Residual tumor discovered in routine second transurethral resection in patients with stage T1 transitional cell carcinoma of the bladder

Prognostic significance of residual tumor at restaging transurethral bladder resection in high-risk non-muscle-invasive bladder cancer

PURPOSE

To assess prognostic significance of residual tumor at repeat transurethral resection (reTUR) in contemporary non-muscle-invasive bladder cancer (NMIBC) patients.

METHODS

Patients were identified retrospectively from eight referral centers in France, Italy and Spain. The cohort included consecutive patients with high or very-high risk NMIBC who underwent reTUR and subsequent adjuvant BCG therapy.

RESULTS

A total of 440 high-risk NMIBC patients were screened, 29 (6%) were upstaged ≥ T2 at reTUR and 411 were analyzed (T1 stage: n = 275, 67%). Residual tumor was found in 191 cases (46%). In patients with T1 tumor on initial TURBT, persistent T1 tumor was found in 18% of reTUR (n = 49/275). In patients with high-grade Ta tumor on initial TURBT, T1 tumor was found in 6% of reTUR (n = 9/136). In multivariable logistic regression analysis, we found no statistical association between the use of photodynamic diagnosis (PDD, p = 0.4) or type of resection (conventional vs. en bloc, p = 0.6) and the risk of residual tumor. The estimated 5-yr recurrence and progression-free survival were 56% and 94%, respectively. Residual tumor was significantly associated with a higher risk of recurrence (p < 0.001) but not progression (p = 0.11). Only residual T1 tumor was associated with a higher risk of progression (p < 0.001) with an estimated 5-yr progression-free survival rate of 76%.

CONCLUSIONS

ReTUR should remain a standard for T1 tumors, irrespective of the use of en bloc resection or PDD and could be safely omitted in high-grade Ta tumors. Persistent T1 tumor at reTUR should not exclude these patients from conservative management, and further studies are needed to explore the benefit of a third resection in this subgroup.

Second TURB, restaging TURB or repeat TURB in primary T1 non-muscle invasive bladder cancer: impact on prognosis?

PURPOSE

A re-transurethral resection of the bladder (re-TURB) is a well-established approach in managing non-muscle invasive bladder cancer (NMIBC) for various reasons: repeat-TURB is recommended for a macroscopically incomplete initial resection, restaging-TURB is required if the first resection was macroscopically complete but contained no detrusor muscle (DM) and second-TURB is advised for all completely resected T1-tumors with DM in the resection specimen. This study assessed the long-term outcomes after repeat-, second-, and restaging-TURB in T1-NMIBC patients.

METHODS

Individual patient data with tumor characteristics of 1660 primary T1-patients (muscle-invasion at re-TURB omitted) diagnosed from 1990 to 2018 in 17 hospitals were analyzed. Time to recurrence, progression, death due to bladder cancer (BC), and all causes (OS) were visualized with cumulative incidence functions and analyzed by log-rank tests and multivariable Cox-regression models stratified by institution.

RESULTS

Median follow-up was 45.3 (IQR 22.7-81.1) months. There were no differences in time to recurrence, progression, or OS between patients undergoing restaging (135 patients), second (644 patients), or repeat-TURB (84 patients), nor between patients who did or who did not undergo second or restaging-TURB. However, patients who underwent repeat-TURB had a shorter time to BC death compared to those who had second- or restaging-TURB (multivariable HR 3.58, P = 0.004).

CONCLUSION

Prognosis did not significantly differ between patients who underwent restaging- or second-TURB. However, a worse prognosis in terms of death due to bladder cancer was found in patients who underwent repeat-TURB compared to second-TURB and restaging-TURB, highlighting the importance of separately evaluating different indications for re-TURB.

Clinical and pathological risk factors for tumour recurrence and upstaging in second TURBT for patients with NMIBC: a systematic review and meta-analysis

ZIEL: Offenlegung signifikanter Risikofaktoren durch Identifizierung gepoolter Effektschätzungsstatistiken in einer systemischen Überprüfung und Metaanalyse klinischer und pathologischer Risikofaktoren, die ein Tumorrezidiv und ein Upstaging auf eine zweite TURBT bei Patienten mit hochgradigem NMIBC vorhersagen.

MATERIAL-METHODE

Alle Datenquellen wurden umfassend bis Oktober 2022 untersucht. Die Daten wurden aus den relevanten Studien extrahiert und mit der Software RevMan analysiert. In einem inversen Varianzmodell mit zufälligen und festen Effekten werden Odds Ratio (OR)-Werte mit 95%-Konfidenzintervallen [95%-KI] angegeben.

ERGEBNISSE

Der Review umfasste insgesamt 18 Studien und 4548 Patienten. Gemäß den gepoolten Effektschätzern waren Carcinoma in situ (CIS), Tumorgrad, Multiplizität und Chirurgenfaktoren signifikante Risikofaktoren. Die gepoolten Effektschätzungen für das Tumorstadium und die Tumormorphologie waren sehr nahe an der Signifikanz. Für CIS, Grad, Multiplizität und Chirurgenfaktor, OR, IVR oder IVF [95%-KI] waren die p- und I2-Werte 1,8 [1,1, 3,0], 0,03, 75%; 2 [1,1, 3,4], 0,02, 53%; 1,3 [1,2, 1,6], <0,01, 40%; und 2 [1,4, 3], <0,01, 66%.

SCHLUSSFOLGERUNGEN

Als Ergebnis der ersten TURBT; Eine zweite TURBT sollte in den 2-6 Wochen der postoperativen Phase für Patienten mit hochgradigem, begleitendem CIS, multipler, solider Morphologie, DM(-) im pathologischen Präparat und NMIBC, das von Trainern/Juniorchirurgen operiert wird, geplant werden.

How to Perform Intravesical Chemotherapy after Second TURBT for Non-Muscle-Invasive Bladder Cancer: A Single-Center Experience

PURPOSE

The objective of this study aimed to explore whether the original IVC regimen should be continued after the second TURBT or whether the IVC induction phase should be restarted from the beginning.

METHODS

A retrospective analysis was performed on 137 patients who underwent a second TURBT at the Affiliated Hospital of Xuzhou Medical University between April 2014 and June 2022. Based on the pathological findings, patients were divided into two groups: group A patients, who did not have a residual tumor on pathological examination after the second TURBT; and group B patients, who had residual tumor. Recurrence was determined using cystoscopy and imaging every three months. The endpoint was recurrence-free survival.

RESULT

In the entire cohort, there was a statistically significant difference in the RFS between patients in the two IVC regimens (p = 0.029). The RFS of patients in group B1 was significantly lower than that of patients in group B2 (p = 0.009). There was no significant difference in RFS between the subgroups A1 and A2 (p = 0.560). Multivariate Cox regression analysis confirmed that the IVC regimen after a second TURBT (p = 0.012) and T stage after a second TURBT (p = 0.005) were both independent predictors for patient RFS.

CONCLUSION

If the pathological findings of the second TURBT specimen is benign, patients can continue their previous treatment regimen without restarting an IVC induction phase. Unnecessary IVC can be avoided in these patients. In contrast, for patients with residual tumors in the second TURBT specimen, the need to restart the IVC induction phase should be emphasized to improve patient prognosis.

