Vesical Imaging-Reporting and Data System (VI-RADS) as a grouping imaging biomarker combined with a decision-tree mode to preoperatively predict the pathological grade of bladder cancer

AIM

To investigate whether the Vesical Imaging-Reporting and Data System (VI-RADS) could be used to develop a new non-invasive preoperative grade-prediction system to partially predict high-grade bladder cancer (HG-BC).

MATERIALS AND METHODS

The present study enrolled 89 primary BC patients prospectively from March 2022 to June 2023. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic performance of VI-RADS for predicting HG-BC and muscle-invasive bladder cancer (MIBC) in the entire group. In the low VI-RADS (≤2) group, the decision tree-based method was used to obtain significant predictors and construct the decision-tree model (DT model). The performance of the DT model and low VI-RADS scores for predicting HG-BC was determined using ROC, calibration, and decision curve analyses.

RESULTS

At a cut-off of ≥3, the specificity and positive predictive value of VI-RADS for predicting HG-BC in the entire group was 100%, and the area under the ROC curve (AUC) was 0.697. Among 65 patients with low VI-RADS scores, the DT model showed an AUC of 0.884 in predicting HG-BC compared to 0.506 for low VI-RADS scores. Calibration and decision curve analyses showed that the DT model performed better than the low VI-RADS scores.

CONCLUSION

Most VI-RADS scores ≥3 correspond to HG-BCs. VI-RADS could be used as a grouping imaging biomarker for a pathological grade-prediction procedure, which in combination with the DT model for low VI-RADS (≤2) populations, would provide a potential preoperative non-invasive method of predicting HG-BC.

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

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

PATIENT SUMMARY

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

A Restaging Transurethral Resection of Bladder Tumor Is Always Necessary For High-grade T1 Non-muscle-invasive Bladder Cancer

Patients with high-grade T1 non-muscle-invasive bladder cancer (NMIBC) have a high risk of recurrence and upstaging. Restaging transurethral resection of bladder tumor allows better staging so that patients can proceed to the appropriate treatment in a timely manner. This should be done in all patients with high-grade T1 NMIBC.

Thulium laser enucleation of bladder tumour (Thulebt): Changing paradigm in the management of nonmuscle invasive urinary bladder carcinoma

OBJECTIVES

To analyse the safety and efficacy of Thulium laser en bloc enucleation of bladder tumour (ThuLEBT) in comparison to transurethral resection of bladder tumour (TURBT) for treatment of non-muscle invasive bladder cancer (NMIBC).

METHODS

Prospective observational study involving 30 patients in each group of ThuLEBT and TURBT admitted in tertiary care centre from 1st January 2021 to December 2021.

RESULTS

Significant difference was found in terms of less operative time (p-0.01468), less intraoperative blood loss, a lower incidence of obturator nerve reflex (p-0.00006), bladder perforation (p-0.0455) and bladder irrigation (p-0.0027), better acquisition of detrusor muscle (p-0.0466), less recurrence rate (p-0.0455) in favour of ThuLEBT over TURBT group. The analysis also demonstrated faster postoperative recovery in terms of the duration of catheterisation, bladder irrigation and hospitalisation time in ThuLEBT group.

CONCLUSIONS

ThuLEBT is an efficient and safe treatment for non-muscle invasive bladder cancer and it can be a better alternative choice in place of TURBT.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Will repeat resection after initial transurethral en bloc resection benefit patients with high-risk non-muscle-invasive bladder cancer? A propensity score matching analysis

PURPOSE

To evaluate the efficacy of repeat transurethral resection on restaging, preventing tumor recurrence and progression in high-risk non-muscle invasive bladder cancer patients who received initial en bloc resection.

METHODS AND PATIENTS

We reviewed retrospectively the clinical records of 330 consecutive patients who received en bloc resection for non-muscle invasive bladder cancer. Eligible patients with and without repeat transurethral resection were matched 1:1 by propensity score. Important covariates were balanced between the two groups. We compared the recurrence-free survival, progression-free survival, recurrence rate, and progression rate between groups. And the perioperative results regarding residual tumors and the safety of the repeat resection were also evaluated.

RESULTS

Finally, there are 245 patients included in our analysis with a median follow-up duration of 19 months (range 3-50). Detrusor muscle presented in 244 (99.6%) specimens at initial en bloc resection. And among them, 30 (12.2%) patients had undergone a repeat resection and 215 (87.8%) did not. After 1:1 propensity score matching, 30 pairs were further analyzed.No case of upstaging was identified in repeat resection. During the follow-up, recurrence was observed in 5 (16.7%) and 7 (23.3%) patients in reresection group and non-reresection group, respectively. And progression was found only in 1 (3.3%) patient in each group. The 1-year recurrence-free survival estimates were comparable (86.7% vs 83.3%, p = 0.86) between groups.

CONCLUSION

Our study demonstrates that repeat resection after initial transurethral en bloc resection for bladder tumor appears not to improve staging accuracy, recurrence, and progression.

An Evaluation of Peer-Rated Surgical Skill and its Relationship With Detrusor Muscle Sampling in Transurethral Resection of Bladder Tumor

OBJECTIVE

To assess the reliability of peer-review of TURBT videos as a means to evaluate surgeon skill and its relationship to detrusor sampling.

METHODS

Urologists from an academic health system submitted TURBT videos in 2019. Ten blinded peers evaluated each surgeon's performance using a 10-item scoring instrument to quantify surgeon skill. Normalized composite skill scores for each surgeon were calculated using peer ratings. For surgeons submitting videos, we retrospectively reviewed all TURBT pathology results (2018-2019) to assess surgeon-specific detrusor sampling. A hierarchical logistic regression model was fit to evaluate the association between skill and detrusor sampling, adjusting for patient and surgeon factors.

RESULTS

Surgeon skill scores and detrusor sampling rates were determined for 13 surgeons performing 245 TURBTs. Skill scores varied from -6.0 to 5.1 [mean: 0; standard deviation (SD): 2.40]. Muscle was sampled in 72% of cases, varying considerably across surgeons (mean: 64.5%; SD: 30.7%). Among 8 surgeons performing >5 TURBTs during the study period, adjusted detrusor sampling rate was associated with sending separate deep specimens (odds ratio [OR]: 1.97; 95% confidence interval [CI]: 1.02-3.81, P = .045) but not skill (OR: 0.81; 95% CI: 0.57-1.17, P = .191).

CONCLUSION

Surgeon skill was not associated with detrusor sampling, suggesting there may be other drivers of variability of detrusor sampling in TURBT.

Surgical experience is predictive for bladder tumour resection quality

OBJECTIVES

To assess the resection quality of transurethral bladder tumour resection (TURBT) and the association to surgeon experience depending on the presence of detrusor muscle.

METHODS

A retrospective study on 640 TURBT procedures performed at Zealand University Hospital, Denmark, from 1 January 2015 - 31 December 2016. Data included patient characteristics, procedure type, surgeon category, supervisor presence, surgical report data, pathological data, complications data and recurrence data. Analysis was performed using simple and multiple logistic regression on the association between surgeon experience and the presence of detrusor muscle in resected tissue from TURBT.

RESULTS

Supervised junior residents had significant lower detrusor muscle presence (73%) compared with consultants (83%) (OR = 0.4, 95% CI = 0.21-0.83). Limitations were the retrospective design and the diversity of included TURBT.

CONCLUSIONS

It was found that surgical experience predicts detrusor muscle presence and supervised junior residents performing TURBT on patients resulted in less detrusor muscle than consultants.

