Long-Term Outcome of Simultaneous Transurethral Resection of Bladder Tumor and Prostate in Patients With Nonmuscle Invasive Bladder Tumor and Bladder Outlet Obstruction

The association between postvoid residual and response to standard therapy in male and female patients with non-muscle-invasive bladder cancer

Background

The urinary retention is recognized as a promoting factor for bladder cancer, but its role as prognostic factor of therapeutic response has not yet been widely considered. To correlate bladder outlet characteristics with short-term response to treatment in non-muscle-invasive bladder cancer.

Materials and methods

We carried out a case-control study on 600 consecutive patients with a first diagnosis of non-muscle-invasive bladder cancer, recruited at the first endoscopic follow-up visit after standard treatment: 200 patients were not tumor-free (cases) and 400 were tumor-free (controls). Patients were compared based on baseline and bladder-outlet characteristics ("functional parameters": postvoid residual volume [PVR], International Prostatic Symptoms Score, perceived quality of bladder outlet). t Test, χ2 test, receiver operating characteristic curves, logistic correlations, and multivariate analysis were applied.

Results

The cases had higher statistically significant PVR values compared with controls. We reported a linear correlation of no-tumor-free status with PVR (R2 = 0.087, p < 0.005); the receiver operating characteristic curves revealed an area under the curve of 0.824 (95%confidence interval, 0.783-0.865; optimal PVR cutoff, 50 mL). In the multivariate analysis, age, American Society of Anesthesiologists score ≥2, risk category ≥intermediate, and all functional parameters represented independent factors for no-tumor-free status.

Conclusions

Urinary retention could represent a prognostic factor of treatment response, and its active treatment should be considered as an important therapeutic step into the clinical management of bladder cancer patients.

Noninvasive studies may have potential to replace cystoscopy in non-muscle invasive bladder cancer follow-up

Bladder cancer has a high recurrence rate which requires frequent follow-up. Cystoscopy is currently the gold standard for follow-up which is invasive and undesirable procedure for patients. We aimed to investigate the feasibility of noninvasive studies for follow-up of non-muscle invasive bladder cancer. This retrospective study was done for non-muscle invasive bladder cancer patients with abnormal lesion at follow up cystoscopy, therefore those needed transurethral resection of bladder tumor (TUR-BT). Inclusion criteria was patients who had preoperative bladder magnetic resonance imaging (MRI) within 1 month to TUR-BT and urine cytology results. MRI, urine cytology, and surgical pathology results were analyzed for sensitivity, specificity, positive and negative predictive values, accuracy, diagnostic odds ratio, and number needed to misdiagnose for the diagnostic performance of non-invasive studies. From total of 2,258 TUR-BT cases, 1,532 cases of primary TUR-BT and 481 cases which bladder MRI were not done was excluded. Finally, 245 cases of TUR-BT were included. Combined urine cytology and bladder MRI showed 96% sensitivity, 43% specificity, 89% positive and 67% negative predictive values, 87% accuracy, 16.2 diagnostic odds ratio, and 7.4 number needed to misdiagnose values. Among nine false-negative cases, three (1.2%) were missed by the radiologist, two (0.8%) had an empty bladder during magnetic resonance imaging, and three (1.2%) had gross hematuria which needed cystoscopy despite of bladder MRI or urine cytology result. Only one case (0.4%) was missed based on symptoms and noninvasive tests. However, none of the false-negative cases showed rapid extensive progression requiring radical or partial cystectomy. The combination of bladder MRI and urine cytology was comparable to cystoscopy for the follow-up of recurred lesions in non-muscle invasive bladder cancer patients for sensitivity, but not for specificity. However, it may reduce the need for cystoscopy and allowing patients to have choices for follow up diagnostic methods. Also, additional imaging tests to evaluate kidney, ureter and peri-vesical lesions can be reduced.

Oncological safety of simultaneous transurethral resection of high-grade urothelial carcinoma of the bladder and benign prostatic hyperplasia

Objectives

To examine the oncological safety of simultaneous resection of bladder tumor and prostate in the presence of non-muscle invasive high-grade urothelial carcinoma of the bladder (UCB).

