most common malignancies worldwide.

Aim

To analyse the influence of restaging transurethral resection of bladder tumour (reTURB) on outcomes in patients treated with BCG immunotherapy.

Material and methods

We analysed a database of 491 patients who were treated in a Bacillus Calmette-Guérin (BCG) outpatient department between 1998 and 2016. A minimum of 12 months of follow-up was required. The study included 235 patients with a history of the reTURB procedure and 256 patients without reTURB. The patients were analysed in terms of recurrence-free (RFS), progression-free (PFS), cancer-specific and overall survival.

Results

The RFS was significantly higher in the reTURB group for both general and subgroup analysis (T1HG, TaHG). The PFS was significantly higher in the reTURB group for both general and subgroup analysis (TaHG). In patients without lamina muscularis in the specimen there was a greater improvement in RFS due to the reTURB procedure than for other patients. ReTURB performed in T1 tumours with massive lamina propria infiltration had a positive influence on RFS. In patients with reTURB the presence of focal invasion was related to lower risk of progression. Both overall and cancer-specific survival were significantly improved by the reTURB procedure in T1HG and HG tumours.

Conclusions

This study highlights the importance of reTURB. It was found that the patients with TaHG tumours benefited the most in terms of RFS, PFS and cancer-specific survival. It was also demonstrated that massive lamina propria infiltration in T1 tumours is associated with the worst outcomes.

Novel nomograms to predict recurrence and progression in primary non-muscle-invasive bladder cancer: validation of predictive efficacy in comparison with European Organization of Research and Treatment of Cancer scoring system

PURPOSE

To develop and validate novel nomograms to predict recurrence and progression after transurethral resection of bladder tumor (TURBT) in Korean patients with non-muscle-invasive bladder cancer (NMIBC).

METHODS

We retrospectively analyzed the clinical data on 970 newly diagnosed NMIBC patients after TURBT between 2000 and 2013 in a single institution. We used multivariate Cox proportional hazard models to identify the significant predictors of recurrence and progression, which resulted in the construction of the nomograms predicting the 5-year probability of recurrence and progression. We internally validated the nomograms using the area under the receiver-operating characteristics' curves and calibration plots. In addition, the clinical usefulness of each nomogram was assessed and compared with that of the European Organization of Research and Treatment of Cancer (EORTC)-scoring system using decision curve analysis (DCA).

RESULTS

The significant factors related to recurrence were gross hematuria at diagnosis, previous or concomitant upper urinary tract urothelial carcinoma (UTUC), pT1 tumor, high tumor grade, multiple tumors, and intravesical therapy. The significant predictors of progression were previous or concomitant UTUC, pT1 tumor, high tumor grade, carcinoma in situ, and lymphovascular invasion. The 5-year predictive accuracy of each nomogram was 65% for recurrence and 70% for progression, respectively. Compared with the EORTC-scoring system, the nomograms were generally well calibrated. On DCA, each nomogram presented better net benefit gains than did the EORTC-scoring system across a wide range of threshold probabilities.

CONCLUSIONS

Our novel nomograms are not completely accurate, but they show a reasonable level of discriminative ability, adequate calibration, and meaningful net benefit gain for the prediction of recurrence and progression after TURBT in Korean NMIBC patients. Additional external validation will be required to generalize the nomograms which we developed.

Dose, duration and strain of bacillus Calmette-Guerin in the treatment of nonmuscle invasive bladder cancer: Meta-analysis of randomized clinical trials

BACKGROUND

Intravesical bacillus Calmette-Guerin (BCG) instillation is widely used as an adjuvant therapy after transurethral resection of bladder tumor (TURBT) in patients with intermediate- and high-risk nonmuscle invasive bladder cancer (NMIBC). However, the effective dose, duration, and strain of BCG have not yet been clearly determined. We aimed to elucidate the relationship between dose, duration, and strain of BCG and clinical outcomes in NMIBC patients treated with TURBT.