[Interpretation of biopsy material after transuretral and laser en bloc resection of non-muscle-invasive bladder cancer]

Bladder cancer is one of the most common onco-urological diseases, ranked second in frequency among all tumors of the urinary system after prostate cancer. At the time of detection of the primary tumor, approximately 75% of patients have no invasion into the muscularis layer (non-muscle-invasive carcinoma), with tumor growth limited to the basal membrane (stage Ta) or submucosal base (stage T1). Removal of the tumor in a «unified block» (laser en-bloc resection or L-ERBT), unlike routine transurethral resection, allows to obtain qualitative biopsy material for precise pathomorphological staging of the tumor process. In order to accurately stratify a patient into one or another risk group, verification of the following morphological parameters is required: degree of tumor differentiation and its malignancy, depth of invasion, foci of carcinoma in situ at resection margins, presence or absence of lymphovascular invasion. Identification of tumor variant histology is also recommended. Information on presence or absence of detrusor elements in the specimen is necessary in the morphological report, as this parameter is considered as a criterion of radically performed tumor removal. According to ICCR recommendations (International Collaboration on cancer reporting), it is recommended to use subclassification of T1 stage using all possible criteria: volume and/or depth of invasion (assessed in mm), and/or width of invasion «spot» (assessed in mm), and/or involvement of anatomical structure - muscularis mucosae. Full morphological examination of the material obtained during the primary resection of the tumor is an important step in the diagnosis and treatment of bladder cancer, as it allows to stratify the patient into one or another risk group and, accordingly, allows to develop a personalized postoperative management.

Risk Stratification for the Rate and Location of Residual Bladder Tumor for the Decision of Re-Transurethral Resection of Bladder Tumor

Introduction

To assess the rate and location of residual tumor in re-transurethral resection of bladder tumor (re-TURBT) and develop a risk stratification tool to assist clinicians in making treatment decisions.

Patients and Methods

The data of 144 patients with high-risk bladder cancer who received re-TURBT were retrospectively reviewed. The rate and location of residual tumors was recorded. Logistic regression was performed to explore risk factors for residual tumors, and a risk classification tool was developed.

Results

Among the 144 patients, the rates of residual tumor and tumor location at the base of the primary tumor were 22.2% and 10.4%, respectively. Non-urothelial carcinoma subspecialist, piecemeal resection and the absence of detrusor muscle in the first specimen were defined as risk factors. Patients were categorized into low-, intermediate-, and high-risk groups according to the number of risk factors. The rate of residual tumor in the high-risk group was significantly higher than that in the low- and intermediate-risk groups (50% vs. 7.8%, P=0.001; 50% vs. 18.6%, P=0.002). Moreover, high-risk patients benefitted more from a second resection at the base of the primary tumor due to the high rate of residual tumor located at this site than low- and intermediate-risk patients (23.5% vs. 2.0%, P=0.002; 23.5% vs. 10.2%, P=0.083).

Conclusions

Risk stratification based on the subspecialist category, operative method, and presence or absence of detrusor muscle in the first specimen could help identify patients who benefit from re-TURBT and second resection the base of the primary tumor.

Restaging transurethral resection in ta high-grade nonmuscle invasive bladder cancer: a systematic review

PURPOSE OF REVIEW

The role of a re-transurethral resection (TUR) is clearly demonstrated in T1 high-grade nonmuscle invasive bladder cancer. However, its role remains controversial for Ta high-risk tumors and the recent European guidelines stated that the second look procedure could be avoided for these patients despite harboring a high-risk of both disease recurrence and progression. We aimed to evaluate the added benefit on staging, response to bacillus Calmette-Guérin and oncological outcomes of re-TUR in patients with Ta high-grade nonmuscle invasive bladder cancer.

RECENT FINDINGS

Overall, we identified 15 studies, including 3912 patients from which 743 harbored Ta high-grade disease. Delay between first and second TUR was ranging from 2 to 12 weeks (median 5.6 weeks). The rate of residual disease was 52.8% (range 17-67%). The rate of overall upstaging to T1 and muscle-invasive disease were 10.9 and 4.7%, respectively. Although there was a trend toward improvement of recurrence-free survival outcomes, no definitive conclusions can be drawn due to the retrospective design of the studies included.

SUMMARY

Residual tumor is common after initial TUR for Ta high-grade. Re-TUR is useful in reducing the rates of residual disease, may improve staging, response to bacillus Calmette-Guérin and oncological outcomes.

T1 Bladder Cancer: Comparison of the Prognostic Impact of Two Substaging Systems on Disease Recurrence and Progression and Suggestion of a Novel Nomogram

Background: The T1 substaging of bladder cancer (BCa) potentially impacts disease progression. The objective of the study was to compare the prognostic accuracy of two substaging systems on the recurrence and progression of primary pathologic T1 (pT1) BCa and to test a nomogram based on pT1 substaging for predicting recurrence-free survival (RFS) and progression-free survival (PFS). Methods: The medical records of 204 patients affected by pT1 BCa were retrospectively reviewed. Substaging was defined according to the depth of lamina propria invasion in T1_a-c and the extension of the lamina propria invasion to T1-microinvasive (T1_m) or T1-extensive (T1_e). Uni- and multivariable Cox regression models evaluated the independent variables correlated with recurrence and progression. The predictive accuracies of the two substaging systems were compared by Harrell's C index. Multivariate Cox regression models for the RFS and PFS were also depicted by a nomogram. Results: The 5-year RFS was 47.5% with a significant difference between T1_c and T1_a (p = 0.02) and between T1_e and T1_m (p < 0.001). The 5-year PFS was 75.9% with a significant difference between T1_c and T1_a (p = 0.011) and between T1_e and T1_m (p < 0.001). Model T1_m-e showed a higher predictive power than T1_a-c for predicting RFS and PFS. In the univariate and multivariate model subcategory T1e, the diameter, location, and number of tumors were confirmed as factors influencing recurrence and progression after adjusting for the other variables. The nomogram incorporating the T1_m-e model showed a satisfactory agreement between model predictions at 5 years and actual observations. Conclusions: Substaging is significantly associated with RFS and PFS for patients affected by T1 BCa and should be included in innovative prognostic nomograms.

Clinicopathological patterns of bladder carcinoma over 1 year: experience from University Hospital of Nepal

PURPOSE

To define the clinical and pathological patterns of urinary bladder carcinoma from the University Hospital of Nepal.

METHODS

This is a retrospective analytical study. Patients with bladder mass who underwent surgery over 1 year and who had data record were included in the study. Demographic profile, type of surgery, findings on clinical examination, cystoscopy findings, histopathological report, tumor stage, and post-surgery adjuvant therapy were analyzed.

RESULTS

Out of 86 patients who underwent transurethral resection of bladder tumor, 77 patients had biopsy-proven malignant bladder tumor. Urothelial cancer was present in 96.1%. Male were 78.6%. The mean age of diagnosis was 65.5 ± 11.8 years. Non-muscle-invasive bladder cancer (NMIBC) was 3.7 times more common than muscle-invasive bladder cancer (MIBC). High-grade tumors (58.6%) were more common than low grade (41.4%). The detrusor muscle was present inthe biopsy specimen of 48 patients (64%). Re-TURBT within 2-6 weeks was considered based on histopathology reports for about half of the patients (45.3%). Upstaging and upgrading of the tumor was present in 5.8 and 5.8% of the patients, respectively. Residual tumor without upstaging and upgrading was present in 23.5%. One patient (1.3%) had Clavien-Dindo grade 1, three (4%) patients had grade 2 and two patients (2.7%) had grade 3b.