Materials and Methods

Between 2007 and 2019, 170 men with high-grade UCB who had a follow-up of at least 12 months were included in the study, including 123 with transurethral resection of bladder tumor (TURBT) only and 47 with simultaneous TURBT and transurethral resection of the prostate (TURP). We recorded and compared patients' clinicopathological parameters, recurrence, and progression rates during the follow-up period, as well as time to UCB recurrence in the bladder and the prostatic urethra/fossa.

Results

Baseline demographic and pathological characteristics were comparable between the groups. At a median follow-up of 31 months in both groups, there were no significant differences in recurrence rates in the bladder and the prostatic urethra/fossa in either group (34.1% and 7.3% vs. 36.2 and 6.4%, p=0.402, p=0.363). No statistically significant differences were found between the two groups in terms of follow-up time, elapsed time to recurrence, or and progression in the bladder or prostatic urethra/fossa.

Conclusions

Simultaneous TURBT and TURP in the presence of high-grade UCB appears to be oncologically safe in selected patients.

Concomitant Endoscopic Surgery for Bladder Tumors and Prostatic Obstruction: Are We Safely Hitting Two Birds with One Stone? A Systematic Review and Meta-Analysis

BACKGROUND

Lower urinary tract symptoms (LUTS) caused by benign prostatic obstruction (BPO) and bladder tumors may co-exist, especially among elderly patients. Transurethral resection of bladder tumors (TURBT) and endoscopic surgery for benign prostatic obstruction in the same setting are avoided by many surgeons due to concerns for tumor cell seeding and recurrences in the prostatic urethra.

AIM

The aim of this study was assess the effect of concomitant TURBT and endoscopic BPO surgery on oncological safety and patient quality of life via systematic review and meta-analysis.

METHODS

We searched the PubMed, Cochrane Library, EMBASE, Scopus, and Clinicaltrials.gov databases and sources of grey literature published before June 2021 for relevant studies. We performed a random-effects meta-analysis of odds ratios (ORs) or weighted mean differences (WMD) to compare concomitant TURBT and BPO surgery versus TURBT alone in terms of recurrence and progression rates. Accordingly, we undertook multiple subgroups and sensitivity analyses (PROSPERO: CRD42020173363).

RESULTS

Three randomized and twelve retrospective observational studies with 2421 participants were included. Across studies with good methodological quality, no statistically significant differences were demonstrated regarding overall bladder tumors recurrence rates between concomitant endoscopic BPO surgery and TURBT versus TURBT alone (OR: 0.81, 95% CI: 0.60-1.09, I² = 42%). Similarly, no significant differences were observed in recurrences located at the bladder neck and/or prostatic urethra (OR: 1.06, 95% CI: 0.76-1.47, I² = 0%), time to first recurrence (WMD: -0.2 months, 95% Cl: -2.2-1.8, I² = 48%), and progression rate (OR: 1.05, 95% CI: 0.67-1.64, I² = 0%). Subgroup analyses based on tumor grade, number of tumors, and utilization of single-instillation chemotherapy post-TURBT did not detect any significant differences in overall bladder tumor recurrence. The level of evidence was estimated as low for all outcomes. Concomitant surgery improved lower urinary tract symptoms.

CONCLUSION

Concomitant endoscopic BPO surgery and TURBT are oncologically safe and improve LUTS-related quality of life.

Prognostic value of prostate volume in non-muscle invasive bladder cancer

There is evidence that a history of benign prostatic hyperplasia increases the incidence of bladder cancer, and treatment with 5-alpha reductase inhibitor or androgen deprivation therapy reduces recurrence of non-muscle invasive bladder cancer. We aimed to evaluate whether prostate volume affects its prognosis. We reviewed medical records of men who underwent transurethral resection of bladder tumor due to non-muscle invasive bladder cancer from January 2012 to December 2017. Patients were divided into two groups based on prostate volume measured by computed tomography (group 1: 264 patients with ≤ 30 mL, group 2: 124 patients with > 30 mL). Propensity score matching analysis was used for adjust selection bias, and then assessed recurrence-free survival and progression-free survival. With a median follow up duration of 52 months, group 1 showed higher 5-year recurrence-free and progression-free survival (69.3% vs 47.0%, p = 0.001; 96.7% vs 87.7%, p = 0.002). Further, cox-regression analysis showed that tumor size (HR = 1.292 p < 0.001), multifocal tumor (HR = 1.993, p < 0.001), adjuvant intravesical therapy (chemotherapy: HR = 0.580, p = 0.037 and bacillus Calmette-Guérin: HR = 0.542, p = 0.004) and prostate volume (HR = 2.326, p < 0.001) were significant predictors of recurrence-free survival. Prostate volume (HR = 2.886, p = 0.014) was also associated with PFS with age (HR = 1.043, p = 0.044) and tumor grade (HR = 3.822, p = 0.013). We conclude higher prostate volume is associated with worse recurrence and progression-free survival in non-muscle invasive bladder cancer.

