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Goto Y. Editorial Comment to Recent advancements in the diagnosis and treatment of non-muscle invasive bladder cancer: Evidence update of surgical concept, risk stratification, and BCG-treated disease. Int J Urol 2023; 30:957-958. [PMID: 37608457 DOI: 10.1111/iju.15286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Affiliation(s)
- Yusuke Goto
- Department of Urology, Chiba University Graduate School of Medicine, Chiba, Japan
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Moon YJ, Cho KS, Jeong JY, Chung DY, Kang DH, Jung HD, Lee JY. Effects of intravesical BCG maintenance therapy duration on recurrence rate in high-risk non-muscle invasive bladder cancer (NMIBC): Systematic review and network meta-analysis according to EAU COVID-19 recommendations. PLoS One 2022; 17:e0273733. [PMID: 36074771 PMCID: PMC9455878 DOI: 10.1371/journal.pone.0273733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 08/12/2022] [Indexed: 12/01/2022] Open
Abstract
Purpose During the coronavirus disease 2019 (COVID-19) pandemic, the European Association of Urology (EAU) recommended that courses of intravesical bacillus Calmette-Guérin (BCG) therapy lasting more than 1 year could be safely terminated for patients with high-risk non-muscle-invasive bladder cancer (NMIBC). Thus, we conducted a systematic review and network meta-analysis according to EAU’s COVID-19 recommendations. Materials and methods A systematic review was performed following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. We conducted a network meta-analysis of recurrence rate in patients with NMIBC receiving induction therapy (M0) and those receiving maintenance therapy lasting 1 year (M1) and more than 1 year (M2). Results Nineteen studies of 3,957 patients were included for the network meta-analysis. In a node-split forest plot using Bayesian Markov Chain Monte Carlo (MCMC) modeling, there were no differences between the M1 and M2 groups in recurrence rate [odds ratio (OR) 0.95 (0.73–1.2)]. However, recurrence rate in the M0 group was higher than that in the M1 [OR 1.9 (1.5–2.5)] and M2 [OR 2.0 (1.7–2.4)] groups. P-score tests using frequentist inference to rank the treatments in the network demonstrated that the therapy used in the M2 group (P-score 0.8701) was superior to that used in the M1 (P-score 0.6299) and M0 groups (P-score 0). In rank-probability tests using MCMC modeling, the M2 group showed the highest rank, followed by the M1 and M0 groups. Conclusion In the network meta-analysis, there were no differences between those receiving BCG maintenance therapies in terms of recurrence rate. In the rank tests, therapy lasting more than 1-year appears to be most effective. During the COVID-19 pandemic, 1-year maintenance therapy can be used, but after the COVID-19 pandemic, therapy lasting more than 1-year could be beneficial.
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Affiliation(s)
- Young Joon Moon
- Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kang Su Cho
- Department of Urology, Gangnam Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Yong Jeong
- Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Doo Yong Chung
- Department of Urology, Inha University College of Medicine, Incheon, Korea
| | - Dong Hyuk Kang
- Department of Urology, Inha University College of Medicine, Incheon, Korea
| | - Hae Do Jung
- Department of Urology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Joo Yong Lee
- Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
- Center of Evidence Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Korea
- * E-mail:
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Intravesical Bacillus Calmette-Guerin (BCG) Therapy for Non-muscle Invasive Bladder Cancers: Long-term Results of a Modified Schedule. Indian J Surg Oncol 2021; 12:796-801. [DOI: 10.1007/s13193-021-01439-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 09/01/2021] [Indexed: 11/26/2022] Open
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Thyavihally YB, Dev P, Waigankar S, Pednekar A, Athikari N, Raut A, Khandekar A, Badlani N, Asari A. Intravesical bacillus Calmette-Guerin (BCG) in treating non-muscle invasive bladder cancer—analysis of adverse effects and effectiveness of two strains of BCG (Danish 1331 and Moscow). Asian J Urol 2021; 9:157-164. [PMID: 35509489 PMCID: PMC9051354 DOI: 10.1016/j.ajur.2021.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 10/26/2020] [Accepted: 02/07/2021] [Indexed: 11/17/2022] Open
Abstract
Objective To compare the differences in adverse effects and efficacy profile between bacillus Calmette-Guerin (BCG) Danish 1331 and BCG Moscow-I strain in management of non-muscle invasive bladder cancer. Methods Clinical data of 188 cases of non-muscle invasive bladder cancer treated with BCG between January 2008 and December 2018 in our institute were collected prospectively and analysed retrospectively, and 114 patients who completed a minimum of 12 months of follow-up were analysed. Patient and tumor characteristics, strain of BCG, adverse effects, and tumor progression were included for analysis. Intravesical BCG was instilled in intermediate- and high-risk patients. Six weeks of induction BCG, followed by three weekly maintenance BCG at 3, 6, 12, 18, and 24 months was advised in high-risk patients. Results Overall 68 patients received BCG Danish 1331 strain and 46 patients received Moscow-I strain. Patient and tumor characteristics were well balanced between the two groups. The median follow-up period was 42.5 months and 34.5 months in Danish 1331 and Moscow-I groups, respectively. Adverse events like dropout rate, antitubercular treatment requirement, and need of cystectomy were higher in Moscow-I group (n=31, 67.4%) when compared to Danish 1331 strain (n=33, 48.5%) (p=0.046). On direct comparison between Danish 1331 and Moscow-I strain, there was similar 3-year recurrence-free survival (80.0% vs. 72.9%) and 3-year progression-free survival (96.5% vs. 97.8%). Conclusion Study results suggest no significant differences between Danish 1331 and Moscow-I strain in recurrence-free survival and progression-free survival, but a significantly higher incidence of moderate to severe adverse events in BCG Moscow-I strain.