CONCLUSION

In the present study, patients with bladder cancer are younger than reported in other studies. Smokers are strongly predisposed. The histological pattern is similar to the Western and Asian populations. NMIBC and MIBC occur in proportion to that described as in other studies. We had a lower rate of recurrence, upstaging and upgrading. We had a lesser rate of acceptance for radical cystectomy in our patients.

Clinical outcomes of reresection in patients with high-risk nonmuscle-invasive bladder cancer treated with en bloc transurethral resection: a retrospective study with a 1-year follow-up

Purpose To evaluate the impact of reresection on the clinical outcome in patients with primary high-risk nonmuscle-invasive bladder cancer (NMIBC) who initially received en bloc transurethral resection. Methods A retrospective analysis of data on eligible high-risk NMIBC with en bloc resection from June 2015 to June 2019 was performed. Patients were divided into two groups based on the presence or absence of reresection after the initial en bloc resection. The primary study endpoint was recurrence-free survival. The secondary outcomes were the residual rate of the tumor after initial en bloc resection, tumor upstaging rate and progression-free survival. Results We identified 115 eligible patients, including 51 (44.3%) who underwent reresection within 6 weeks of the initial en bloc resection and 64 (55.7%) who did not undergo en bloc reresection after the initial en bloc resection. The clinicopathological features were similar in patients with or without reresection. On finding tumor residues after the first en bloc resection, there were 3 cases (5.9%) in the reresection group compared to 2 cases (3.1%) in the non-reresection group (P=0.473). Two patients (3.9%) in the reresection group had tumor progression to muscle-invasive bladder cancer, whereas one patient (1.6%) in the non-reresection group exhibited tumor progression (P=0.430). The 1-year recurrence-free survival rate was 94.1% in the reresection group and 90.6% in the non-reresection group (P=0.269). In multivariate analysis, multifocality and T1 staging were independent prognostic factors for recurrence in patients with high-risk NMIBC who underwent en bloc resection. Conclusion In patients with high-risk NMIBC not exceeding 4 cm in diameter with no more than 4 lesions and not in the anterior bladder wall, reresection after en bloc resection seems to have failed to improve the patient's prognosis. However, a randomized controlled clinical study is required to confirm this hypothesis.

Novel transurethral resection technologies and training modalities in the management of nonmuscle invasive bladder cancer: a comprehensive review

PURPOSE OF REVIEW

Conventional transurethral resection (TURBT) with tumor fragmentation is the primary step in the surgical treatment of nonmuscle invasive bladder cancer. Recently, new surgical techniques and training modalities have emerged with the aim to overcome short-comings of TURBT and improve oncologic outcomes. In this review, we provide a comprehensive update of recent techniques/techniques that aim to improve upon conventional TURBT and beyond.

RECENT FINDINGS

A systemic approach during conventional TURBT that features the use of a surgical checklist has been shown to improve recurrence-free survival. Several simulators have been developed and validated to provide additional training opportunities. However, transfer of improved simulator performance into real world surgery still requires validation. While there is no convincing data that demonstrate superior outcomes with bipolar TURBT, en-bloc resection already promises to offer lower rates of complications as well as potentially lower recurrence probabilities in select patients.

SUMMARY

TURBT remains the quintessential procedure for the diagnosis and treatment of bladder cancer. Urologists need to be aware of the importance and challenges of this procedure. Aside of embracing new resection techniques and a conceptual-systematic approach, training opportunities should be expanded upon to improve patient outcomes.

Risk factors for residual disease at re-TUR in a large cohort of T1G3 patients

INTRODUCTION AND OBJECTIVES

The goals of transurethral resection of a bladder tumor (TUR) are to completely resect the lesions and to make a correct diagnosis in order to adequately stage the patient. It is well known that the presence of detrusor muscle in the specimen is a prerequisite to minimize the risk of under staging. Persistent disease after resection of bladder tumors is not uncommon and is the reason why the European Guidelines recommended a re-TUR for all T1 tumors. It was recently published that when there is muscle in the specimen, re-TUR does not influence progression or cancer specific survival. We present here the patient and tumor factors that may influence the presence of residual disease at re-TUR.

MATERIAL AND METHODS

In our retrospective cohort of 2451 primary T1G3 patients initially treated with BCG, pathology results for 934 patients (38.1%) who underwent re-TUR are available. 74% had multifocal tumors, 20% of tumors were more than 3 cm in diameter and 26% had concomitant CIS. In this subgroup of patients who underwent re-TUR, there was no residual disease in 267 patients (29%) and residual disease in 667 patients (71%): Ta in 378 (40%) and T1 in 289 (31%) patients. Age, gender, tumor status (primary/recurrent), previous intravesical therapy, tumor size, tumor multi-focality, presence of concomitant CIS, and muscle in the specimen were analyzed in order to evaluate risk factors of residual disease at re-TUR, both in univariate analyses and multivariate logistic regressions.

RESULTS

The following were not risk factors for residual disease: age, gender, tumor status and previous intravesical chemotherapy. The following were univariate risk factors for presence of residual disease: no muscle in TUR, multiple tumors, tumors > 3 cm, and presence of concomitant CIS. Due to the correlation between tumor multi-focality and tumor size, the multivariate model retained either the number of tumors or the tumor diameter (but not both), p < 0.001. The presence of muscle in the specimen was no longer significant, while the presence of CIS only remained significant in the model with tumor size, p < 0.001.

CONCLUSIONS

The most significant factors for a higher risk of residual disease at re-TUR in T1G3 patients are multifocal tumors and tumors more than 3 cm. Patients with concomitant CIS and those without muscle in the specimen also have a higher risk of residual disease.

Risk factors for residual disease at re-TUR in a large cohort of T1G3 patients

INTRODUCTION AND OBJECTIVES

The goals of transurethral resection of a bladder tumor (TUR) are to completely resect the lesions and to make a correct diagnosis in order to adequately stage the patient. It is well known that the presence of detrusor muscle in the specimen is a prerequisite to minimize the risk of under staging. Persistent disease after resection of bladder tumors is not uncommon and is the reason why the European Guidelines recommended a re-TUR for all T1 tumors. It was recently published that when there is muscle in the specimen, re-TUR does not influence progression or cancer specific survival. We present here the patient and tumor factors that may influence the presence of residual disease at re-TUR.

MATERIAL AND METHODS

In our retrospective cohort of 2451 primary T1G3 patients initially treated with BCG, pathology results for 934 patients (38.1%) who underwent re-TUR are available. 74% had multifocal tumors, 20% of tumors were more than 3 cm in diameter and 26% had concomitant CIS. In this subgroup of patients who underwent re-TUR, there was no residual disease in 267 patients (29%) and residual disease in 667 patients (71%): Ta in 378 (40%) and T1 in 289 (31%) patients. Age, gender, tumor status (primary/recurrent), previous intravesical therapy, tumor size, tumor multi-focality, presence of concomitant CIS, and muscle in the specimen were analyzed in order to evaluate risk factors of residual disease at re-TUR, both in univariate analyses and multivariate logistic regressions.

RESULTS

The following were not risk factors for residual disease: age, gender, tumor status and previous intravesical chemotherapy. The following were univariate risk factors for presence of residual disease: no muscle in TUR, multiple tumors, tumors > 3 cm, and presence of concomitant CIS. Due to the correlation between tumor multi-focality and tumor size, the multivariate model retained either the number of tumors or the tumor diameter (but not both), p < 0.001. The presence of muscle in the specimen was no longer significant, while the presence of CIS only remained significant in the model with tumor size, p < 0.001.