Intravesical Prostatic Protrusion and Prognosis of Non-Muscle Invasive Bladder Cancer: Analysis of Long-Term Data over 5 Years with Machine-Learning Algorithms

We aim to investigate the significance of intravesical prostate protrusion (IPP) on the prognosis of non-muscle invasive bladder cancer (NMIBC) after the transurethral resection of bladder tumors (TURBT). For newly diagnosed NMIBC, we retrospectively analyzed the association between prognosis and IPP for at least a 5-year follow-up. A degree of IPP over 5 mm in a preoperative CT scan was classified as severe. The primary endpoint was recurrence-free survival, and the secondary endpoint was progression-free survival. The machine learning (ML) algorithm of a support vector machine was used for predictive model development. Of a total of 122 patients, ultimately, severe IPP was observed in 33 patients (27.0%). IPP correlated positively with age, BPH, recurrence, and prognosis. Severe IPP was significantly higher in the recurrence group and reduced in the recurrence-free survival group (p = 0.038, p = 0.032). Severe IPP independently increased the risk of intravesical recurrence by 2.6 times. The addition of IPP to the known oncological risk factors in the prediction model using the ML algorithm improved the predictability of cancer recurrence by approximately 6%, to 0.803. IPP was analyzed as a potential independent risk factor for NMIBC recurrence and progression after TURBT. This anatomical feature of the prostate could affect the recurrence of bladder tumors.

Assessment of the clinical efficacy of simultaneous transurethral resection of both bladder cancer and the prostate: a systematic review and meta-analysis

OBJECTIVE

In this study, we aimed to examine the clinical efficacy of simultaneous transurethral resection of bladder cancer and the prostate (TURBT + TURP) in non-muscle invasive bladder cancer (NMIBC) and benign prostatic hyperplasia (BPH) patients.

METHOD

We conducted systematic research in PubMed, EMBASE, and Cochrane Library databases to identify retrospective studies and prospective randomized controlled trials (RCTs) comparing patient outcomes between TURBT + TURP and TURBT-only patients. The meta-analysis was conducted using Review Manager 5.3.

RESULTS

We identified eight relevant studies involving a total of 1032 patients. We found that patients that underwent TURBT + TURP exhibited significantly lower recurrence rates [odds ratio (OR), 0.70; 95% confidence interval (CI), 0.53-0.93; p = .01] and increased maximal urinary flow rate (Qmax) (WMD, 5.92; 95% CI, 4.67-7.16; p < .001) compared with patients that underwent TURBT-only. However, rates of recurrence at the prostatic urethra/bladder neck and bladder tumor progression, as well as the time to recurrence did not differ significantly between these two groups.

CONCLUSIONS

Simultaneous TURBT + TURP can be safely performed in patients with NMIBC and BPH and improves patient quality of life, without any risk of increasing tumor recurrence or metastasis rates. Comprehensive RCTs are needed to confirm the results of this study.

The recurrence and progression risk after simultaneous endoscopic surgery of urothelial bladder tumour and benign prostatic hyperplasia: a systematic review and meta-analysis

Objectives

To evaluate recurrence and progression risk after simultaneous endoscopic surgery of bladder cancer and benign prostatic hyperplasia (BPH), as simultaneous surgery is not an unusual scenario and theoretically simultaneous transurethral resection of bladder tumour (TURBT) and transurethral resection of the prostate (TURP) can lead to an increased risk of recurrence in the bladder neck and prostatic urethra (BN/PU).