Survival Outcome of Partial Cystectomy versus Transurethral Bladder Tumor Resection in T1 High-Grade Bladder Cancer Patients: A Propensity Score Matching Study

Purpose

Partial cystectomy was investigated as a method of bladder preservation with better disease outcomes than transurethral bladder tumor resection in T1 high-grade bladder cancer patients. Method and materials. The national Surveillance, Epidemiology, and End Results database (SEER) (2004-2015) were used to obtain patients diagnosed with T1 high-grade bladder cancer, and finally, 25263 patients were enrolled in our study. The Kaplan-Meier method with the log-rank test was performed to analyze the outcome of overall survival (OS) and cancer-specific survival (CSS) between patients undergoing partial cystectomy (PC), transurethral resection of bladder tumor (TURBT), or radical cystectomy (RC). Moreover, the propensity score matching (PSM) and multivariable Cox proportional hazard model were also utilized in the study.

Results

Ultimately, 24635 patients were undergoing TURBT, while 190 and 438 patients were, respectively, assigned to the PC and RC groups. Compared with patients with TURBT, a tendency of a higher proportion of higher older and male patients was observed in the PC group. When matching with RC patients, patients in the PC group were commonly older and had bigger tumor sizes and single tumors (All P < 0.05). After 1 : 1 PSM, 190 patients with TURBT and 160 patients receiving PC were selected. In survival analysis, the patients in the PC group had a higher survival probability of both OS and CSS before and after PSM compared with those in the TURBT group. Meanwhile, no significant differences were observed between the RC and PC groups in OS and CSS analysis. Moreover, multivariable Cox regression showed that PC was a protective factor for overall mortality (ACM) and cancer-specific mortality (CSM) compared with TURBT in T1 high-grade patients (All P < 0.05).

Conclusion

Patients undergoing partial cystectomy were shown to have a better outcome compared with those with transurethral bladder tumor resection in T1 high-grade bladder cancer patients. Partial cystectomy could be the more worthwhile choice for bladder preservation in T1 high-grade bladder cancer patients.

Transurethral resection of bladder tumour (TURBT) as a day-case: A real-world practice and patients’ perspective from a district general hospital (DGH)

Introduction:

Day-case transurethral resection of bladder tumour (TURBT) is currently only performed in 18% cases across the United Kingdom. To determine 30-day readmission rate and morbidity after day-case TURBT in a district general hospital (DGH) and to report patient demographics, quality of TURBT and early recurrence rate as well as patient feedback after day-case TURBT.

Methods:

A retrospective audit of day-case TURBTs over a 3-year pre-COVID19 (2017–20) was performed. We only included patients who underwent a TURBT and excluded any cystoscopy and biopsy or fulguration. A day-case TURBT pathway is in place in this centre. Feedback was obtained using hospital patient feedback forms.

Results:

We included 77 patients who underwent TURBT in the day-case theatre, of these 5 patients required in-patient stay after the surgery. Of the remaining 72 discharged on the same day, 8 were re-admitted (11%) for Clavien-Dindo I complications. The readmission/failed discharge group had a higher rate of older patients, with higher ASA scores and longer operative times, however resection quality and tumour characteristics were not different from the day-case TURBTs. All patients reported an overall positive experience (good or very good).

Conclusions:

In the first of its kind audit reporting patient feedback after day-case TURBT, the data obtained can provide us and other centres adopting day-case TURBTs guidance to employ better patient selection to reduce readmission rates. Hence, day-case TURBT can be a feasible option in appropriately selected patients, with a suitable pathway in place.

The Role of New Technologies in the Diagnosis and Surveillance of Non-Muscle Invasive Bladder Carcinoma: A Prospective, Double-Blinded, Monocentric Study of the XPERT© Bladder Cancer Monitor and Narrow Band Imaging© Cystoscopy

Simple Summary

Patients with bladder cancer (BC) require close follow-up with white-light cystoscopy (WLC) and cytology. In this study, we sought to assess (a) the performance of a novel cystoscopy technology based on Narrow Band Imaging© (NBI), and (b) a new urine test (XPERT© Bladder Cancer Monitor, XBCM) that detects cancer proteins. We compared these to the established standard follow-up diagnostics. Our study showed that NBI cystoscopy does not provide any additional benefit over standard WLC. However, the XBCM urine test performed particularly well in instances of aggressive high-grade tumor recurrence. Therefore, XBCM may have enhanced utility in the early detection of potentially harmful BC recurrence.

Abstract

Follow-up is essential for the early detection of recurrent non-muscle invasive bladder cancers (NMIBC). This study investigates the clinical relevance of new diagnostic tools such as an mRNA-based urine test (XPERT© Bladder Cancer Monitor, XBCM) and Narrow Band Imaging© (NBI) and compares them with the established follow-up diagnostics (white-light cystoscopy (WLC) and urine cytology). This was a prospective, double-blind, single-center study that involved patients undergoing NMIBC screening at a tertiary care center. Enrollment occurred between January 2018 and March 2020. In addition to standard care (WLC, cytology, and ultrasound), patients underwent XBCM urine testing and NBI cystoscopy. In total, 301 WLCs were performed; through this, 49 patients demonstrated NMIBC recurrence. NBI cystoscopy was congruent with WLC in all patients. Cytology showed a sensitivity (SE) and specificity (SP) of 27% and 97% (PPV: 65%; NPV 87%), respectively, whereas XBCM showed SE and SP of 58% and 89%, respectively (PPV: 51%; NPV: 92%; AUC: 0.79 (0.716–0.871)). Subgroup analysis showed improved SE and similar SP (PPV, NPV) for high grade (HG) recurrence, with a SE of 74% and SP of 89% (39%, 97%). NBI cystoscopy does not necessarily provide additional benefit over standard WLC. However, the XBCM may provide better SE and a diagnostic advantage in instances of HG disease recurrence.

A 25-year perspective on advances in an understanding of the biology, evaluation, treatment and future directions/challenges of urothelial cancer

The Urologic Oncology Journal was founded 25 years ago and we reviewed the literature since that time in the area of urothelial cancer to see the progress and pitfalls we have made over this time period. A comprehensive literature search was conducted by the authors involved who are all actively involved in research, clinical trials, and treatment for urothelial cancer and the results were summarized over the past 25 years. The field of urothelial cancer has evolved tremendously in the last 25 years with the incorporation of molecular subtyping, novel imaging, immunotherapy, and robotic surgery. However, treatments such as BCG and radical cystectomy have remained steadfast over the last 25 years. Although we have a better understanding of the biology of bladder cancer, we still have a long way from being able to cure patients with bladder cancer and eliminate morbidity from treatments. Nevertheless, considerable progress has been made since the founding of the Urologic Oncology Journal 25 years ago.

Primary Complete Transurethral Resection of Bladder Tumor Using Photodynamic Diagnosis for High-Risk Nonmuscle Invasive Bladder Cancer: Is a Restaging Photodynamic Transurethral Resection Really Necessary?