CONCLUSIONS

The most significant factors for a higher risk of residual disease at re-TUR in T1G3 patients are multifocal tumors and tumors more than 3 cm. Patients with concomitant CIS and those without muscle in the specimen also have a higher risk of residual disease.

The sustaining of fluorescence in photodynamic diagnosis after the administration of 5-aminolevulinic acid in carcinogen-induced bladder cancer orthotopic rat model and urothelial cancer cell lines

BACKGROUND

The administration of 5-aminolevulic acid hydrochloride (5-ALA·HCl) 3 h (range: 2-4 h) before photodynamic diagnosis (PDD) is recommended for detecting bladder tumors. However, there is insufficient evidence on the time duration for the fluorescence of PDD after oral administration of 5-ALA. We investigated the sustainability of the photodynamic effect and protoporphyrinⅨ (PpⅨ) after 5-ALA administration in a carcinogen-induced bladder tumor rat model and bladder cancer cell lines.

METHODS

The carcinogen-induced bladder tumor orthotopic rat model was established by the administration of N-butyl-N-(4-hydroxybutyl) nitrosamine.

RESULTS

Red fluorescence was visible 2-8 h after the oral administration of 5-ALA in the carcinogen-induced bladder tumor rat model. Plasma and intratissue PpⅨ (nM) progressed to a higher level at 2 h and remained almost constant 2-8 h after oral administration of 5-ALA. The peak fluorescence intensity of PpⅨ was observed 3-4 h after the administration of 5-ALA in bladder cancer cell lines. The accumulated PpⅨ remained for 4 h after the removal of 5-ALA in UMUC3 cells. It was not clearly visible 3 h after the removal of 5-ALA in MGHU3 and T24 cells. The expression level of ferrochelatase was significantly lower in UMUC3 cells than in other cells. Our findings suggest that 5-ALA-assisted PDD (ALA-PDD) can aid in detecting non-muscle-invasive bladder cancer 2-8 h after 5-ALA administration.

CONCLUSION

Urologists might not be required to make excess effort to start ALA-PDD-assisted transurethral resection of bladder tumor after the administration of 5-ALA.

The Management of Newly-Diagnosed Non-muscle Invasive Bladder Cancer in Veterans Integrated Services Network 02 of the Veterans Health Administration

INTRODUCTION

Over 1,500 bladder cancers were diagnosed among US Veterans in 2010, the majority of which were non-muscle invasive bladder cancer (NMIBC). Little is known about NMIBC treatment within the Veterans Health Administration. The objective of the study was to assess the quality of care for Veterans with newly-diagnosed NMIBC within Veterans Integrated Service Network (VISN) 02.

MATERIALS AND METHODS

We used ICD-9 and ICD-10 codes to identify patients with newly-diagnosed bladder cancer from 1/2016-8/2017. We risk-stratified the patients into low, intermediate, and high-risk based on the 2016 American Urological Association Guidelines on NMIBC. Our primary objectives were percentages of transurethral resection of bladder tumors (TURBTs) with detrusor, repeat TURBT in high-risk and T1 disease, high-risk NMIBC treated with induction intravesical therapy (IVT), and responders treated with maintenance IVT. We performed logistic regression for association between distance to diagnosing hospital and receipt of induction IVT in high-risk patients.

RESULTS

There were 121 newly-diagnosed NMIBC patients; 16% low-risk, 28% intermediate-risk, and 56% high-risk. Detrusor was present in 80% of all initial TURBTs and 84% of high-risk patients. Repeat TURBT was performed in 56% of high-risk NMIBC and 60% of T1. Induction IVT was given to 66% of high-risk patients and maintenance IVT was given to 59% of responders. On multivariate logistic regression, distance to medical center was not associated with receipt of induction IVT (OR = 0.99, 95% CI [0.97,1.01], p = 0.52).

CONCLUSIONS

We observed high rates of sampling of detrusor in the first TURBT specimen, utilization of repeat TURBT, and administration of induction and maintenance intravesical BCG for high-risk patients among a regional cohort of US Veterans with NMIBC. While not a comparative study, our findings suggest high quality NMIBC care in VA VISN 02.

Long-term Follow-up After En Bloc Transurethral Resection of Non-muscle-invasive Bladder Cancer: Results from a Single-center Experience

BACKGROUND

En bloc resection (ERBT) is a valid alternative to piecemeal resection for non-muscle-invasive bladder cancer (NMIBC), guaranteeing pathological outcomes. However, very few studies investigated long-term oncological outcomes of ERBT.

OBJECTIVE

To report long-term oncological outcome of ERBT.

DESIGN SETTING AND PARTICIPANTS

This is a retrospective analysis of prospectively collected data. We included patients who underwent ERBT from June 2010 to February 2014, and were diagnosed with NMIBC at pathology evaluation.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary study endpoint was recurrence-free survival at 5 yr. Secondary outcomes were presence of detrusor muscle, recurrence rate at the first follow-up cystoscopy, progression to muscle-invasive bladder cancer (MIBC) at 5 yr, and factors associated with long-term oncological outcomes. Kaplan-Meier curves were used to describe recurrence-free survival time. A univariate analysis was used to investigate factors associated with recurrence.

RESULTS AND LIMITATIONS

Overall, 74 patients were included in this study. The median age was 71 (66-76) yr. Most of the patients presented with only one bladder tumor, and the median tumor diameter was 2 (interquartile range [IQR] 1-2.5) cm. After histopathological examination, eight, 35, and 31 patients were diagnosed with low-, intermediate-, and high-risk disease, respectively. All the en bloc resected tumors showed the presence of detrusor muscle. The median follow-up was 72 (IQR 66-90) mo. The recurrence rate at the first follow-up cystoscopy was 5.4% (four out of 74 patients). Overall, 57 (77%) patients were free of recurrence at 5 yr. No progression to MIBC was observed: progression-free survival was 100%. Limitations include retrospective design and small size.

CONCLUSIONS

Our findings showed that ERBT for NMIBC presents an optimal long-term oncological outcome. Further studies with larger cohorts are necessary for confirming our preliminary results and for a direct comparison with the traditional piecemeal resection.

PATIENT SUMMARY

In case of superficial bladder tumors, transurethral resection of the entire tumor and its base in one piece seems to provide good long-term results in terms of recurrence and progression rates.

The validity, reliability, and reviewer acceptance of VI-RADS in assessing muscle invasion by bladder cancer: a multicenter prospective study

OBJECTIVE

To assess diagnostic validity and reliability of VI-RADS in predicting muscle invasion by bladder cancer (BCa) and evaluate reviewer acceptance of VI-RADS for clinical routine.

METHODS

A prospective multicenter study enrolled 331 patients with suspected/untreated BCa who underwent preoperative multiparametric MRI examination (mp-MRI) of the urinary bladder. Four experienced radiologists independently evaluated all mp-MRI using VI-RADS. The diagnostic validity of VI-RADS for predicting muscle invasion by BCa was calculated using histopathology of the first transurethral resection bladder tumor (TURBT) and second TURBT as the reference standards. The kappa statistics (κ) were applied to assess the interreader agreement (IRA). Reviewer acceptance was evaluated with questionnaires.

