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

Role of repeat transurethral resection in no-muscle-invasive bladder tumour: an umbrella review

Background

Repeat transurethral resection of bladder tumour (reTURB) is a conventional treatment for non-muscle-invasive bladder cancer (NMIBC) to enhance prognosis. However, the necessity of reTURB in NMIBC remains controversial owing to upstaging of treatments and new evidence.

Objectives

We performed an umbrella review to determine the need for reTURB in patients with NMIBC.

Design

We extracted data from meta-analyses that were screened out after a systematic search of PubMed, Embase, the Web of Science and the Cochrane Database of Systematic Reviews.

Methods

Risk of Bias in Systematic Reviews and the Grading of Recommendations, Assessment, Development and Evaluation tools were used to assess the quality of each included meta-analysis and outcomes.

Results

Our study included seven meta-analyses. Two studies assessed the efficiency of reTURB in patients who underwent en bloc resection of bladder tumours (ERBT). Patients who underwent ERBT reported low residual tumour and upstaging rates of 5.9% and 0.3%, respectively. Conversely, patients who underwent conventional transurethral resection for bladder cancer (cTURB) had high residual tumour rates. Patients who underwent cTURB and reTURB had significantly improved 1-year recurrence-free survival (RFS) compared to those who underwent initial cTURB alone. In terms of progression-free survival (PFS), a meta-analysis reported that patients who underwent cTURB and reTURB had significantly improved PFS compared with those who underwent initial cTURB alone. In the subgroup analyses of ERBT, reTURB did not affect the RFS and PFS of patients who received ERBT. Currently, only a limited number of randomised clinical trials have evaluated reTURB, and various factors have influenced its efficacy.

Conclusion

There was significant variation in survival outcomes among patients undergoing reTURB. The necessity and efficacy of reTURB depend on numerous factors, such as surgical approach, equipment and medication usage. Patients eligible for ERBT may constitute a group that does not require reTURB. Further clinical trials are required to validate these findings.

Registration

This umbrella review was registered with the International Prospective Register of Systematic Reviews (CRD42023439078).

French AFU Cancer Committee Guidelines - Update 2024-2026: Non-muscle invasive bladder cancer (NMIBC)

OBJECTIVE

To update the CCAFU recommendations for the management of non-muscle invasive bladder cancer (NMIBC).

METHODS

A systematic review (Medline) of the literature from 20222024 was performed, taking into account the elements of diagnosis, treatment options and monitoring of NMIBC and evaluating references with their level of evidence.

RESULTS

The diagnosis of NMIBC (Ta, T1, or CIS) is made after complete and deep tumour resection. The use of bladder photodynamic diagnosis and the indication for a second TURBT (4 to 6weeks later) help to improve the initial diagnosis. The risk of recurrence and/or tumour progression is assessed via the EORTC score. By stratifying patients into low-, intermediate- and high-risk groups, adjuvant treatment can be proposed, including endovesical instillations of chemotherapy (immediate postoperative regimen), BCG (induction and maintenance regimen), or even the indication of cystectomy for unresponsive patients.

CONCLUSION

Updating the CCAFU's recommendations should help improve patient management, as well as the diagnosis and treatment of NMIBC.

Optimal timing for the first cystoscopic follow-up using time-to-treatment initiation analysis of oncologic outcomes in primary non-muscle invasive bladder cancer

Various guidelines recommend the first follow-up cystoscopy at 3 months; however, no data exist on the optimal timing for initial follow-up cystoscopy. We tried to provide evidence on the timing of the first cystoscopy after the initial transurethral resection of bladder tumor (TUR-BT) for patients with non-muscle invasive bladder cancer (NMIBC) using big data. This was a retrospective National Health Insurance Service database analysis. The following outcomes were considered: recurrence, progression, cancer-specific mortality, and all-cause mortality. Exposure was the time-to-treatment initiation (TTI), a continuous variable representing the time to the first cystoscopy from the first TUR-BT within 1 year. Additionally, we categorized TTI (TTIc) into five levels: < 2, 2-4, 4-6, 6-8, and 8-12 months. A landmark time of 1 year after the initial TUR-BT was described to address immortal-time bias. We identified the optimal time for the first cystoscopy using Cox regression models with and without restricted cubic splines (RCS) for TTI and TTIc, respectively. Among 26,660 patients, 16,880 (63.3%) underwent cystoscopy within 2-4 months. A U-shaped trend of the lowest risks at TTI was observed in the 2-4 months group for progression, cancer-specific mortality, and all-cause mortality. TTI within 0-2 months had a higher risk of progression (aHR 1.36; 95% confidence intervals [CI] 1.15-1.60; p < 0.001) and cancer-specific mortality (aHR 1.29; 95% CI 1.05-1.58; p = 0.010). Similarly, TTI within 8-12 months had a higher risk of progression (aHR 2.09; 95% CI 1.67-2.63; p < 0.001) and cancer-specific mortality (aHR 1.96; 95% CI 1.48-2.60; p < 0.001). Based on the RCS models, the risks of progression, cancer-specific mortality, and all-cause mortality were lowest at TTI of 4 months. The timing of the first cystoscopy follow-up was associated with oncologic prognosis. In our model, undergoing cystoscopy at 4 months has shown the best outcomes in clinical course. Therefore, patients who do not receive cystoscopy at approximately 4 months for any reason need more careful follow-up to predict a poor clinical course.

A Systematic Review on the Role of Repeat Transurethral Resection after Initial en Bloc Resection for Non-Muscle Invasive Bladder Cancer

International guidelines recommend repeat transurethral resection of bladder tumors (reTURB) for selected patients with high-risk non-muscle invasive bladder cancer to remove possible residual tumors, restage tumors and improve the therapeutic outcome. However, most evidence supporting the benefits of reTURB is from conventional TURB. The role of reTURB in patients receiving initial En bloc resection of bladder tumor (ERBT) is still unknown. PubMed, Embase, Web of Science, The Cochrane Library, and China National Knowledge Infrastructure (CNKI) were systematically searched. Finally, this systematic review and meta-analysis included twelve articles, including 539 patients. The rates of residual tumor and tumor upstaging detected by reTURB after ERBT were 5.9% (95%CI, 2.0%–11.1%) and 0.0% (95%CI, 0.0%–0.5%), respectively. Recurrence-free survival, tumor recurrence and progression were comparable between patients with and without reTURB after initial ERBT. The pooled hazard ratios of 1-year, 2-year, 3-year and 5-year recurrence-free survival were 0.74 (95%CI, 0.36–1.51; p = 0.40), 0.76 (95%CI, 0.45–1.26; p = 0.28), 0.83 (95%CI, 0.53–1.32; p = 0.43) and 0.83 (95%CI, 0.56–1.23; p = 0.36), respectively. The pooled relative risks of recurrence and progression were 0.87 (95%CI, 0.64–1.20; p = 0.40) and 1.11 (95%CI, 0.54–2.32; p = 0.77), respectively. Current evidence demonstrates that reTURB after ERBT for bladder cancer can detect relatively low rates of residual tumor and tumor upstaging and appears not to improve either recurrence or progression.