Objectives: To evaluate the risk of residual tumor and tumor upstaging during a second resection after primary complete transurethral resection of bladder tumor (TURBT) using photodynamic diagnosis (PDD) for high-risk nonmuscle invasive bladder cancer (NMIBC). Patients and Methods: From January 2014 to March 2020, a single-institutional study was conducted including consecutive patients with high-risk NMIBC (T1 and/or cis and/or high grade) who underwent a restaging transurethral resection (reTUR) within 12 weeks after a primary complete resection. Each TURBT was performed using blue light after intravesical instillation of hexaminolevulinate. The primary endpoint was detection of residual tumor at reTUR, proved with positive pathology report. Results: A total of 109 consecutive patients with high-risk NMIBC underwent reTUR after a primary complete blue light resection. Pathologic evaluation of the surgical specimens of the primary TURBT revealed stage T1 and high-grade tumors in 69 (68.3%) and 108 (99%) patients, respectively, and concomitant carcinoma in situ was found in 45 patients (41.3%). The median time to reTUR was 8 (6-10) weeks. Residual tumor was detected histopathologically in 64 of 109 patients (58.7%) at the second TURBT with PDD. In five of these patients (4.5%), initial T1 tumors were upstaged to T2 tumors. Conclusions: We examined a contemporary series of patients undergoing reTUR with PDD as management of high-risk NMIBC proven at the first blue light resection. We reported a 54.2% risk of disease persistence and a 4.5% risk of understaging in T1 tumors. These findings support that reTUR is still necessary after initial complete TURBT with PDD. Further studies are needed to assess the long-term oncologic outcomes of reTUR with PDD.

Utility and Safety of Repeat Transurethral Resection of Bladder Tumor Performed at a Tertiary Center

Introduction  Repeat transurethral resection of bladder tumor (ReTURBT) has become an integral part of the management of superficial bladder cancers at various urological centers around the world. Early detection of residual disease, leading to upstaging in some cases, leads to decrease in recurrence rates. Our study aimed to analyze the impact of ReTURBT in detecting residual tumor and tumor recurrences, hence validating the benefits of procedure as a routine.

Materials and Methods  A total of 152 patients with superficial bladder cancer who were treated at Cancer Institute (WIA) between January 2005 and December 2013 were analyzed and followed up for 3 years.

Results  Of the 152 cases who underwent ReTURBT, 47 patients had residue in the final histopathology of the resected specimen (31%). The overall rate of upstaging to muscle-invasive disease following ReTURBT was 3.3%. The mean follow-up period was 47.13 months, during which 25 (17%) out of 147 patients who underwent ReTURBT had disease recurrence. There was no additional morbidity due to ReTURBT as compared with the primary procedure.

Conclusion  ReTURBT is an effective procedure in treating recurrent tumors also as long as they remain superficial. The procedure when performed with utmost care in experienced hands remains a very safe procedure to be followed as a routine and standard.

Optical and Cross-Sectional Imaging Technologies for Bladder Cancer

Optical and cross-sectional imaging plays critical roles in bladder cancer diagnostics. White light cystoscopy remains the cornerstone for the management of non-muscle-invasive bladder cancer. In the last decade, significant technological improvements have been introduced for optical imaging to address the known shortcomings of white light cystoscopy. Enhanced cystoscopy modalities such as blue light cystoscopy and narrowband imaging survey a large area of the urothelium and provide contrast enhancement to detect additional lesions and decrease cancer recurrence. However, higher false-positive rates accompany the gain of sensitivity. Optical biopsy technologies, including confocal laser endomicroscopy and optical coherence tomography, provide cellular resolutions combined with subsurface imaging, thereby enabling optical-based cancer characterization, and may lead to real-time cancer grading and staging. Coupling of fluorescently labeled binding agents with optical imaging devices may translate into high molecular specificity, thus enabling visualization and characterization of biological processes at the molecular level. For cross-sectional imaging, upper urinary tract evaluation and assessment potential extravesical tumor extension and metastases are currently the primary roles, particularly for management of muscle-invasive bladder cancer. Multi-parametric MRI, including dynamic gadolinium-enhanced and diffusion-weighted sequences, has been investigated for primary bladder tumor detection. Ultrasmall superparamagnetic particles of iron oxide (USPIO) are a new class of contrast agents that increased the accuracy of lymph node imaging. Combination of multi-parametric MRI with positron emission tomography is on the horizon to improve accuracy rates for primary tumor diagnostics as well as lymph node evaluation. As these high-resolution optical and cross-sectional technologies emerge and develop, judicious assessment and validation await for their clinical integration toward improving the overall management of bladder cancer.

Differences in Pathologic Results of Repeat Transurethral Resection of Bladder Tumor (TURBT) according to Institution Performing the Initial TURBT: Comparative Analyses between Referred and Nonreferred Group

Objective

Although transurethral resection of bladder tumor (TURBT) is a standard treatment and determines staging for nonmuscle invasive bladder cancer, many deficiencies persist. There is a risk of upstaging and residual cancer when repeat TURBT is performed. Authors compared the results of repeat TURBT by institution performing the initial TURBT.

Methods

We retrospectively reviewed the medical records of 289 patients who underwent repeat TURBT within 2-6 weeks after initial TURBT between 1998 and 2013. The patients were divided into the referred group and the nonreferred group by institution performing the initial TURBT. And we analyzed the intergroup differences in residual tumor and upstaging rate and the factors significantly correlated with residual tumor.

Results

The mean age was 69.6 ± 11.1 years and the mean follow-up was 49.7 (range: 0–191) months. The referred group included 69 patients, while the nonreferred group included 220 patients. The referred group included 57 (82.6%) patients with residual tumor after repeat TURBT. Overall upstaging occurred in 15 (21.7%), and upstaging to T2 occurred in 11 (15.9%) of the initial Ta and T1 patients. In the nonreferred group, there were 123 (55.9%) patients with residual tumor. Overall upstaging occurred in 10 (4.5%) and upstaging to T2 occurred in 7 (3.2%) patients.

Conclusions

Gross hematuria, grade, and tumor quantity and size were significantly associated with residual cancer on multivariate analysis. In the referred group, repeat TURBT and restaging are necessary.

Recurrence and upstaging rates of T1 high-grade urothelial carcinoma of the bladder on repeat resection in a Canadian, resource-limited, healthcare system

INTRODUCTION

Non-muscle-invasive bladder cancer is the most expensive malignancy to treat. Current Canadian guidelines recommend repeat transurethral resection of bladder tumour (TURBT) within six weeks after initial resection of T1 high-grade (T1HG) urothelial carcinoma, prior to initiation of intravesical bacillus Calmette-Guerin treatment. This is a burden on operating room usage and adds further cost and risk of complications. Internationally, major cancer centres report significant rates of recurrence and upstaging on repeat resection, however, minimal Canadian data is available. We aimed to determine the rate of recurrence and upstaging in a resource-limited, Canadian healthcare system.

METHODS

A retrospective review of patients receiving TURBT between November 2009 and November 2014 was performed. Patients were included if they had all three of the following: a pathological diagnosis of T1HG, adequate muscularis propria present in the specimen, and a repeat resection.

RESULTS

We reviewed 3166 patients who underwent TURBT and found 173 to meet our inclusion criteria. The overall recurrence and upstaging rates were 57.2% and 9.2%, respectively. Tumour recurrence and upstaging occurred more often in patients who had repeat resection after 12-24 weeks compared to those patients whose repeat resection occurred within 12 weeks.

CONCLUSIONS

Although recurrence rates are similar, we have found upstaging rates to be three- to four-fold lower than those previously reported. Despite this, one in 10 patients will be upstaged, justifying use of this resource within our healthcare system. Finally, timely repeat resection, within 12 weeks appears to be associated with preventing disease progression.