RESULTS

The risk of muscle invasion in VI-RADS 2, 3, 4, and 5 after the first and second TURBT was 21.8%, 45.8%, 69.6%, and 96.4% and 24.4%, 58.3%, 87%, and 99.2%, respectively. The overall diagnostic validity of VI-RADS was high. The optimal cut-off value for predicting muscle invasion after first TURBT was > VI-RADS 3 (sensitivity = 84.1% and specificity = 92.3%), and after second TURBT was > VI-RADS 2 (sensitivity = 89.9% and specificity = 90.1%). VI-RADS categorization showed a very good IRA (κ = 0.93). Reviewers fully agreed with the statement, "The application of structured reporting of bladder tumor should be encouraged" (score = 20).

CONCLUSIONS

VI-RADS showed high diagnostic validity and reliability for predicting muscle invasion by BCa, especially VI-RADS 4 and 5. However, VI-RADS 2 and 3 require further modifications to enhance their diagnostic validity. VI-RADS is highly encouraged to be used in daily practice.

KEY POINTS

• VI-RADS showed high diagnostic validity and reliability in predicting BCa muscle invasion, especially VI-RADS 4 and 5. • In VI-RADS 2 and 3, we observed a notable percentage of BCa with muscle invasion and this would require further modifications to enhance the diagnostic validity for these scores. • Overall VI-RADS is well-accepted by radiologists who recommend it for daily practice.

Deciding When to Omit Repeat Transurethral Resection of Superficial Bladder Cancer: Do Photodynamic Diagnostics help?

BACKGROUND: Repeat transurethral resection of bladder tumor is recommended when certain risk constellations are present on initial resection. Current evidence is conflicting, leading to dissenting recommendations in multinational guidelines around the world. Photodynamic diagnostics (PDD) is a tool which has been shown to increase diagnostic accuracy, but evidence is still lacking if this may permit omission of repeat resections in certain cases. OBJECTIVE: To evaluate whether the use of photodynamic diagnostics has an impact on resection quality and residual tumor rate, and to explore which parameters may have an impact on the necessity of repeat transurethral resections. METHODS: We retrospectively evaluated 373 patients in the timeframe of ten years, in whom a repeat transurethral resection of bladder tumor has been performed following initial resection at our department. About half of those resections were performed using photodynamic diagnostics. RESULTS: When PDD was used, more tumor mass was revealed and resected, but the shown trend toward a lower residual tumor rate was non-significant. Muscularis was shown more often on PDD resections. While being a rare occurrence, upstaging on repeat resection happened significantly less often after initial PDD use. Furthermore, tumor size and multifocality significantly influenced residual tumor rate in Ta high-grade stage. CONCLUSIONS: PDD use may lead to a more accurate initial staging but this may not have an impact on short-term residual tumor rate. Tumor size and multifocality should be granted more weight in the decision-making process as when to perform a repeat resection.

Transurethral needle electrode resection and transurethral holmium laser resection of bladder cancer

Purpose

The aim of the present study was to explore the efficacy and safety of transurethral needle electrode resection and transurethral holmium laser resection of non-muscular invasive bladder cancer (NMIBC).

Patients and methods

In this prospective, case-control study, patients from the Urinary Surgery or Oncology Department who met the inclusion and exclusion criteria received transurethral needle electrode resection (n = 52) or transurethral holmium laser resection (n = 51).

Results

A total of 103 patients with NMIBC were included in the present study, with 68 males and 35 females. Their mean age was 57.3 years. Sixty-two patients had Ta, 15 patients had T1, and 26 patients had Tis. Operative time, intraoperative blood loss, postoperative gross hematuria time, bladder irrigation time, and postoperative hospitalization time were all significantly lower in the transurethral holmium laser resection group than the transurethral needle electrode resection group. After resection, transurethral holmium laser resection significantly decreased the value of HGF, TSH, and TNF-α versus the transurethral needle electrode resection group. The incidence of obturator reflex was significantly lower in the transurethral holmium laser resection group than the transurethral needle electrode resection group. There was no significant difference in disease-free survival rate and progression-free survival rate between the two groups.

Conclusions

Transurethral holmium laser resection has clinical advantages in the treatment of NMIBC.

Vesical Imaging-Reporting and Data System for Multiparametric MRI to Predict the Presence of Muscle Invasion for Bladder Cancer

BACKGROUND

The Vesical Imaging-Reporting and Data System (VI-RADS) is a newly developed system of bladder cancer staging with multiparametric MRI (mpMRI), which can be used to predict the presence of muscle invasion for bladder cancer.

PURPOSE

To evaluate the accuracy of three mpMRI series (T₂ WI, diffusion-weighted imaging [DWI], and dynamic contrast-enhanced image [DCEI]) and VI-RADS for diagnosing the muscle invasive bladder cancer (MIBC).

STUDY TYPE

Retrospective.

POPULATION

In all, 66 pathologically proven bladder cancers in 32 patients.

FIELD STRENGTH/SEQUENCE

Before the diagnostic MRI with an intramuscular antispasmodic agent, optimal bladder distension was confirmed. 3.0T MRI with T₂ WI, DWI, and DCEI.

ASSESSMENT

Three reviewers independently assessed and scored the bladder cancers in T₂ WI, DWI, and DCEI using a five-point score system. Based on the scores in the three sequences, reviewers scored each bladder cancer with reference to VI-RADS categories. We evaluated the diagnostic performance of each of three mpMRI sequences and the final VI-RADS categorization for diagnosing MIBC.

STATISTICAL TESTS

Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the area under the curve (AUC) of each of three sequences separately and VI-RADS categorization for diagnosing the MIBC.

RESULTS

The diagnostic performances of each of the three mpMRI series and VI-RADS for diagnosing MIBC were excellent. Especially using the optimal cutoff score >3 for predicting MIBC on DWI, DCEI, and VI-RADS, the sensitivity, specificity, PPV, NPV, and AUC values were 90% (95% confidence interval [CI]: 0.56, 1.00), 100% (95% CI: 0.94, 1.00), 100% (95% CI: 0.66. 1.00), 98.3% (95% CI: 0.91, 1.00), and 0.95, respectively. DATA CONCLUSION: mpMRI based on VI-RADS can stratify patients with bladder cancer according to the presence of muscle invasion.

LEVEL OF EVIDENCE

3.

TECHNICAL EFFICACY STAGE

2. J. Magn. Reson. Imaging 2020;52:1249-1256.

Red cell distribution width predicts time to recurrence in patients with primary non-muscle-invasive bladder cancer and improves the accuracy of the EORTC scoring system

PURPOSE

To investigate the clinical prognostic value of red cell distribution width (RDW) in patients with non-muscle-invasive bladder cancer (NMIBC).

MATERIALS AND METHODS

We retrospectively evaluated 582 consecutive patients with primary NMIBC. The efficacy of preoperative RDW at predicting treatment outcome was assessed. A cut-off point for predicting recurrence was also identified. Uni- and multivariable analyses of time to recurrence (TTR) and progression were conducted. Harrell's concordance index (c-index) was used to evaluate the additive value of RDW to the European Organization of Research and Treatment of Cancer (EORTC) risk scoring model for recurrence.

RESULTS

According to the receiver operating characteristic curve of RDW for recurrence, a RDW ≥ 14.5% was classified as high. In the multivariable analysis, a high RDW could independently predict shorter TTR (subdistribution hazard ratio [SHR]: 2.65, 95% confidence interval [CI]: 1.83-3.84, P < 0.001), irrespective of tumor characteristics. No significant relationship was observed between RDW and time to progression (SHR: 1.75, 95% CI: 0.76-4.08, P = 0.19). Adding binary-coded RDW to the EORTC risk scoring model significantly improved its discriminatory performance in assessing recurrence risk (c-index: 0.62, improvement: 0.052, P < 0.001). High RDW was associated with shorter TTR in patients treated with bacillus Calmette-Guerin in the multivariable analysis (SHR: 2.0, 95% CI: 1.01-3.98, P = 0.047).

