Factors that predict residual tumors in re-TUR patients

Repeat Transurethral Resection for Non-muscle-invasive Bladder Cancer: An Updated Systematic Review and Meta-analysis in the Contemporary Era

CONTEXT

Repeat transurethral resection (reTUR) is a guideline-recommended treatment strategy in high-risk non-muscle-invasive bladder cancer (NMIBC) patients treated with transurethral resection of bladder tumor (TURBT); however, the impact of recent procedural/technological developments on reTUR outcomes has not been assessed yet.

OBJECTIVE

To assess the outcomes of reTUR for NMIBC in the contemporary era, focusing on whether temporal differences and technical advancement, specifically, photodynamic diagnosis and en bloc resection of bladder tumor (ERBT), affect the outcomes.

EVIDENCE ACQUISITION

Multiple databases were queried in February 2023 for studies investigating reTUR outcomes, such as residual tumor and/or upstaging rates, its predictive factors, and oncologic outcomes, including recurrence-free (RFS), progression-free (PFS), cancer-specific (CSS), and overall (OS) survival. We synthesized comparative outcomes adjusting for the effect of possible confounders.

EVIDENCE SYNTHESIS

Overall, 81 studies were eligible for the meta-analysis. In T1 patients initially treated with conventional TURBT (cTURBT) in the 2010s, the pooled rates of any residual tumors and upstaging on reTUR were 31.4% (95% confidence interval [CI]: 26.0-37.2%) and 2.8% (95% CI: 2.0-3.8%), respectively. Despite a potential publication bias, these rates were significantly lower than those in patients treated in the 1990-2000s (both p < 0.001). ERBT and visual enhancement-guided cTURBT significantly improved any residual tumor rates on reTUR compared with cTURBT based on both matched-cohort and multivariable analyses. Among studies adjusting for the effect of possible confounders, patients who underwent reTUR had better RFS (hazard ratio [HR]: 0.78, 95% CI: 0.62-0.97) and OS (HR: 0.86, 95% CI: 0.81-0.93) than those who did not, while it did not lead to superior PFS (HR: 0.74, 95% CI: 0.47-1.15) and CSS (HR: 0.94, 95% CI: 0.86-1.03).

CONCLUSIONS

reTUR is currently recommended for high-risk NMIBC based on the persistent high rates of residual tumors after primary resection. Improvement of resection quality based on checklist applications and recent technical/procedural advancements hold the promise to omit reTUR.

PATIENT SUMMARY

Recent endoscopic/procedural developments improve the outcomes of repeat resection for high-risk non-muscle-invasive bladder cancer. Further investigations are urgently needed to clarify the potential impact of the use of these techniques on the need for repeat transurethral resection in the contemporary era.

Does repeat transurethral resection of bladder tumor influence the diagnosis and prognosis of T1 bladder cancer? A systematic review and meta-analysis

BACKGROUND

To reduce recurrence or progression of tumor, NCCN guidelines recommend repeat transurethral resection of bladder tumors (reTURB) for non-muscle-invasive bladder cancer (NMIBC). The study aims to compare the impact of initial TURB and reTURB on the rate of residual or upstaging tumors and short-term and long-term survival outcomes of T1 bladder cancer (BC).

MATERIALS AND METHODS

We searched through several public database, including PubMed, Embase, Ovid Medline and Ovid EBM Reviews - Cochrane Central Register of Controlled Trials. The latest search time was October 2021.

RESULTS

In general, 68 articles were involved. Short-term RFS (1-year and 3-year) of reTURB group was better compared with TURB group in T1 patients. The pooled RR were 1.10 (95%CI: 1.01-1.19) and 1.15 (95%CI: 1.03-1.28), respectively. While reTURB did not improve long-term RFS (5-year, 10-year, 15-year) in T1 patients. The pooled RR were 1.12 (95%CI: 0.97-1.30), 1.11 (95%CI: 0.82-1.50) and 1.37 (95%CI: 0.50-3.74), respectively. Analysis of PFS, OS and CSS demonstrated similar outcomes with RFS. We found that about two-thirds of samples contained detrusor. The residual tumor rate in stage T1 was 0.48 (95%CI: 0.42-0.53). While the rate of upstaging in stage T1 was 0.10 (95%CI: 0.07-0.13).

CONCLUSIONS

In conclusion, reTURB might provide short-term survival benefits for T1 BC, but it was not the same for long-term outcomes. The residual and upstaging rates of T1 BC in reTURB were around 50% and 10%, respectively. Our study might be conducive to clinically informed consents when patients expressed their concerns about the necessity of reTURB and its impact on diagnosis, treatment and prognosis.

Repeat Transurethral Resection in Non-muscle-invasive Bladder Cancer: A Systematic Review

CONTEXT

Initial treatment for most bladder cancers (BCs) involves transurethral resection (TUR) or tumours. Often more cancer is found after the initial treatment in around half of patients, requiring a second resection. Repeat transurethral resection (reTUR) is recommended for high-risk, non-muscle-invasive bladder cancer (NMIBC) to remove any residual disease and improve cancer outcomes.

OBJECTIVE

To systematically review the practice and therapeutic benefit of an early reTUR for high-risk NMIBC.

EVIDENCE ACQUISITION

A systematic review of original articles was performed using PubMed/Medline and Web of Science databases in December 2016 (initial) and October 2017 (final). We searched the references of included papers.

EVIDENCE SYNTHESIS

We screened 15 209 manuscripts and selected 31 detailing 8409 persons with high-grade Ta and T1BC for inclusion. Detrusor muscle was found at initial TUR histology in 30-100% of cases. Residual tumour at reTUR was found in 17-67% of patients following Ta and in 20-71% following T1 cancer. Most residual tumours (36-86%) were found at the original resection site. Upstaging occurred in 0-8% (Ta to ≥T1) and 0-32% (T1 to ≥T2) of cases. Conflicting data report the impact of reTUR on subsequent recurrence and cancer-specific mortality. Recurrence for Ta was 16% in the reTUR group versus 58% in the non-reTUR group. For T1, recurrence ranged from 18% to 56%, but no clear trend was identified between reTUR and control. No clear relationship between reTUR and progression was found for Ta, although for T1 rates were higher in the non-reTUR group in series with control populations (5/6 studies). Overall mortality was slightly reduced in the reTUR group in two studies with controls (22-30% vs 26-36% [no reTUR]).

CONCLUSIONS

Residual tumour is common after TUR for high-risk NMIBC. The reTUR helps in the diagnosis of this residual cancer and may improve outcomes for cancers initially staged as T1.

PATIENT SUMMARY

Some bladder cancers (BCs) are aggressive but confined to the bladder surface. Initial treatment includes endoscopic resection. More cancer is found after the initial treatment in approximately half of patients. In the aggressive but confined group of BC, a second resection, a few weeks after the first, may help find this residual cancer and improve outcomes, although the evidence quality for this is weak.