Efficacy and Safety of Blue Light Flexible Cystoscopy with Hexaminolevulinate in the Surveillance of Bladder Cancer: A Phase III, Comparative, Multicenter Study

PURPOSE

We compared blue light flexible cystoscopy with white light flexible cystoscopy for the detection of bladder cancer during surveillance.

MATERIALS AND METHODS

Patients at high risk for recurrence received hexaminolevulinate intravesically before white light flexible cystoscopy and randomization to blue light flexible cystoscopy. All suspicious lesions were documented. Patients with suspicious lesions were referred to the operating room for repeat white and blue light cystoscopy. All suspected lesions were biopsied or resected and specimens were examined by an independent pathology consensus panel. The primary study end point was the proportion of patients with histologically confirmed malignancy detected only with blue light flexible cystoscopy. Additional end points were the false-positive rate, carcinoma in situ detection and additional tumors detected only with blue light cystoscopy.

RESULTS

Following surveillance 103 of the 304 patients were referred, including 63 with confirmed malignancy, of whom 26 had carcinoma in situ. In 13 of the 63 patients (20.6%, 95% CI 11.5-32.7) recurrence was seen only with blue light flexible cystoscopy (p <0.0001). Five of these cases were confirmed as carcinoma in situ. Operating room examination confirmed carcinoma in situ in 26 of 63 patients (41%), which was detected only with blue light cystoscopy in 9 of the 26 (34.6%, 95% CI 17.2-55.7, p <0.0001). Blue light cystoscopy identified additional malignant lesions in 29 of the 63 patients (46%). The false-positive rate was 9.1% for white and blue light cystoscopy. None of the 12 adverse events during surveillance were serious.

CONCLUSIONS

Office based blue light flexible cystoscopy significantly improves the detection of patients with recurrent bladder cancer and it is safe when used for surveillance. Blue light cystoscopy in the operating room significantly improves the detection of carcinoma in situ and detects lesions that are missed with white light cystoscopy.

Is restaging transurethral resection necessary in patients with non-muscle invasive bladder cancer and limited lamina propria invasion?

OBJECTIVES

To evaluate the influence of lamina propria invasion type at initial transurethral resection (TUR) on restaging pathology.

MATERIALS AND METHODS

We reviewed prospectively maintained records of all patients with a high-grade pT1 nonmuscle invasive bladder cancer who underwent both initial and restaging TUR within 6 weeks at our center between 2001 and 2016. The pathology of second TUR specimens was analyzed with regard to the characteristics of lamina propria invasion found at initial resection.

RESULTS

We included 198 patients, with a median age of 70 years (interquartile range: 63-79). Muscle was present in the initial TUR specimen in 107 patients (54%). Pathology restaging was pT0 in 73 patients (37%), pTis in 44 (22%), pTa in 27 (14%), pT1 in 50 (25%), and pT2 in 4 (2%). Eighty-seven patients (44%) had tumors with minimal lamina propria invasion at initial TUR: 53 specimens (27%) had focal invasion (few malignant cells in the lamina propria); 15 specimens (7.6%) had superficial invasion (invasion of the lamina propria to the level of the muscularis mucosae [T1a]); and 19 specimens (10%) had multifocal superficial invasion (multiple areas of T1a). Of the patients with minimal lamina propria invasion, residual disease was found in 54 patients (62%). However, none of those patients had T2 disease.

CONCLUSIONS

A significant number of patients with T1 tumors have residual disease at restaging TUR as do patients with minimal lamina propria invasion. The extent of T1 invasion does not eliminate the need for repeat TUR.

Narrow band imaging-assisted transurethral resection reduces the recurrence risk of non-muscle invasive bladder cancer: A systematic review and meta-analysis

CONTEXT

Compared with white light imaging (WLI) cystoscopy, narrow band imaging (NBI) cystoscopy could increase the visualization and detection of bladder cancer (BC) at the time of transurethral resection (TUR). NBI cystoscopy could increase the detection of BC, but it remains unclear whether narrow band imaging-assisted transurethral resection (NBI-TUR) could reduce the recurrence risk of non-muscle invasive bladder cancer (NMIBC). Several randomized clinical trials (RCTs) have recently tested the efficacy of NBI-TUR for NMIBC.

OBJECTIVE

To perform a systematic review and meta-analysis of RCTs and evaluate the efficacy of NBI-TUR for NMIBC compared with white light imaging-assisted transurethral resection (WLI-TUR). The end point was recurrence risk.

EVIDENCE ACQUISITION

A systematic review of PubMed, Medline, Ovid, Embase, Cochrane and Web of Science was performed in February 2016 and updated in July 2016.

EVIDENCE SYNTHESIS

Overall, six (n = 1084) of 278 trials were included. Three trials performed narrow band imaging-assisted electro-transurethral resection (NBI-ETUR), and two trials performed narrow band imaging-associated bipolar plasma vaporization (NBI-BPV). The last trial performed narrow band imaging-associated holmium laser resection (NBI-HLR). Statistical analysis was performed using Review Manager software (RevMan v.5.3; The Nordic Cochrane Center, Copenhagen, Denmark). The recurrence risk was compared by calculating risk ratios (RRs) with 95% confidence interval (CIs). Risk ratios with 95% CIs were calculated to compare 3-mo, 1-yr, and 2-yr survival rates. NBI-TUR was associated with improvements in the 3-mo recurrence risk (RR: 0.39; 95% CI, 0.26-0.60; p < 0.0001), 1-yr recurrence risk (RR: 0.52; 95% CI, 0.40-0.67; p < 0.00001) and 2-yr recurrence risk (RR: 0.60; 95% CI, 0.42-0.85; p = 0.004) compared with WLI-TUR.

CONCLUSIONS

Compared with WLI-TUR, NBI-TUR can reduce the recurrence risk of NMIBC. The results of this review will facilitate the appropriate application of NBI in NMIBC.

Bacillus Calmette-Guérin (BCG) Treatment Failures in Non-Muscle Invasive Bladder Cancer: What Truly Constitutes Unresponsive Disease

Bacillus Calmette-Guérin (BCG) remains the most effective intravesical therapy for non-muscle invasive bladder cancer but will fail in up to 40% of patients. The ability to identify patients who are least likely to respond to further BCG therapy allows urologists to pursue secondary treatments more likely to convey a recurrence or survival benefit to the patient. We examined the literature to determine what constitutes BCG unresponsive disease. After review, we believe that BCG unresponsive disease should be defined as (1) patients with recurrent high grade T1 disease within 6 months of their primary tumor after at least one course of BCG or patients who have failed at least 2 courses of BCG with either (2) persistent or recurrent pure papillary (Ta) disease within 6 months or (3) persistent or recurrent carcinoma in situ (CIS) within 12 months.

The importance of second-look transurethral resection for superficial bladder cancer

Objectives:

The objective of this article is to evaluate the importance of a second-look transurethral resection of bladder tumour (TURBT) in patients with newly diagnosed superficial bladder cancer and its impact on subsequent treatment plan.

Methods:

We carried out a prospective study on 100 consecutive patients with newly diagnosed superficial bladder cancer in whom a second-look TURBT was performed two to six weeks after initial resection. We assessed the incidence of residual tumours, sufficiency of initial pathological staging and grading. We also assessed the need for re-staging and grading after the second-look TURBT.