CONCLUSIONS

RDW was an independent, significant prognostic factor of TTR in patients with primary NMIBC. Adding RDW to the EORTC risk model significantly improved the model's predictability for tumor recurrence.

How well do we manage non-muscle invasive bladder tumors? A UK audit of real-life practices

OBJECTIVE

The aim of this study was to assess the quality of TURBT (transurethral resection of bladder tumor) using surrogate parameters and evaluate adherence to the guidelines regarding the management of bladder tumors.

MATERIALS AND METHODS

A clinical audit of all new diagnosis of bladder cancer was undertaken from January 2016 to January 2017. A total of 101 new bladder cancer cases were included. Surrogates of TURBT quality including presence of detrusor in the specimen, rate of re-TUR, presence of carcinoma in situ, and 3-month recurrence rates were analyzed. Adherence to guidelines regarding management of non-muscle invasive bladder cancer including time to re-TUR and utilization of single instillation chemotherapy was evaluated.

RESULTS

Absence of detrusor muscle in the specimen of the initial TURBT was noted in 22.8% of the cases. The chance of including muscle in the specimen was almost four-fold for tumors larger than 3 cm. A single instillation of intravesical chemotherapy following TURBT was administered in only 40% of eligible patients; 54.3% of patients had a re-TUR, the majority (61.3%) for high-grade non-muscle invasive bladder cancer on initial TURBT. Re-TUR was done on average 10 weeks after initial TURBT. The 3-month recurrence rate was 36.0% with larger tumors (>3 cm) being more prone to early recurrences. Early recurrences were not affected by intravesical instillations with bacillus Calmette-Guérin or mitomycin C although there was a positive association between the presence of carcinoma in situ on initial resection and early recurrences.

DISCUSSION AND CONCLUSION

One in two patients will have a re-TUR, and approximately one in two patients will have tumor on re-TUR. Single immediate chemotherapy instillations after TURBT are underutilized. The presence of carcinoma in situ on initial TURBT and tumor size were predictors of early recurrences.

[Interest of reTURB for pTa high grade bladder urothelial carcinoma]

INTRODUCTION

Second look TURB (Transurethral Resection of Bladder Tumor) is recommended for high-risk pT1 tumors. It is well acquired for tumors classified pT1 high grade but its interest is still discussed for high-grade pTa tumors in the absence of high level of evidence. We evaluated the impact of second-look resection for the high-grade pTa bladder tumor.

METHODS

We performed a retrospective study in 2 centers from 2007 to 2016. We included all urothelial tumors classified pTa high grade. We studied the anatomopathological findings of reTURB and its consequences on survival without recurrence and progression.

RESULTS

Eighty-four patients were included. Thirty-five patients (41.7%) had reTURB and residual tumor was found in 42.9% of cases. The anatomopathology of reTURB was in 20% of cases high grade pTa, in 14.3% of cases pTis, and in 8.6% of cases pT1. Forty-three patients had recurrence, 13 reTURB patients (30.2%). In the patients who had a reTURB, 12 had recurrence (34.3%) against 31 without reTURB, (63.3%). After the first TURB, 45 patients (53.6%) had bladder instillation: 38 received BCG (45.2%) and 7 ametycin (8.3%). The main factor decreasing recurrence was BCG adjuvant therapy (HR=0.4 [0.2-0.9], P=0.02). The absence of reRTUV appeared to be a recurrence factor, but the result was not statistically significant (HR=1.4 [0.7-3], P=0.3).

CONCLUSION

reTURB confirms that residual tumor is often found. His interest in survival without recurrence remains to be proved by a prospective study with a larger number of patients.

LEVEL OF EVIDENCE

3.

Factors affecting guideline adherence in the initial treatment of non-muscle invasive bladder cancer: Retrospective study in a French peripheral hospital

OBJECTIVES

To assess whether the initial treatment of non-muscle invasive bladder cancer (NMIBC) was performed according to the guidelines, and to determine the reasons why initial treatment was not provided in nonadherence cases.

MATERIALS AND METHODS

We retrospectively reviewed all patients with NMIBC who underwent their first transurethral resection of bladder tumor (TURBT) at a peripheral hospital, between 2007 and 2016. The treatment offered to the patient was compared to the European Association of Urology guidelines according to risk stratification. For each patient who did not receive the treatment according to the guidelines, one of the following reasons was identified: poor patient compliance, poor patient general health status, urologist's decision, lack of resources.

RESULTS

One hundred fifty-nine patients were included with a mean age of 72.2 years at the time of NMIBC diagnosis. The low-risk patients were strictly treated according to the guidelines. Among the intermediate-risk patients, 14% received mitomycin C. Among the high-risk patients, 39% received intravesical Bacillus Calmette-Guerin. In the nonadherence cases (61%), the reasons were related to the patient in 44% of cases (poor compliance, 21%; poor patient general health status, 23%), urologist's decision in 54% of cases, and lack of resources in 2% of cases. Thirty-seven percent of the high-risk patients underwent re-resection.

CONCLUSIONS

Overall, adherence to NMIBC guidelines was low in all treatment types (intravesical therapy, re-resection, or cystectomy for very high-risk patients), but this finding was similar to that in previous studies. Reasons were mainly related to the urologist's decision or to the patient condition (poor compliance or poor general health status).

LEVEL OF EVIDENCE

3.

The prognostic value of routine second transurethral resection in patients with newly diagnosed stage pT1 non-muscle-invasive bladder cancer: results from randomized 10-year extension trial

PURPOSE

To evaluate the impact of routine second TUR on the long-term outcome of patients with newly diagnosed stage pT1 non-muscle-invasive bladder cancer (NMIBC) MATERIAL AND METHODS: A total of 210 patients (mean age 62.1 years, 89.5% were males) with stage pT1 NMIBC who underwent first TUR were prospectively randomized into two groups including second TUR (n = 105) and no second TUR (n = 105) groups. Data on recurrence, disease progression, 7-year and 10-year recurrence-free survival (RFS), progression-free survival (PFS) and overall survival (OS) were recorded.

RESULTS

The median follow-up time was 119 months (IQR 65-168). Per-protocol (PP) analysis revealed that compared to patients without second TUR, patients with second TUR had significantly higher 5-year, 7-year and 10-year rates for RFS (59.4%, 57.9% and 54.8% vs. 36.3%, 31.7% and 26.8%, respectively, p < 0.001) and PFS (93.3%, 91.9% and 90.4% vs. 74.0%, 71.4% and 68.5%, respectively, p < 0.001). According to PP and intention-to-treat (ITT) analyses, the 10-year OS rate was significantly higher in patients with second TUR (59.1 vs. 40.8%, p = 0.004). Multivariate analysis revealed that undergoing second TUR (OR 1.661, 95% CI 1.156-2.385, p = 0.006) was an independent determinant of prolonged OS.

CONCLUSIONS

In conclusion, these findings indicate the prognostic value of second TUR in stage pT1 NMIBC patients, not only for RFS and PFS advantages but also for the long-term OS advantage. Therefore, second TUR should be routinely performed in all stage pT1 NMIBC patients with life expectancy of at least 10 years, given the positive contribution to all oncological outcomes.