METHODS

We conducted a literature search in Embase, Scopus, and PubMed databases for all relevant articles published up to October 2016 in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. The relative risks of clinical outcomes, including recurrence, progression, cancer-specific mortality, and all-cause mortality according to dose (standard vs low), duration (induction vs maintenance), and strain of BCG were presented as the pooled risk ratio (RR) and 95% confidence interval (CI).

RESULTS

Nineteen studies meeting the inclusion criteria were finally selected in this meta-analysis. The risk of recurrence was significantly highly observed in case of low-dose BCG (RR, 1.17; 95% CI 1.06-1.30) and induction BCG (RR, 1.33; 95% CI 1.17-1.50) only group without heterogeneity among the included studies. Although there were no significant differences between dose or duration and other clinical outcomes. On direct comparison in each study comparing BCG strains, the Tice stain showed a relatively high probability of recurrence compared with the Connaught (RR, 1.29; 95% CI 1.01-1.64) and RIVM (RR, 2.04, 95% CI 1.28-3.25) strains. Funnel plot testing revealed no significant publication bias.

CONCLUSION

The use of standard dose and maintenance BCG instillation may be effective to reduce recurrence rate after TURBT for NMIBC. Further large scale, well-designed, and prospective studies, with stratification of the patients into risk group at randomization, will be required to determine the optimal guideline of BCG use to improve clinical outcomes in NMIBC.

Comparison of Detrusor Muscle Sampling Rate in Monopolar and Bipolar Transurethral Resection of Bladder Tumor: A Randomized Trial

PURPOSE

Our aim was to investigate the detrusor muscle sampling rate after monopolar versus bipolar transurethral resection of bladder tumor (TURBT).

METHODS

This was a single-center, prospective, randomized, phase III trial on monopolar versus bipolar TURBT. Baseline patient characteristics, disease characteristics and perioperative outcomes were compared, with the primary outcome being the detrusor muscle sampling rate in the TURBT specimen. Multivariate logistic regression analyses on detrusor muscle sampling were performed.

RESULTS

From May 2012 to December 2015, a total of 160 patients with similar baseline characteristics were randomized to receive monopolar or bipolar TURBT. Fewer patients in the bipolar TURBT group required postoperative irrigation than patients in the monopolar TURBT group (18.7 vs. 43%; p = 0.001). In the whole cohort, no significant difference in the detrusor muscle sampling rates was observed between the bipolar and monopolar TURBT groups (77.3 vs. 63.3%; p = 0.057). In patients with urothelial carcinoma, bipolar TURBT achieved a higher detrusor muscle sampling rate than monopolar TURBT (84.6 vs. 67.7%; p = 0.025). On multivariate analyses, bipolar TURBT (odds ratio [OR] 2.23, 95% confidence interval [CI] 1.03-4.81; p = 0.042) and larger tumor size (OR 1.04, 95% CI 1.01-1.08; p = 0.022) were significantly associated with detrusor muscle sampling in the whole cohort. In addition, bipolar TURBT (OR 2.88, 95% CI 1.10-7.53; p = 0.031), larger tumor size (OR 1.05, 95% CI 1.01-1.10; p = 0.035), and female sex (OR 3.25, 95% CI 1.10-9.59; p = 0.033) were significantly associated with detrusor muscle sampling in patients with urothelial carcinoma.

CONCLUSIONS

There was a trend towards a superior detrusor muscle sampling rate after bipolar TURBT. Further studies are needed to determine its implications on disease recurrence and progression.

Prognostic Factors for Recurrence and Progression in Korean Non-Muscle-Invasive Bladder Cancer Patients: A Retrospective, Multi-Institutional Study

PURPOSE

To identify the prognostic factors related to tumor recurrence and progression in Korean patients with non-muscle-invasive bladder cancer (NMIBC).

MATERIALS AND METHODS

Data were collected and analyzed for 2412 NMIBC patients from 15 centers who were initially diagnosed after transurethral resection of bladder tumor (TURBT) from January 2006 to December 2010. Using univariable and multivariable Cox proportional hazards models, the prognostic value of each variable was evaluated for the time to first recurrence and progression.