Results:

Forty-five out of 75 patients (60%) who underwent second-look TURBT had no tumours, 18 (24%) had visible residual tumours and 12 (16%) had microscopic residual tumours. Of the 30 (40%) patients with residual tumours, five had pTa, three had carcinoma in situ (CIS), 12 had pT1, and 10 had pT2 disease. Upstaging and change of treatment plan as a result of the second-look TURBT were necessary in 18/75 (24%) cases, of which 10 cases (13%) underwent radical cystectomy for muscle-invasive tumours.

Conclusions:

A second cystoscopy with or without TURBT is recommended two to six weeks after initial resection of stage Ta and T1 bladder tumours in patients with high-grade transitional carcinoma of the bladder or in patients with multiple tumours. Second-look cystoscopy in this category of patients may reveal the need for early change of treatment plan in about 25% of patients.

Genetic Variations in Glutathione Pathway Genes Predict Cancer Recurrence in Patients Treated with Transurethral Resection and Bacillus Calmette-Guerin Instillation for Non-muscle Invasive Bladder Cancer

BACKGROUND

Glutathione (GSH) is an important molecule involved in cell detoxification and antioxidation and may affect cancer development or outcome. We hypothesized that genetic variation in the GSH pathway might influence the clinical outcome of patients who have non-muscle invasive bladder cancer (NMIBC).

METHODS

A total of 114 single nucleotide polymorphisms (SNPs) in 21 GSH pathway genes were genotyped in 414 NMIBC patients treated with transurethral resection alone (TUR) and both TUR and intravesical bacillus Calmette-Guérin instillation (BCG) therapy. The effect of each SNP on time to recurrence was estimated using the multivariate Cox proportional hazards model. Cumulative effect and survival tree analyses were performed to determine the joint effects of unfavorable genotypes and gene-gene interactions on bladder cancer prognosis.

RESULTS

Seven SNPs showed significant associations with cancer recurrence in the TUR group and 15 SNPs showed significant associations with recurrence in the BCG group. The most significant SNP in the TUR group was rs3746162 in GPX4, whose variant genotype conferred a 5.4-fold increased risk of recurrence compared with wild-type (hazard ratio [HR] = 5.43, 95 % confidence interval [CI] = 2.19-13.46), whereas the most significant SNP in the BCG group was rs7265992 in GSS (HR 3.43, 95 % CI 1.56-7.56). The risk of recurrence increased with the number of unfavorable genotypes in both groups. Within treatment group, stratified analyses by tumor grade also indicated predictive variants.

CONCLUSIONS

Genetic variants in GSH pathway may influence cancer recurrence in NMIBC patients receiving curative treatment.

Confocal laser endomicroscopy of bladder and upper tract urothelial carcinoma: a new era of optical diagnosis?

Urothelial carcinoma of the bladder and upper tract pose significant diagnostic and therapeutic challenges. White light endoscopy plays a central role in the management of urothelial carcinoma but has several well-recognized shortcomings. New optical imaging technologies may improve diagnostic accuracy, enhance local cancer control, and better stratify treatment options. Confocal laser endomicroscopy enables dynamic imaging of the cellular structures below the mucosal surface and holds promise in providing real time optical diagnosis and grading of urothelial carcinoma. A variety of imaging probes are available that are compatible with the full spectrum of cystoscopes and ureteroscopes. We review the underlying principles and technique of confocal laser endomicroscopy in the urinary tract, with emphasis on specific application towards urothelial carcinoma. While the available data are largely related to urothelial carcinoma of the bladder, the lessons learned are directly applicable to the upper tract, where the clinical needs are significant. Ongoing efforts to optimize this technology offer an exciting glimpse into future advances in optical imaging and intraoperative image guidance.

[Clinical practice and adherence to the diagnosis and treatment of NMIBC guidelines: a report of a recognition based clinical cases study]

For non-muscle invasive bladder cancer, a disease with a considerable epidemiological and socio-economic impact, the introduction of the Guidelines has always evoked as a tool for the resolution of long-standing disputes in terms of diagnosis and therapy. Check the degree of routine clinical practice adherence to the Recommendations is for this disease, more than for other uro-oncology pathology, an urgent need felt by the urological community. To assess the level of Guidelines adherence's, and study issues related to the paths of diagnosis and treatment of non-muscle invasive bladder cancer, and identifying the processes actually implemented in daily clinical practice, a series of case studies has submitted to a group of experts. The acknowledgement study allowed testing the impact of the current Evidence Based Medicine Recommendations in the everyday clinical practice identifying strengths and weaknesses. Questions Responses Analysis' of 5 clinical cases (Ta low grade, T1 low grade, T1 high grade, T1 high grade + CIS, Ta low-grade multiple recurrence) showed a moderate amendment to the European Association of Urology (EAU)-Guidelines. On the other hand, it was emphasized that there are clear discrepancies between what should be done, in accordance with the Evidence Based Medicine Recommendations, and what is actually do in everyday clinical practice. The most common reason for the low Recommendations adherences are structural and organizational practical limitations.

Advances in imaging technologies in the evaluation of high-grade bladder cancer

Bladder cancer ranges from a low-grade variant to high-grade disease. Assessment for treatment depends on white light cystoscopy, however because of its limitations there is a need for improved visualization of flat, multifocal, high-grade, and muscle-invasive lesions. Photodynamic diagnosis and narrow-band imaging provide additional contrast enhancement of bladder tumors and have been shown to improve detection rates. Confocal laser endomicroscopy and optical coherence tomography enable real-time, high-resolution, subsurface tissue characterization with spatial resolutions similar to histology. Molecular imaging offers the potential for the combination of optical imaging technologies with cancer-specific molecular agents to improve the specificity of disease detection.

A preoperative marker panel for the prediction of residual tumor and the decision making for repeat transurethral resection

OBJECTIVE

To assess the ability of a combined preoperative marker panel to identify patients with residual non-muscle-invasive bladder cancer who might benefit from repeat transurethral resection (reTUR).

METHODS

Ki67, p53, vascular endothelial growth factor-C, E-cadherin, and survivin expressions were evaluated by immunohistochemical staining of surgical specimens from 72 patients who underwent reTUR. Related clinical and molecular markers were analyzed by univariate analyses to develop a marker panel. The predictive value of the marker panel was calculated by receiver operating characteristic curves.

RESULTS

Univariate analyses identified tumor size, number of tumors, p53 expression, E-cadherin expression, and the number of altered markers as risk factors for residual tumor (P = 0.03, 0.05, 0.06, 0.024, and 0.005, respectively). After adjusting for the effects of tumor stage and grade, multivariate analyses identified the number of altered markers as a risk factor for residual tumor (P = 0.004). The addition of tumor size, E-cadherin, and the number of altered markers to the base model (based on tumor stage and tumor grade) increased its discrimination for predicting residual tumor (5%, 6%, and 10%, respectively).

CONCLUSION

Some clinical and molecular markers could improve the accuracy of residual tumor prediction at reTUR. Such a marker panel may help to identify patients with non-muscle-invasive bladder cancer who have residual tumor after first TUR and who may therefore benefit from reTUR.

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.

Predictive factors for residual tumor and tumor upstaging on relook transurethral resection of bladder tumor in non-muscle invasive bladder cancer

Context:

Relook transurethral resection of bladder tumor (TURBT) improves the diagnostic and therapeutic efficacy of primary TURBT. However, it is still not established as to which category of patients would benefit most from this repeat invasive procedure.