Effectiveness of Intravesical Doxorubicin Immediately Following Resection of Primary Non-muscle-invasive Bladder Cancer: A Propensity Score-matched Analysis

BACKGROUND

The purpose of this study was to investigate whether adding single immediate postoperative intravesical instillation of doxorubicin (SID) to transurethral resection of bladder tumor (TURBT) significantly reduced the risk of recurrence in patients with non-muscle-invasive bladder cancer (NMIBC).

MATERIALS AND METHODS

We retrospectively analyzed the records of 720 patients diagnosed with primary NMIBC between 2002 through 2018 at the Kameda Medical Center. The primary outcome measure was time to recurrence. Time to progression was also compared. The cohort of SID and the cohort of TURBT alone were matched one-to-one by propensity scores. Matching was done by patient age, gender, and factors of the European Organization of Research and Treatment of Cancer recurrence risk table. The associations of adding SID and clinical outcomes were assessed with uni- and multivariate competing-risk regression models.

RESULTS

After matching, a total of 364 patients, including 182 receiving SID and 182 receiving TURBT alone, were analyzed. No statistically significant differences existed among the measured baseline characteristics in propensity score-matched cohorts. In the multivariate analysis, there was a significantly longer time to recurrence in patients receiving SID (subdistribution hazard ratio, 0.68; 95% confidence interval, 0.49-0.95; P = .024) in propensity score-matched cohorts. There was no significant difference in time to progression (subdistribution hazard ratio, 0.61; 95% confidence interval, 0.11-3.49; P = .58) in univariate analysis.

CONCLUSIONS

Our results demonstrated that SID significantly reduced the recurrence risk of primary NMIBC. Doxorubicin could be an inexpensive alternative to other evidenced-based chemotherapeutic agents for single immediate intravesical chemotherapy.

Management and outcome of TaG3 tumours of the urinary bladder in the nationwide, population-based bladder cancer database Sweden (BladderBaSe)

Purpose: To investigate the management of TaG3 tumours of the urinary bladder using nationwide population-based data in relation to the prevailing guidelines, patients' characteristics, and outcome.Materials and methods: The Bladder Cancer Data Base Sweden (BladderBaSe), including data from the Swedish National Register for Urinary Bladder Cancer (SNRUBC), was used to study all patients with TaG3 bladder cancer diagnosed from 2008 to 2014. Patients were divided into the following management groups: (1) transurethral resection (TUR) only, (2) TUR and intravesical instillation therapy (IVIT), (3) TUR and second-look resection (SLR), and (4) TUR with both SLR and IVIT. Patient and tumour characteristics and outcome were studied.Results: There were 831 patients (83% males) with a median age of 74 years. SLR was performed more often on younger patients, on men, and less often in the Western and Uppsala/Örebro Healthcare regions. IVIT was performed more often with younger patients, with men, in the Western Healthcare region, and less often in the Uppsala/Örebro Healthcare region. Death from bladder cancer occurred in 6% of cases within a median of 29 months (0-84 months) and was lower in the TUR/IVIT and TUR/SLR/IVIT groups compared to the other two groups.Conclusion: In the present study, there was, according to the prevailing treatment guidelines, an under-treatment with SLR for older patients, women, and in some healthcare regions and, similarly, there was an under-treatment with IVIT for older patients. Cancer-specific survival and relative survival were lower in the TUR only group compared to the TUR/IVIT and TUR/SLR/IVIT groups.

En bloc re-resection of high-risk NMIBC after en bloc resection: results of a multicenter observational study

PURPOSE

To investigate the role of en bloc re-resection (EBRS) in patients who had undergone previous en bloc resection for high-risk non-muscle-invasive bladder cancer (NMIBC).

METHODS

An international, multicenter, observational retrospective analysis of prospectively collected data. Patients with a high-risk NMIBC who had previously undergone en bloc resection were scheduled for EBRS of the resected area after 40 days. The primary outcome was the presence of residual tumor or recurrence-free survival.

RESULTS

Overall, 78 patients underwent EBRS. Only five (6.41%) residual cancers were found: one patient had a pTa G3 (1.28%) cancer and four (5.13%) had a pTis. The detrusor muscle was preserved in all samples. Only one patient had a positive margin on EBRS. No procedure called for a conversion to traditional re-TURBT. No patient experienced bladder perforation or other intra-operative complications. The recurrence rate at the first follow-up cystoscopy (RRFF-C at 3 months) was 3.85% (three patients). The median follow-up period was 30.8 months (range 6.9-76.0 months). In univariate analysis, the only predictor of recurrence was grade. Overall we observed 11 recurrences. Only one tumor progressed to T2 MIBC.

CONCLUSIONS

The low rates of residual tumor, recurrence, and progression seem to raise doubts about the efficacy of EBRS in patients who have previously undergone en bloc resection. EBRS appears to be a feasible and safe procedure with a low rate of complications. However, further data will be needed before EBRS can be used in clinical trials or recommended as a treatment modality.

Three-dimensional histopathological reconstruction of bladder tumours

BACKGROUND

Histopathological analysis is the cornerstone in bladder cancer (BCa) diagnosis. These analysis suffer from a moderate observer agreement in the staging of bladder cancer. Three-dimensional reconstructions have the potential to support the pathologists in visualizing spatial arrangements of structures, which may improve the interpretation of specimen. The aim of this study is to present three-dimensional (3D) reconstructions of histology images.

METHODS

En-bloc specimens of transurethral bladder tumour resections were formalin fixed and paraffin embedded. Specimens were cut into sections of 4 μm and stained with Hematoxylin and Eosin (H&E). With a Phillips IntelliSite UltraFast scanner, glass slides were digitized at 20x magnification. The digital images were aligned by performing rigid and affine image alignment. The tumour and the muscularis propria (MP) were manually delineated to create 3D segmentations. In conjunction with a 3D display, the results were visualized with the Vesalius3D interactive visualization application for a 3D workstation.

RESULTS

En-bloc resection was performed in 21 BCa patients. Per case, 26-30 sections were included for the reconstruction into a 3D volume. Five cases were excluded due to export problems, size of the dataset or condition of the tissue block. Qualitative evaluation suggested an accurate registration for 13 out of 16 cases. The segmentations allowed full 3D visualization and evaluation of the spatial relationship of the BCa tumour and the MP.

CONCLUSION

Digital scanning of en-bloc resected specimens allows a full-fledged 3D reconstruction and analysis and has a potential role to support pathologists in the staging of BCa.

Multiparametric MRI of the bladder: inter-observer agreement and accuracy with the Vesical Imaging-Reporting and Data System (VI-RADS) at a single reference center

OBJECTIVES

To evaluate accuracy and inter-observer variability using Vesical Imaging-Reporting and Data System (VI-RADS) for discrimination between non-muscle invasive bladder cancer (NMIBC) and muscle-invasive bladder cancer (MIBC).

METHODS

Between September 2017 and July 2018, 78 patients referred for suspected bladder cancer underwent multiparametric MRI of the bladder (mpMRI) prior to transurethral resection of bladder tumor (TURBT). All mpMRI were reviewed by two radiologists, who scored each lesion according to VI-RADS. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each VI-RADS cutoff. Receiver operating characteristics curves were used to evaluate the performance of mpMRI. The Ƙ statistics was used to estimate inter-reader agreement.