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Miyamoto T, Miyake M, Toyoshima Y, Fujii T, Shimada K, Nishimura N, Iida K, Nakahama T, Hori S, Gotoh D, Nakai Y, Torimoto K, Tanaka N, Ohbayashi C, Fujimoto K. Clinical outcomes after intravesical bacillus Calmette-Guérin for the highest-risk non-muscle-invasive bladder cancer newly defined in the Japanese Urological Association Guidelines 2019. Int J Urol 2021; 28:720-726. [PMID: 33734503 DOI: 10.1111/iju.14545] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 02/14/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the clinical outcomes of highest-risk non-muscle-invasive bladder cancer patients treated with intravesical bacillus Calmette-Guérin. METHODS The medical charts of patients with non-muscle-invasive bladder cancer treated with intravesical bacillus Calmette-Guérin between 2000 and 2018 at a single institution were retrospectively reviewed. Patients were stratified into three groups (intermediate-, high- and highest-risk groups) according to the risk classification of the updated Japanese Urological Association guidelines 2019. Among the three groups, the intravesical recurrence-free survival and progression-free survival were estimated and compared, respectively. Furthermore, the different types of risk factors in the highest-risk group were analyzed. RESULTS Of the 165 patients, 49 (30%) patients had intravesical recurrence and 23 (14%) patients showed progression to muscle-invasive disease during a median follow-up period of 53 months. Significant differences were not noted in the recurrence-free survival and progression-free survival among the three groups. Multivariable survival analysis of 74 patients in the highest-risk group showed that carcinoma in situ in the prostatic urethra was a significant predictor associated with recurrence (hazard ratio 3.20, P = 0.026) and progression (hazard ratio 4.36, P = 0.013). CONCLUSIONS Intravesical bacillus Calmette-Guérin can control highest-risk non-muscle-invasive bladder cancer in most patients. Our findings might aid in decision-making regarding the treatment of this subset of patients who require intensive treatment, such as intravesical therapy with bacillus Calmette-Guérin and radical cystectomy.