Methods

We conducted a systematic review and meta‐analysis to assess the risk of recurrence (i.e. whole bladder and/or BN/PU) and tumour progression as outcomes after a simultaneous endoscopic surgery of bladder tumour and BPH, as compared to TURBT alone. We queried PubMed and Web of Science database on 1 January 2020. We used random‐ and/or fixed‐effects meta‐analytic models in the presence or absence of heterogeneity according to the I² statistic, respectively.

Results

Nine retrospective and three clinical trial studies were selected after considering inclusion and exclusion criteria. We conducted the meta‐analysis on retrospective and randomised controlled trials (RCTs) separately. Eight retrospective and three RCT studies were included to assess the BN/PU recurrence risk and the summarised risk ratio (RR) was 1.02 (95% confidence interval [CI] 0.74–1.41) and 0.93 (95% CI 0.47–1.84), respectively. Five retrospective and two RCT studies were included to assess the progression risk and the summarised RR was 0.91 (95% CI 0.56–1.48) and 1.16 (95% CI 0.30–4.51), respectively. Eight retrospective and three RCT studies were included to assess the whole bladder recurrence risk and the summarised RR was 0.87 (95% CI 0.78–0.97) and 0.89 (95% CI 0.65–1.21), respectively.

Conclusion

We did not observe any increased risk of total bladder recurrence, BN/PU recurrence, or progression after a simultaneous endoscopic surgery of bladder tumour and BPH, as compared to TURBT alone.

Bladder lesions as incidental findings during transurethral resection of the prostate: prevalence, diagnosis, and pathological findings

PURPOSE

The purpose of this study was to determine the prevalence of bladder lesions diagnosed during transurethral resection of the prostate (TURP), to identify the associated risk factors, and to correlate the macroscopic descriptions with the pathological findings.

METHODS

This was a single-center retrospective case series conducted at a hospital in the city of São Paulo, Brazil. We reviewed the medical and surgical records of patients who underwent TURP between January 2012 and December 2017.

RESULTS

The final sample comprised 513 patients, with a mean age of 70.8 years. Bladder lesions were identified during TURP in 109 (21.2%) of the patients, and 90 of those lesions were submitted for pathological examination. The most common macroscopic finding was bullous edema, which was seen in 57 (63.3%) of the 90 lesions examined. The pathological analysis revealed chronic cystitis in 61 lesions (67.8%) and malignant lesions in 16 (17.8%). Of the 57 lesions described as bullous edema, 5 (8.8%) were found to be malignant.

CONCLUSIONS

Alterations in the bladder mucosa appear to be more common among elderly patients who use an indwelling urinary catheter for a prolonged period and among patients with recurrent urinary tract infections. In addition, the risk of a bladder lesion being malignant is apparently higher in current and former smokers than in never smokers. Our findings suggest that at-risk patients should undergo biopsy or resection of incidental bladder lesions even if those lesions seem to be benign, due to the low level of agreement between the visual analysis and the pathological examination.

Moderate or severe LUTS is associated with increased recurrence of non - muscle - invasive urothelial carcinoma of the bladder

Purpose:

Non - muscle - invasive bladder cancer (NMIBC) can recur despite transurethral resection (TURBT) and adjuvant intravesical therapy. Tobacco products excreted in the urine are hypothesized to cause tumor - promoting effects on urothelial cells through direct contact. We determined if moderate or severe lower urinary tract symptoms (LUTS) (defined as International Prostate Symptom Score [IPSS] ≥ 8) was associated with increased tumor recurrence.

Materials and Methods:

We retrospectively identified 70 consecutive men initially diagnosed with NMIBC at our institution from 2010 – 2016. Means were compared with independent T - test and proportions with chi - square analysis. Multivariate logistic regression was performed to determine independent predictors of recurrence.

Results:

The majority of patients had Ta disease (58.6%) followed by T1 (28.6%) and Tis (12.9%). Forty - one (58.6%) patients had moderate or severe LUTS upon presentation within 30 days of initial TURBT with mean IPSS of 13.2 vs. 5.2 in the control group (p < 0.01). Biopsy - proven tumor recurrence occurred in 24 (34.3%) patients at mean follow-up of 31.7 months. Mean time to recurrence was 14.6 months. Moderate or severe LUTS was an independent predictor of tumor recurrence (odds ratio [OR]: 19.1, 95% confidence interval [CI]: 2.86 – 127; p = 0.002). Voiding or storage symptoms based on the IPSS did not independently correlate with tumor recurrence (p = 0.08 and p = 0.31, respectively) although total mean IPSS score did (OR: 1.26, 95% CI: 1.07 – 1.47, p = 0.005).