Aims:

This prospective interventional study was designed to identify the category of patients with non-muscle invasive bladder cancer who may benefit from a routine relook procedure.

Setting and Design:

A total of 52 consecutive patients with biopsy proven non muscle invasive bladder cancer on primary TURBT underwent a relook TURBT between March 2011 and September 2012.

Materials and Methods:

The incidence of residual tumor and tumor upstaging on relook procedure was correlated with various histopathological (stage, grade, CIS, presence of muscle) and cystoscopic (type and focality of tumor, any apparent field change) parameters on primary TURBT.

Results:

Out of the total 52 patients, 23 (44.2%) had a residual tumor on relook TURBT. 12 (23.1%) were upstaged (of these 9 i.e. 17.3% to muscle invasion). While most of the parameters studied showed a positive correlation with incidence of residual tumor and upstaging to muscle invasion, statistical significance (for both) was reached only for tumor stage (P = 0.028 and 0.010), tumor grade (P = 0.010 and 0.002) and tumor type (solid vs. papillary; P = 0.007 and 0.001). Carcinoma in situ showed a significant correlation with incidence of residual tumor (P = 0.016) while the absence of muscle in the primary TURBT specimen was significantly associated with upstaging to muscle invasive disease (P = 0.018).

Statistical Analysis:

The data was analyzed using SPSS software v. 16.0.

Conclusions:

Relook TURBT may be especially recommended for high grade and T1 tumors and tumors with a solid/sessile appearance on primary TURBT especially when deep muscle was absent in the primary TURBT specimen.

Novel endoscopic diagnosis for bladder cancer

Advances in endoscopic imaging technology may improve sensitivity for the detection of bladder cancer and provide a more complete understanding of the urothelial landscape, and it also may lead to improved short-term and long-term cancer control. Fluorescence cystoscopy requires intravesical administration of a photosensitizing agent (5-aminolevulinic acid or hexaminolevulinate), and imaging with a blue-light endoscopy system demonstrably improves the detection of papillary and flat bladder lesions compared with conventional white-light cystoscopy. Prospective phase 3 clinical trials have demonstrated improved diagnostic ability, enhanced tumor resection, and a small but significant reduction in recurrence-free survival. Optical coherence tomography delineates subsurface microarchitecture information about bladder lesions in real time and has the ability to discriminate between noninvasive and invasive cancers. Narrow-band imaging may augment white-light cystoscopy by providing increased contrast between normal and abnormal tissue on the basis of neovascularity. Confocal laser endoscopy has been applied to the urinary tract using thinner probes adapted from use in gastrointestinal malignancies and provides exquisite images at microscopic resolution. More technology is on the horizon that may further enhance our ability to detect and accurately stage bladder tumors and distinguish benign from malignant or dysplastic lesions.

Controversial issues and optimal management of stage T1G3 bladder cancer

The management of T1G3 bladder cancer is controversial. Diagnostic methods, such as bladder mapping or second-look transurethral resection are recommended to assess risk. Bacillus Calmette-Guérin intravesical therapy with a maintenance regimen is recommended for solitary T1G3 tumors. The timing of radical cystectomy for these patients is controversial, but early recurrence during intravesical therapy is an indication for radical cystectomy. Multifocal disease, concomitant carcinoma in situ and disease in the prostatic urethra and bladder neck also suggest aggressive disease and cystectomy should be considered in these patients.

The interaction of celecoxib with MDR transporters enhances the activity of mitomycin C in a bladder cancer cell line

BACKGROUND

An in vitro model was developed to understand if celecoxib could synergize with Mitomycin C (MMC), commonly used for the prevention of non-muscle invasive bladder cancer recurrence, and eventually elucidate if the mechanism of interaction involves multi drug resistance (MDR) transporters.

METHODS

UMUC-3, a non COX-2 expressing bladder cancer cell line, and UMUC-3-CX, a COX-2 overexpressing transfectant, as well as 5637, a COX-2 overexpressing cell line, and 5637si-CX, a non COX-2 expressing silenced 5637 cell line, were used in the present study. The expression of COX-2 and MDR pumps (P-gp, MDR-1 and BCRP) was explored through western blot. The anti-proliferative effect of celecoxib and MMC was studied with MTT test. Three biological permeability assays (Drug Transport Experiment, Substrate Transporter Inhibition, and ATP cell depletion) were combined to study the interaction between MDR transporters and celecoxib. Finally, the ability of celecoxib to restore MMC cell accumulation was investigated.

RESULTS

The anti-proliferative effect of celecoxib and MMC were investigated alone and in co-administration, in UMUC-3, UMUC-3-CX, 5637 and 5637si-CX cells. When administered alone, the effect of MMC was 8-fold greater in UMUC-3. However, co-administration of 1 μM, 5 μM, and 10 μM celecoxib and MMC caused a 2,3-fold cytotoxicity increase in UMUC-3-CX cell only. MMC cytotoxicity was not affected by celecoxib co-administration either in 5637, or in 5637si-CX cells. As a result of all finding from the permeability experiments, celecoxib was classified as P-gp unambiguous substrate: celecoxib is transported by MDR pumps and interferes with the efflux of MMC. Importantly, among all transporters, BCRP was only overexpressed in UMUC-3-CX cells, but not in 5637 and 5637si-CX.

CONCLUSIONS

The UMUC-3-CX cell line resembles a more aggressive phenotype with a lower response to MMC compared to the wt counterpart. However, the administration of celecoxib in combination to MMC causes a significant and dose dependent gain of the anti-proliferative activity. This finding may be the result of a direct interaction between celecoxib and MDR transporters. Indeed, BCRP is overexpressed in UMUC-3-CX, but not in UMUC-3, 5637, and 5637si-CX, in which celecoxib is ineffective.

Photodynamic diagnosis of non-muscle-invasive bladder cancer with hexaminolevulinate cystoscopy: a meta-analysis of detection and recurrence based on raw data

BACKGROUND

Studies on hexaminolevulinate (HAL) cystoscopy report improved detection of bladder tumours. However, recent meta-analyses report conflicting effects on recurrence.

OBJECTIVE

To assess available clinical data for blue light (BL) HAL cystoscopy on the detection of Ta/T1 and carcinoma in situ (CIS) tumours, and on tumour recurrence.

DESIGN, SETTING, AND PARTICIPANTS

This meta-analysis reviewed raw data from prospective studies on 1345 patients with known or suspected non-muscle-invasive bladder cancer (NMIBC).

INTERVENTION

A single application of HAL cystoscopy was used as an adjunct to white light (WL) cystoscopy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We studied the detection of NMIBC (intention to treat [ITT]: n=831; six studies) and recurrence (per protocol: n=634; three studies) up to 1 yr. DerSimonian and Laird's random-effects model was used to obtain pooled relative risks (RRs) and associated 95% confidence intervals (CIs) for outcomes for detection.