RESULTS

Seventy-five patients were included in the final analysis, 53 with NMIBC and 22 with MIBC. Sensitivity and specificity were 91% and 89% for reader 1 and 82% and 85% for reader 2 respectively when the cutoff VI-RADS > 2 was used to define MIBC. At the same cutoff, PPV and NPV were 77% and 96% for reader 1 and 69% and 92% for reader 2. When the cutoff VI-RADS > 3 was used, sensitivity and specificity were 82% and 94% for reader 1 and 77% and 89% for reader 2. Corresponding PPV and NPV were 86% and 93% for reader 1 and 74% and 91% for reader 2. Area under curve was 0.926 and 0.873 for reader 1 and 2 respectively. Inter-reader agreement was good for the overall score (Ƙ = 0.731).

CONCLUSIONS

VI-RADS is accurate in differentiating MIBC from NMIBC. Inter-reader agreement is overall good.

KEY POINTS

• Traditionally, the local staging of bladder cancer relies on transurethral resection of bladder tumor. • However, transurethral resection of bladder tumor carries a significant risk of understaging a cancer; therefore, more accurate, faster, and non-invasive staging techniques are needed to improve outcomes. • Multiparametric MRI has proved to be the best imaging modality for local staging; therefore, its use in suitable patients has the potential to expedite radical treatment when necessary and non-invasive diagnosis in patients with poor fitness.

The rational and benefits of the second look transurethral resection of the bladder for T1 high grade bladder cancer

The second look transurethral resection of the bladder (TURB) represents a fundamental step in the treatment of papillary non-muscle invasive bladder cancer (NMIBC); it is therefore recommended by all guidelines. However, not all the literature agrees on its staging value and its ability to improve oncological outcomes of patients. Therefore, the purpose of this review is to evaluate the strengths and weaknesses of second look TURB, trying to depict its evolving role in the management of high grade NMIBC. Using Medline, a non-systematic review was performed including articles between January 2000 and June 2018. English language original articles, reviews and editorials were selected based on their clinical relevance. To date, TURB seems to be largely inadequate in retrieving a correct diagnosis and in removing all tumor tissue. Second look TURB maximizes staging accuracy, allows to clear residual cancer and yields prognostic advantages allowing key information to identify possible candidates for immediate radical cystectomy for very high risk T1HG tumors. Moreover, it seems to have a therapeutic benefit by improving recurrence- and progression-free survivals. However, few recent large studies showed that these advantages seem to be limited to patients without detrusor muscle present at first resection. Similarly, the presence of residual disease and the risk of upstaging are related to the presence of detrusor muscle in specimen. It could well be that in the future the presence of detrusor muscle would be a quality criteria to avoid an unnecessary second look TURB as shown by recent studies using the en-bloc resection technique. Finally, it has to be underlined that this is a surgical procedure not free of risks and complications and with a non-negligible impact on patients’ quality of life, waiting lists and healthcare costs. Therefore, future studies trying to identify the criteria that may better allow which patients to select for a second look TURB while avoiding an unnecessary intervention with possible risks and associated cost are needed to allow a personalized approach to even this one size fits all strategy.

A retrospective comparison of thulium laser en bloc resection of bladder tumor and plasmakinetic transurethral resection of bladder tumor in primary non-muscle invasive bladder cancer

Bladder cancer is currently considered the most common malignancy of the urinary tract. Thulium laser en bloc resection of bladder tumor (TmLRBT) and plasmakinetic transurethral resection of bladder tumor (PK-TURBT) are two alternative common procedures used in our department to manage patients with primary non-muscle invasive bladder cancer (NMIBC) over the past decade. In this work, the safety and efficacy of TmLRBT were retrospectively compared to those of PK-TURBT in patients with primary NMIBC. From January 2013 to December 2015, 256 patients diagnosed with primary NMIBC were selected for this retrospective study. A total of 136 consecutive patients diagnosed with primary NMIBC were enrolled in the TmLRBT group. A similar historical cohort of 120 consecutive patients who underwent PK-TURBT was used to compare the two procedures. Clinical data, including age, gender, tumor characteristics, operation duration, hospitalization, irrigation, catheterization, and intraoperative and postoperative complications, were recorded. There were no significant differences in age, gender, mean tumor size, mean tumor number, tumor location, or risk between the TmLRBT and PK-TURBT groups. The TmLRBT group was associated with a significantly shorter operation duration (25.96 ± 21.19 min vs 37.18 ± 25.77 min, P = 0.018) and a shorter hospitalization time (3.11 ± 1.05 days vs 5.24 ± 2.06 days, P = 0.036). The postoperative irrigation time (6.33 ± 4.05 h vs 14.76 ± 6.28 h, P = 0.027) and catheterization time (2.03 ± 1.61 days vs 4.27 ± 1.17 days, P = 0.035) in the TmLRBT group were lower than those in the PK-TURBT group. No significant differences in fever and rebleeding were found in the TmLRBT and PK-TURBT groups. There were no significant differences in the overall, low-risk, intermediate-risk, and high-risk recurrence-free rates between the two groups (P = 0.43, P = 0.68, P = 0.71, and P = 0.24, respectively). The proportion of bladder detrusor muscle (BDM) identified in pathologic specimens of the TmLRBT group was higher than that in the PK-TURBT group (P = 0.006). TmLRBT may reduce operation duration time, hospitalization time, postoperative irrigation time, and catheterization time. TmLRBT is considered safer and more effective in treating primary NMIBC. Recurrence-free rates did not differ between groups.

Advances in risk stratification of bladder cancer to guide personalized medicine

Bladder cancer is a heterogeneous disease that poses unique challenges to the treating clinician. It can be limited to a relatively indolent papillary tumor with low potential for progression beyond this stage to muscle-invasive disease prone to distant metastasis. The former is best treated as conservatively as possible, whereas the latter requires aggressive surgical intervention with adjuvant therapies in order to provide the best clinical outcomes. Risk stratification traditionally uses clinicopathologic features of the disease to provide prognostic information that assists in choosing the best therapy for each individual patient. For bladder cancer, this informs decisions regarding the type of intravesical therapy that is most appropriate for non-muscle-invasive disease or whether or not to administer neoadjuvant chemotherapy prior to radical cystectomy. More recently, tumor genetic sequencing data have been married to clinical outcomes data to add further sophistication and personalization. In the next generation of risk classification, we are likely to see the inclusion of molecular subtyping with specific treatment considerations based on a tumor’s mutational profile.

Narrow Band Imaging reduces persistence of cancer in patients with pT1 high grade bladder cancer

PURPOSE

To evaluate persistence rate on repeated transurethral resection of the bladder (re-TURB) 6 weeks after the first TURB in patients with pT1HG disease undergoing resection of the margins and bed on Narrow Band Imaging.

MATERIALS AND METHODS

A consecutive series of patients undergoing TURB and a diagnosis of pT1 high grade disease were prospectively enrolled. On initial TURB patients underwent classic white light resection of the tumour followed by narrow band image (NBI) resection of margins and bed. After 6 weeks from the initial TURB, patients underwent a re-TURB under white light. Persistence rates on re-TURB were recorded.

RESULTS

Overall 797 patients underwent TURB, out of them 126 patients with pT1 high grade disease were included in the study. The total number of lesions was 226 meaning 1.79 lesions per patient. On re-TURB 24/126 (19%) of the patients presented residual disease with a total of 28/226 (12%) lesions identified. All these patients presented a pTa residual disease. Out of them 8/21 (38%) presented bladder cancer on the resection bed and 13/21 (62%) presented bladder cancer on margins.

CONCLUSION

Narrow Band Imaging trans-urethral resection of the bladder is an oncological effective procedure in the treatment of pT1HG disease. The procedure has a 19% of persistence rate which is inferior when compared to the available evidence on white light TURB. Further multicenter studies are needed in order to validate our results.

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

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

PATIENT SUMMARY

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