Conclusions:

The presence of moderate or severe LUTS may be an important prognostic factor in NMIBC. Patients with significant urinary symptoms could be monitored more aggressively due to higher recurrence risk.

Oncological safety and quality of life in men undergoing simultaneous transurethral resection of bladder tumor and prostate: results from a randomized controlled trial

PURPOSE

To assess oncological safety and quality of life (QL) of men undergoing simultaneous transurethral resection of bladder tumor (TURBT) and transurethral resection of the prostate (TURP) for symptomatic benign prostatic hyperplasia (BPH).

METHODS

Ninety-five men with a new diagnosis of bladder cancer (BC) and symptomatic BPH were randomized to receive TURBT + tamsulosin (Group 1) or TURBT + TURP (Group 2). Inclusion criteria were age ≤ 75 years, first diagnosis of BC up to 4 cm, and prostate volume ≤ 80 ml. All patients were evaluated preoperatively with digital rectal examination, PSA, maximal urine flow rate (Q_max), and International Prostate Symptom Score (IPSS). IPSS and Q_max were repeated at 1-year follow-up. QL was evaluated at 1 year using a modified version of the self-report bladder cancer subscale of the Functional Assessment of Cancer Therapy.

RESULTS

Eighty-five men completed the study (43 in Group 1 and 42 in Group 2). Adjuvant instillation therapy was given to 26 patients in Group 1 and to 27 in Group 2. Average time to the first recurrence was 16.64 months in Group 1 and 17.7 in Group 2. Total recurrences were 27 in Group 1 and 22 in Group 2. Bladder neck/prostatic urethra recurrences were 9 in Group 1 vs. 8 in Group 2. QL, IPSS, and Q_max 12 months after surgery were better in Group 2.

CONCLUSION

Concomitant TURBT and TURP appear to be oncologically safe procedures in terms of total and prostatic urethra recurrence, and improve QL in men with BC who require surgery for symptomatic BPH.

Simultaneous transurethral resection of bladder cancer and prostate may reduce recurrence rates: A systematic review and meta-analysis

The aim of this study was to evaluate the recurrence rate of simultaneous transurethral resection of bladder cancer and prostate (TURBT+TURP) in the treatment of non-muscle invasive bladder cancer (NMIBC) with benign prostatic hyperplasia (BPH). We searched PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE and the ISI Web of Knowledge databases from their establishment until March 2012, to collect all the original studies on TURBT+TURP vs. TURBT alone in the treatment of NMIBC with BPH. After screening the literature, methodological quality assessment and data extraction was conducted independently by two reviewers and meta-analysis was performed using the RevMan 5.1 software. The quality of data was assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Eight studies, including seven non-randomized concurrent controlled trials (NRCCTs) and one randomized controlled trial (RCT), involving a total of 1,372 patients met the criteria. Meta-analyses of NRCCTs showed that in the TURBT+TURP group, overall recurrence rates were lower [odds ratio (OR), 0.76; 95% confidence interval (CI), 0.60–0.96; P=0.02] and the difference was statistically significant. The postoperative recurrence rate in the prostatic fossa/bladder neck (OR, 0.96; 95% CI, 0.64–1.45; P=0.86) and bladder tumor progression rates (OR, 0.96; 95% CI, 0.49–1.87; P=0.91) were similar between the TURBT+TURP and TURBT groups, but the difference was not significant. According to the GRADE approach, the level of evidence was moderate or low. Only one RCT demonstrated that overall postoperative tumor recurrence rates, recurrence rates at prostate fossa/bladder neck and bladder tumor progression rates between simultaneous groups and control groups were almost equal. There was no significant difference (P>0.05), and the level of evidence was moderate. For patients with NMIBC and BPH, simultaneous resection did not increase the overall recurrence rate of bladder tumors, it also did not cause metastasis and tumor progression, but it may reduce the recurrence rate. However, due to the low quality of investigations included in the present study, careful selection was necessary, and more large-scale and high-quality randomized controlled trials are also required for further confirmation.