RESULTS AND LIMITATIONS

BL cystoscopy detected significantly more Ta tumours (14.7%; p<0.001; odds ratio [OR]: 4.898; 95% CI, 1.937-12.390) and CIS lesions (40.8%; p<0.001; OR: 12.372; 95% CI, 6.343-24.133) than WL. There were 24.9% patients with at least one additional Ta/T1 tumour seen with BL (p<0.001), significant also in patients with primary (20.7%; p<0.001) and recurrent cancer (27.7%; p<0.001), and in patients at high risk (27.0%; p<0.001) and intermediate risk (35.7%; p=0.004). In 26.7% of patients, CIS was detected only by BL (p<0.001) and was also significant in patients with primary (28.0%; p<0.001) and recurrent cancer (25.0%; p<0.001). Recurrence rates up to 12 mo were significantly lower overall with BL, 34.5% versus 45.4% (p=0.006; RR: 0.761 [0.627-0.924]), and lower in patients with T1 or CIS (p=0.052; RR: 0.696 [0.482-1.003]), Ta (p=0.040; RR: 0.804 [0.653-0.991]), and in high-risk (p=0.050) and low-risk (p=0.029) subgroups. Some subgroups had too few patients to allow statistically meaningful analysis. Heterogeneity was minimised by the statistical analysis method used.

CONCLUSIONS

This meta-analysis confirms that HAL BL cystoscopy significantly improves the detection of bladder tumours leading to a reduction of recurrence at 9-12 mo. The benefit is independent of the level of risk and is evident in patients with Ta, T1, CIS, primary, and recurrent cancer.

Genetic variations in micro-RNA biogenesis genes and clinical outcomes in non-muscle-invasive bladder cancer

Micro-RNAs (miRNAs) are small non-coding RNA molecules, which can act as either oncogenes or tumor suppressors. Dysregulated expression of miRNA genes have been implicated in the development of many different cancers. We hypothesize that genetic variations in miRNA biogenesis genes may be associated with the prognosis of bladder cancer. We genotyped 76 single nucleotide polymorphisms (SNPs) in eight miRNA biogenesis genes in 421 patients with non-muscle-invasive bladder cancer (NMIBC). We analyzed the associations of SNPs with recurrence and progression in all patients as well as stratified by treatment: transurethral resection (TUR) alone or TUR plus intravesical bacillus Calmette-Guérin (BCG) instillation. Two SNPs were significantly associated with tumor recurrence in TUR only subgroup after adjustment for multiple comparisons (Q < 0.1). The most significant SNP was rs197412 in DDX20: the variant allele conferred a decreased risk of recurrence [hazard ratio (HR) = 0.58, 95% confidence interval (95% CI) = 0.40-0.82]. This SNP was validated in a separate group of 586 NMIBC patients and the pooled HR was 0.62 (95% CI = 0.48-0.81, P < 0.001). Two linked SNPs (rs2073778 and rs720012) in DGCR8 showed significant association with tumor progression (HR = 4.00, 95% CI = 1.53-10.46, P = 0.005). A strong gene-dosage effect was observed with higher risk for tumor recurrence and progression with increasing number of unfavorable genotypes. Haplotype and survival tree analyses further characterized the association of miRNA-related SNPs with tumor recurrence and progression. Taken together, our results indicate that genetic variants in miRNA biogenesis pathway may influence bladder cancer clinical outcome in NMIBC patients.

Electroporation enhances mitomycin C cytotoxicity on T24 bladder cancer cell line: a potential improvement of intravesical chemotherapy in bladder cancer

Intravesical mitomycin instillation combined with electric pulses is being used experimentally for the treatment of T1 bladder tumors, in patients unfit for surgery. Electroporation may enhance the uptake of chemotherapeutics by permeabilization of cell membranes. We investigated if electroporation improves the cytotoxicity of mitomycin. In two cell lines, T24 (bladder cancer cell line) and DC3F (Chinese hamster fibroblast), exposure to different concentrations of mitomycin (0.01-2000μM) was tested with and without electroporation (6 pulses of 1kV/cm, duration: 99μs, frequency: 1Hz). Cell viability was assessed by colorimetric assay (MTT). For both cell lines, mitomycin's IC_50 was approximately 1000μM in both pulsed and unpulsed cells. On T24 cells, electroporation and mitomycin caused (relative reduction) RR of survival of: 25%, 31% and 29%, by concentrations 0μM, 500μM and 1000μM respectively. For DC3F cells, the RRs of survival were: 28%, 29%, and 33%, by concentrations 0μM, 500μM and 1000μM respectively. In conclusion, electroporation and mitomycin together are about 30% more effective than mitomycin alone. The results help to elucidate the additive effect of mitomycin and electric pulses and support the use of this combination in the treatment of bladder cancer.

Fluorescence-guided transurethral resection of bladder tumours reduces bladder tumour recurrence due to less residual tumour tissue in Ta/T1 patients: a randomized two-centre study

OBJECTIVES

•To compare the bladder tumour recurrence rate in stage Ta and T1 tumours after conventional transurethral resection of the bladder in white light (WL TURB) and after fluorescence-guided TURB (HAL TURB) using hexaminolaevulinate (HAL: Hexvix®, Photocure, Norway) for photodynamic diagnosis during 12 months of follow-up. •As secondary objectives, to relate the tumour recurrence rate to fluorescence-detected residual tumour after WL TURB and to assess the false positive rate.

PATIENTS AND METHODS

•This was a prospective, comparative, randomized, open-label study carried out in hospital outpatient urology clinics and the operating theatre. A total of 233 patients presenting with suspected superficial bladder tumour were recruited. Both patients with new tumours and patients with recurrent tumours were included. •The study duration was 2.5 years with follow-up cystoscopic investigations at 4, 8 and 12 months. •Patients were randomized to cystoscopy and WL TURB (118 patients) or WL TURB followed immediately by HAL TURB (115 patients). Cystoscopy/TURB and bladder biopsies were performed under general anaesthesia. No patients had intravesical chemotherapy immediately after TURB. •Recurrences were verified histologically.

RESULTS

•The two groups were similar regarding age and previous bladder cancer history. •In all, 90 patients from the HAL TURB group had bladder tumour. Fluorescence-guided cystoscopy after complete WL TURB identified residual tumour tissue in 44 of 90 patients (49%). In 37 of 83 (45%) residual Ta tumour was found; in three of seven residual T1 was found and in four cases carcinoma in situ. •True (and false) positive detection rate of photodynamic diagnosis was 64% (25%) and of white light 83% (16%). •In all, 145 patients were eligible for analysis of tumour recurrence. Twelve patients had their last follow-up after 4 months. The recurrence rate in patients followed for 12 months was 47.3% (35/74) after WL TURB and 30.5% (18/59) after HAL TURB (P= 0.05). •Kaplan-Meier analyses comprising data from all 145 patients showed that the recurrence-free period was significantly longer in the HAL TURB group than in the WL TURB group (P= 0.02).

CONCLUSION

•WL TURB often leaves residual tumour in the bladder. HAL TURB improves the detection of Ta/T1 tumours of the bladder resulting in more complete TURB procedures and thus a reduced recurrence rate.