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Affiliation(s)
- Tatsuki Miyamoto
- Departments of, Department of, Urology and, Nara Medical University, Kashihara, Nara, Japan
| | - Makito Miyake
- Departments of, Department of, Urology and, Nara Medical University, Kashihara, Nara, Japan
| | - Yuta Toyoshima
- Departments of, Department of, Urology and, Nara Medical University, Kashihara, Nara, Japan
| | - Tomomi Fujii
- Department of, Diagnostic Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Shimada
- Department of Pathology, Nara City Hospital, Nara, Nara, Japan
| | - Nobutaka Nishimura
- Departments of, Department of, Urology and, Nara Medical University, Kashihara, Nara, Japan
| | - Kota Iida
- Departments of, Department of, Urology and, Nara Medical University, Kashihara, Nara, Japan
| | - Tomonori Nakahama
- Departments of, Department of, Urology and, Nara Medical University, Kashihara, Nara, Japan
| | - Shunta Hori
- Departments of, Department of, Urology and, Nara Medical University, Kashihara, Nara, Japan
| | - Daisuke Gotoh
- Departments of, Department of, Urology and, Nara Medical University, Kashihara, Nara, Japan
| | - Yasushi Nakai
- Departments of, Department of, Urology and, Nara Medical University, Kashihara, Nara, Japan
| | - Kazumasa Torimoto
- Departments of, Department of, Urology and, Nara Medical University, Kashihara, Nara, Japan
| | - Nobumichi Tanaka
- Departments of, Department of, Urology and, Nara Medical University, Kashihara, Nara, Japan
| | - Chiho Ohbayashi
- Department of, Diagnostic Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Kiyohide Fujimoto
- Departments of, Department of, Urology and, Nara Medical University, Kashihara, Nara, Japan
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Xu S, Tan S, Wu T, Gu J, Xu L, Che X. The value of transurethral thulium laser en bloc resection combined with a single immediate postoperative intravesical instillation of pirarubicin in primary non-muscle-invasive bladder cancer. Lasers Med Sci 2020; 35:1695-1701. [PMID: 31970565 DOI: 10.1007/s10103-020-02960-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 01/10/2020] [Indexed: 01/07/2023]
Abstract
The objective of this study was to evaluate which patients might benefit from a single immediate postoperative intravesical instillation (SII) compared to maintenance intravesical instillations (MII) in primary non-muscle-invasive bladder cancer (NMIBC) after transurethral en bloc resection of bladder tumors (ERBT). A total of 141 patients with primary NMIBC who underwent ERBT with thulium laser between January 2012 and May 2016 were retrospectively enrolled. All the patients were categorized into two groups based on the duration of postoperative intravesical instillation of pirarubicin (THP): single intravesical instillation (SII) group, patients received a single immediate postoperative intravesical instillation of THP (30 mg), and maintenance intravesical instillations (MII) group, patients received a 1-year MII of THP (30 mg). Prognosis and recurrence data of each group were analyzed. One hundred and four (73.8%) patients received MII, and other 37 (26.2%) patients received SII. There was no significant difference in recurrence-free survival (RFS) between the two groups (P = 0.105). Following recurrence risk-stratified analysis, patients with high recurrence risk who accepted SII had a significantly lower RFS rate than those who received MII (P = 0.027). However, there were no significant differences in RFS rate between the two groups in patients with low and intermediate recurrence risk. In the multivariate analysis, the number of tumors was found to be an independent prognostic factor for RFS in NMIBC patients [hazard ratio, 5.665; 95% confidence interval (CI), 2.577-12.454; P < 0.001]. SII seems not to be inferior to MII in patients with initial low-risk and intermediate-risk NMIBC after ERBT.
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Affiliation(s)
- Sheng Xu
- Department of Urology, The Second Affiliated Hospital of Hainan Medical University, No. 368, Yehai Road, Longhua District, Haikou, 570311, China
| | - Shaoying Tan
- Department of Nursing, Haikou Fourth People's Hospital, No. 65, Yehai Road, Qiongshan District, Haikou, 571100, China
| | - Tingming Wu
- Department of Urology, The Second Affiliated Hospital of Hainan Medical University, No. 368, Yehai Road, Longhua District, Haikou, 570311, China
| | - Jun Gu
- Department of Urology, The Second Affiliated Hospital of Hainan Medical University, No. 368, Yehai Road, Longhua District, Haikou, 570311, China
| | - Lei Xu
- Department of Urology, The Second Affiliated Hospital of Hainan Medical University, No. 368, Yehai Road, Longhua District, Haikou, 570311, China
| | - Xianping Che
- Department of Urology, The Second Affiliated Hospital of Hainan Medical University, No. 368, Yehai Road, Longhua District, Haikou, 570311, China.
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Hobbs C, Bass E, Crew J, Mostafid H. Intravesical BCG: where do we stand? Past, present and future. JOURNAL OF CLINICAL UROLOGY 2019. [DOI: 10.1177/2051415818817120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
High and intermediate risk non-muscle invasive bladder cancer poses a real challenge for treatment. Approximately 70% of bladder cancer presents as non-muscle invasive and 20–25% will progress to muscle invasive disease. Recurrences occur in up to 70% but treatment options are limited. Intravesical bacillus Calmette–Guérin is still considered the bladder sparing treatment of choice despite its well documented pitfalls. This review considers how bacillus Calmette–Guérin has become the recommended treatment, its benefits and risks and the alternative options for treatment. Level of evidence: Not applicable for this multicentre audit.
