A Case for Risk-adapted Management of Low-grade Bladder Tumors

Long-term outcomes and cost savings of office fulguration of papillary Ta low-grade bladder cancer

OBJECTIVES

To assess whether office-based fulguration (OF) under local anaesthesia for small, recurrent, pathological Ta low-grade (LG) non-muscle-invasive bladder cancer (NMIBC) is an effective alternative to transurethral resection of bladder tumour (TURBT), avoiding the costs and risks of procedure, and anesthesia.

PATIENTS AND METHODS

Of 521 patients with primary TaLG NMIBC, this retrospective study included 270 patients who underwent OF during follow-up for recurrent, small, papillary LG-appearing tumours at a university centre (University Health Network, University of Toronto, Canada). We assessed the cumulative incidence of cancer-specific mortality (CSM) and disease progression (to MIBC or metastases), as well as possible direct cost savings.

RESULTS

In the 270 patients with recurrent TaLG NMIBC treated with OF, the mean (sd) age was 64.9 (13.3) years, 70.8% were men, and 60.3% had single tumours. The mean (sd, range) number of OF procedures per patient was 3.1 (3.2, 1-22). The median (interquartile range) follow-up was 10.1 (5.8-16.2) years. Patients also underwent a mean (sd) of 3.6 (3.0) TURBTs during follow-up in case of numerous or bulkier recurrence. In all, 44.4% of patients never received intravesical therapy. The 10-year incidence of CSM and progression were 0% and 3.1% (95% confidence interval 0.8-5.4%), respectively. Direct cost savings in Ontario were estimated at $6994.14 (Canadian dollars) per patient over the study follow-up.

CONCLUSIONS

This study supports that properly selected patients with recurrent, apparent TaLG NMIBC can be safely managed with OF under local anaesthesia with occasional TURBT for larger or numerous recurrent tumours, without compromising long-term oncological outcomes. This approach could generate substantial cost-saving to healthcare systems, is patient-friendly, and could be adopted more widely.

Long‐term outcomes of outpatient laser ablation for recurrent non‐muscle invasive bladder cancer: A retrospective cohort study

Objectives

The objective of this study is to determine the long‐term efficacy and safety of office‐based Holmium:YAG laser ablation for the treatment of recurrent non‐muscle‐invasive bladder cancer (NMIBC).

Methods

We retrospectively reviewed the medical records of all consecutive patients who underwent office‐based laser ablation for recurrent bladder cancer between 2008 and 2016. The following data were collected: original histology, date of original histology, date of laser ablation, number of repeat laser ablation procedures required, date of tumor recurrence or progression, number of general anesthesia procedures (transurethral resection or cystodiathermy) required after first laser ablation, and number and severity of complications. Kaplan–Meier survival curves were produced for recurrence‐free survival, progression‐free survival, and overall survival.

Results

A total of 97 patients, with an average age of 84 (62–98) years and an average Charlson Comorbidity Index of 6.9 (4–13), were included. The median follow‐up was 61 (2–150) months. Fifty‐five (56.7%) patients presented with tumor recurrence, and the median recurrence‐free survival time was 1.69 years (95% CI 1.20–2.25). Only 9 (9.3%) patients had evidence of tumor progression to a higher grade or stage, 8 (89%) of which initially had low‐grade tumors; however, no patient progressed to muscle‐invasive disease. The median progression‐free survival time was 5.70 years (95% CI 4.10–7.60), and the median overall survival time was 7.60 years (95% CI 4.90–8.70). No patient required emergency inpatient admission after laser ablation.

Conclusion

Office‐based Holmium:YAG laser ablation offers a safe and effective alternative method for treating low‐volume, low‐grade recurrent NMIBC, especially in elderly patients with significant co‐morbidity, while avoiding general anesthesia and inpatient admission.