Optimal timing of radical cystectomy in T1 high-grade bladder cancer

T1 high-grade (formerly T1G3) bladder cancer is a challenging clinical entity representing approximately 10-15% of all new bladder cancer cases. The variable natural history of the disease and possible impairment in quality of life associated with radical treatment makes T1 high-grade one of the most challenging uro-oncological patient groups to manage. In particular, the risk of clinical understaging and not recognizing muscle-invasive disease may have detrimental effects on patient outcome. The cornerstone of contemporary staging is restaging transurethral resection (TUR), which helps in defining further management. In patients with restaging TUR stage less than T1, induction bacillus Calmette-Guérin combined with maintenance offers good results. The option of radical cystectomy should be discussed with patients with restaging TUR stage T1 or higher and it is highly recommended to all patients with recurrent T1 of carcinoma in situ during bacillus Calmette-Guérin maintenance. In addition to restaging TUR stage, several other clinicopathological factors, such T1 substaging, associated carcinoma in situ, tumor size and appearance, lymphovascular invasion, and hydronephrosis, aid in the decision making between radical and conservative treatment. Future prospects include improved staging and molecular markers that may guide toward conservative therapy or allow more cT1 patients to be offered nerve-sparing cystectomies and neobladders and, thus, improving quality of life for patients undergoing radical surgery.

Early Re-Resection for T1 Transitional Cell Carcinoma of the Bladder—A Study of Current Practice in the South West of England

Objective:

To evaluate resection and re-resection practice in the South West region of England in patients with newly diagnosed T1 bladder cancer.

Patients and methods:

All patients diagnosed with T1 disease between 2005 and 2008 were identified. Patients with incomplete primary resections were excluded.

Results:

Of 344 patients identified, the primary resection specimen did not contain deep muscle in 110 (32%). In total, 76 patients (22%) underwent a planned re-resection within 8 weeks of their primary resection. In 225 patients, a routine check cystoscopy was performed at an interval of 3 months or greater. The remainder had no further cystoscopy. Residual disease was present in 38 (50%) patients undergoing early re-resection and 89 (40%) patients in the routine check cystoscopy group. Upstaging of tumours from T1 to T2 was demonstrated in 7% and 5% of patients within these respective groups. Grade of operating surgeon was not a predictor of adequacy of resection or tumour persistence/recurrence.

Conclusions:

Primary transurethral resection remains an area for improvement in contemporary practice. Early re-resection should be performed in patients with newly diagnosed T1 bladder cancer unless precluded by co-morbidity to ensure complete resection, accurate staging and facilitate risk stratification. Selective approaches to re-resection risk delayed treatment of significant residual disease.

Hexaminolevulinate guided fluorescence cystoscopy reduces recurrence in patients with nonmuscle invasive bladder cancer

PURPOSE

We assessed the impact that improved detection of nonmuscle invasive bladder cancer with hexaminolevulinate fluorescence cystoscopy may have on early recurrence rates.

MATERIALS AND METHODS

This prospective, randomized study enrolled 814 patients suspected of having bladder cancer at increased risk for recurrence. All patients underwent white light cystoscopy and mapping of lesions, followed by transurethral resection of the bladder when indicated. Patients in the fluorescence group also received intravesical hexaminolevulinate solution at least 1 hour before cystoscopy to induce fluorescence of cancerous lesions, and underwent additional inspection with blue light before and after transurethral resection of the bladder. Adjuvant intravesical therapy was based on risk. Followup cystoscopy at 3, 6 and 9 months was conducted with white light.

RESULTS

Detection was performed as a within patient comparison in the fluorescence group. In this group 286 patients had at least 1 Ta or T1 tumor (intent to treat). In 47 patients (16%) at least 1 of the tumors was seen only with fluorescence (p = 0.001). During the 9-month followup (intent to treat) there was tumor recurrence in 128 of 271 patients (47%) in the fluorescence group and 157 of 280 (56%) in the white light group (p = 0.026). The relative reduction in recurrence rate was 16%.

CONCLUSIONS

Hexaminolevulinate fluorescence cystoscopy significantly improves the detection of Ta and T1 lesions and significantly reduces the rate of tumor recurrence at 9 months.

Influence of stage discrepancy on outcome in patients treated with radical cystectomy

AIMS AND BACKGROUND

To evaluate the influence of stage discrepancy on clinical outcome in patients with bladder cancer who have undergone radical cystectomy.

METHODS AND STUDY DESIGN

We reviewed the records of 155 patients who had undergone radical cystectomy. Of the 155 patients (128 males, 27 females), 68 had clinical nonmuscle invasive disease and 87 had muscle invasive disease. Follow-up ranged from 1.0 to 162.4 months (median, 34.3).

RESULTS

There was no significant difference in overall survival according to clinical T stage (P = 0.483). However, the actuarial overall survival rate of the pathological muscle invasive disease group was significantly less than that in the pathological nonmuscle invasive disease group (P < 0.001). Multivariate analysis with the Cox regression model revealed that lymphovascular invasion (P = 0.001, relative risk [RR] = 2.463) and pathological T stage (P = 0.003, RR = 3.148) were strongly associated with overall survival. There was no difference in cancer-specific survival according to clinical T stage (P = 0.455). However, cancer-specific survival rate of the pathological muscle invasive disease group was significantly less than that in the pathological nonmuscle invasive disease group (P < 0.001). Multivariate Cox proportional hazards model analysis showed that lymphovascular invasion (P = 0.001, RR = 2.545) and pathological T stage (P = 0.002, RR = 3.823) were independent predictors of cancer-specific survival.

CONCLUSIONS

Our findings indicate that clinical stage determined by transurethral resection is not predictive of clinical outcome after radical cystectomy in patients with bladder cancer.

The effects of intravesical chemoimmunotherapy with gemcitabine and Bacillus Calmette-Guérin in superficial bladder cancer: a preliminary study

This prospective study investigated the long-term effects of intravesical chemoimmunotherapy with gemcitabine (GEM) and bacillus Calmette-Guérin (BCG; n = 36) versus BCG alone (n = 51) for the treatment of superficial bladder cancer. For the chemoimmunotherapy (GEM + BCG) group, GEM (1000 mg) was instilled immediately after transurethral resection of bladder tumour (TURBT) and again (2000 mg) 1 week later. From 2 to 7 weeks after TURBT, BCG was instilled into the bladder of all patients once weekly. The recurrence-free period of the GEM + BCG group (24.13 months) was significantly longer than that of the BCG monotherapy group (19.81 months). The overall recurrence rate was similar between the groups, although at 6 and 9 months post-TURBT, GEM + BCG produced a significantly lower rate of recurrence compared with BCG alone. This study suggests that intravesical chemoimmunotherapy with GEM + BCG is effective in reducing early tumour recurrence and in prolonging the recurrence-free period of superficial bladder cancer.

Hexyl aminolevulinate fluorescence cystoscopy in bladder cancer

Although bladder cancer occurs frequently, early diagnosis and complete removal of malignant lesions usually lead to good clinical outcomes. In the USA, white light cystoscopy (WLC) is commonly used for bladder cancer diagnosis and guidance of the surgical resection. However, with WLC malignant and precancerous lesions may be missed, resulting in a high rate of disease recurrence. Monitoring for and treating these recurrences carry high direct and indirect costs. Because hexyl aminolevulinate (HAL; 5-ALA-hexylester) fluorescence cystoscopy has greater sensitivity than WLC, especially for detecting early stage lesions, and its use provides more complete resection and lower disease recurrence, it has been recommended in European clinical guidelines. This article reports our own HAL experiences and first time recurrence data, describes how HAL was developed, provides key clinical trial results, and discusses how HAL, which has revolutionized fluorescence cystoscopy and bladder cancer care in Europe, may ultimately revolutionize bladder cancer care in the USA.