RESULTS

With a median follow-up duration of 37 months, 866 patients (35.9%) experienced recurrence, and 137 (5.7%) experienced progression. Patients with recurrence had a median time to the first recurrence of 10 months. Multivariable analysis conducted in all patients revealed that preoperative positive urine cytology (PUC) was independently associated with worse recurrence-free survival [RFS; hazard ratio (HR) 1.56; p<0.001], and progression-free survival (PFS; HR 1.56; p=0.037). In particular, on multivariable analysis conducted for the high-risk group (T1 tumor/high-grade Ta tumor/carcinoma in situ), preoperative PUC was an independent predictor of worse RFS (HR 1.73; p<0.001) and PFS (HR 1.96; p=0.006). On multivariable analysis in patients with T1 high-grade (T1HG) cancer (n=684), better RFS (HR 0.75; p=0.033) and PFS (HR 0.33; p<0.001) were observed in association with the administration of intravesical Bacillus Calmette-Guérin (BCG) induction therapy.

CONCLUSION

A preoperative PUC result may adversely affect RFS and PFS, particularly in high-risk NMIBC patients. Of particular note, intravesical BCG induction therapy should be administered as an adjunct to TURBT in order to improve RFS and PFS in patients with T1HG cancer.

The impact of re-transurethral resection on clinical outcomes in a large multicentre cohort of patients with T1 high-grade/Grade 3 bladder cancer treated with bacille Calmette-Guérin

OBJECTIVES

To determine if a re-transurethral resection (TUR), in the presence or absence of muscle at the first TUR in patients with T1-high grade (HG)/Grade 3 (G3) bladder cancer, makes a difference in recurrence, progression, cancer specific (CSS) and overall survival (OS).

PATIENTS AND METHODS

In a large retrospective multicentre cohort of 2451 patients with T1-HG/G3 initially treated with bacille Calmette-Guérin, 935 (38%) had a re-TUR. According to the presence or absence of muscle in the specimen of the primary TUR, patients were divided in four groups: group 1 (no muscle, no re-TUR), group 2 (no muscle, re-TUR), group 3 (muscle, no re-TUR) and group 4 (muscle, re-TUR). Clinical outcomes were compared across the four groups.

RESULTS

Re-TUR had a positive impact on recurrence, progression, CSS and OS only if muscle was not present in the primary TUR specimen. Adjusting for the most important prognostic factors, re-TUR in the absence of muscle had a borderline significant effect on time to recurrence [hazard ratio (HR) 0.67, P = 0.08], progression (HR 0.46, P = 0.06), CSS (HR 0.31, P = 0.07) and OS (HR 0.48, P = 0.05). Re-TUR in the presence of muscle in the primary TUR specimen did not improve the outcome for any of the endpoints.

CONCLUSIONS

Our retrospective analysis suggests that re-TUR may not be necessary in patients with T1-HG/G3, if muscle is present in the specimen of the primary TUR.

Treatment and management of high-grade T1 bladder cancer: what should we do after second TUR?

Most T1 bladder cancers are high grade and have the potential to progress to muscle invasion and extravesical dissemination. Many studies reported that ∼50% of patients displayed residual tumors when a second transurethral resection was performed 2-6 weeks after the initial resection for patients who were diagnosed with T1 bladder cancer. Furthermore, muscle-invasive disease was detected by the second transurethral resection in 10-25% of those patients. Therefore, a second transurethral resection is strongly recommended for patients newly diagnosed with high-grade T1 bladder cancer in various guidelines. T1 bladder cancers are heterogeneous in terms of progression and prognosis after the second transurethral resection. Optimal management and treatment should be considered for patients with T1 bladder cancer based on the pathological findings for the second transurethral resection specimen. If the second transurethral resection reveals residual tumors, aggressive treatments based on the pathological findings should be performed. Conversely, overtreatment with respect to the tumor status should be avoided. Since the evidence of pathological diagnosis at the second transurethral resection is insufficient and many retrospective studies were carried out before the second transurethral resection era, prospective randomized studies should be conducted.