Is it oncologically safe performing simultaneous transurethral resection of the bladder and prostate? A meta-analysis on 1,234 patients

PURPOSE

It is not unusual to encounter the clinical scenario of a male patient undergoing endoscopic treatment for bladder cancer (TURBT) who also needs transurethral resection of prostate (TURP). The aims of this meta-analysis were to understand whether it is oncologically safe or advantageous to combine the two procedures in terms of subsequent overall recurrences with particular interest to that in the prostatic fossa and to understand whether some characteristics of the bladder tumors can influence the recurrence rate.

METHODS

A bibliographic search covering the period from January 1950 to December 2011 was conducted in PubMed, MEDLINE and EMBASE. Meta-analysis approach was applied comparing prostatic fossa recurrences and total recurrences in simultaneous TURBT and TURP and control. Also, prostatic fossa recurrences and tumors' grading and multifocality in patients treated with simultaneous TURBT and TURP were analyzed. To investigate to what extent observational time influenced relapses/recurrence, a random effect meta-regression logistic model-based approach was applied. All statistical evaluations were performed using SAS version 9.2 and by RevMan 5.0. An α level of 0.05 was considered as statistically significant.

RESULTS

Overall, there were 1,234 participants in the eight studies considered. The study group consists of 634 patients and the control group 600. Mean age was 67.88 and 61.64 years, respectively, in the study and control groups. In the study group, on a total of 634 patients, 65 recurrences in the prostatic fossa appear. In the control group, on a total of 600 patients, 58 recurrences in the prostatic fossa occurred. Data do not show a statistically significant difference in recurrence in the prostatic fossa between patients treated simultaneously with TURB and TURP and the control group. Meta-analysis does not show a statistically significant difference in recurrence in the prostatic fossa with the increased grading of the neoplasms. But there is a statistically significant increased recurrence in patients with multifocal tumors. There is a statistically significant reduction in recurrence between patients treated simultaneously with TURB and TURP and the control group, but there is no reduction in the recurrence rate in the time.

CONCLUSIONS

This meta-analysis emphasized that the two operations could be performed during the same session without any negative oncologic results. The resolution during the same session of bladder outlet obstruction will improve the patients' quality of life and performing the procedures in the same session sparing the patients from a further anesthesiological maneuvers and the need for a further hospitalization for the surgical resolution of the prostatic obstruction.

Does simultaneous transurethral resection of bladder tumor and prostate affect the recurrence of bladder tumor? A meta-analysis

PURPOSE

To evaluate the efficacy and safety of simultaneous resection in the treatment of nonmuscle invasive bladder cancer (NMIBC) with benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

Combined published data from comparative studies on simultaneous transurethral resection of bladder tumor/transurethral resection of the prostate (TURBT/TURP) vs TURBT alone in NMIBC were analyzed, considering possible confounding factors. Odds ratios (ORs) and 95% confidence intervals (CIs) were used as the primary effect size to estimate the outcome of overall tumor recurrence, recurrence in bladder neck/prostatic fossa.

RESULTS

In six eligible clinical trials, 483 patients were treated with simultaneous resection and 500 with TURBT alone. Within the follow-up period, tumor recurrence developed in 203 (42%) patients in the simultaneous resection group and 256 (51.2%) patients in the control group. The combined analysis indicated that the recurrence rate in the simultaneous resection group was statistically significantly lower than in the control group in the overall pooled data (combined OR = 0.67; 95% CI 0.52 to 0.88, P = 0.003). Tumor recurrence of bladder neck/prostatic fossa developed in 37(7.7%) patients in the simultaneous resection group and 42 (8.4%) patients in the control group. No statistically significant difference was found between the two groups (combined OR = 0.92; 95% CI 0.57 to 1.49, P = 0.74). Potential confounders, such as mean age, mean follow-up duration, multiplicity of tumor, and year of publication did not significantly influence the results.

CONCLUSION

There was at least the evidence that simultaneous TURBT/TURP did not increase the overall recurrence rate and recurrence rate in bladder neck/prostatic fossa. Simultaneous TURBT/TURP might be preferable for patients with NMIBC and BPH.