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Affiliation(s)
| | - Edward Bass
- Department of Urology, Royal Surrey County NHS Foundation Trust, UK
| | - Jeremy Crew
- Department of Urology, Churchill Hospital, UK
| | - Hugh Mostafid
- Department of Urology, Royal Surrey County NHS Foundation Trust, UK
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Maintenance versus non-maintenance intravesical Bacillus Calmette-Guerin instillation for non-muscle invasive bladder cancer: A systematic review and meta-analysis of randomized clinical trials. Int J Surg 2018; 52:248-257. [PMID: 29499363 DOI: 10.1016/j.ijsu.2018.02.045] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 01/27/2018] [Accepted: 02/22/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND It is not clear whether maintenance Bacillus Calmette-Guerin (BCG) is necessary for intermediate- or high-risk non-muscle-invasive bladder cancer (NMIBC). This systematic review and meta-analysis aimed to illustrate the effects of maintenance BCG for intermediate- or high-risk NMIBC. METHODS A comprehensive literature search of PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov databases and International Clinical Trials Register (ICTRP) Search was conducted to identify relevant randomized controlled trials (RCTs) that have assessed the efficacy of maintenance or non-maintenance BCG therapy for patients with NMIBC. The maintenance group first received induction BCG instillations, and subsequently received BCG intravesical instillations regularly for at least 1 year, while the control group only received induction BCG instillations. Systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis Criteria. RESULTS Ten RCTs were eligible in this systematic review. The meta-analysis showed that induction BCG followed by maintenance BCG instillation after transurethral resection (TUR) could reduce the risk ratios of tumor recurrence by 21% (RR = 0.79; 95% CI 0.70-0.89; P < 0.0001) and prolong recurrence-free survival (RFS) by 33% (HR: 0.67; 95% CI, 0.54-0.82; P < 0.001), compared with non-maintenance BCG. It could also reduce the risk ratios of tumor progression (RR = 0.81; 95% CI 0.68-0.97; P = 0.02). However, these pooled results should be considered with caution since the quality of evidences for outcomes ranged low. Subgroup analysis implied that different durations of maintenance BCG instillations might be one of the sources of potential clinical heterogeneity of included studies. Begg's funnel plot and Egger's test did not reveal any evidence of publication bias in this meta-analysis. CONCLUSIONS Induction BCG followed by maintenance BCG instillation after TUR, compared with induction BCG along, can reduce the risk ratios of tumor recurrence and tumor progression, and prolong RFS. However, these results with a lower level of evidence should be treated with caution. The optimal maintenance schedule has yet to be determined and a large multi-institutional study in intermediate- and high-risk patients is also needed to determine the optimal maintenance schedule.
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Inamoto T, Ibuki N, Komura K, Juri H, Yamamoto K, Yamamoto K, Fujita K, Nonomura N, Narumi Y, Azuma H. Can bladder preservation therapy come to the center stage? Int J Urol 2017; 25:134-140. [PMID: 29171098 DOI: 10.1111/iju.13495] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 10/23/2017] [Indexed: 12/17/2022]
Abstract
Decision-making in urological cancer care requires a multidisciplinary approach for refinement, but its impact on urothelial carcinoma of the bladder has not been fully addressed for the past three decades, except for the latest immunological checkpoint inhibitor approved by the U.S. Food and Drug Administration for metastatic muscle-invasive bladder cancer that is resistant to platinum-based chemotherapy. For the time being, radical cystectomy is the gold standard of curative therapy for muscle-invasive bladder cancer. Trimodal therapy that combines chemotherapy for the purpose of radiation sensitization, external beam radiotherapy and transurethral resection of bladder tumor has emerged as a potential alternative treatment option that preserves the bladder. In lack of randomized studies for bladder preservation therapy compared with surgery, the principles of management of urothelial carcinoma of the bladder have evolved in recent times, with an emphasis on bladder preservation. A number of bladder preservation techniques are available to the surgeon; however, appropriately selected patients with muscle-invasive bladder cancer should be offered the opportunity to discuss various treatment options, including organ-sparing trimodal therapy. The aim of the present study was to compare the primary outcomes of the available treatment methods and identify the sources of variance among studies. A review of various bladder preservation techniques in vogue for the management of urothelial carcinoma of the bladder is discussed.
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Affiliation(s)
- Teruo Inamoto
- Department of Urology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Naokazu Ibuki
- Department of Urology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Kazumasa Komura
- Department of Urology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Hiroshi Juri
- Department of Radiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Kiyohito Yamamoto
- Department of Radiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Kazuhiro Yamamoto
- Department of Radiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | | | - Norio Nonomura
- Department of Urology, Osaka University, Suita, Osaka, Japan
| | - Yoshifumi Narumi
- Department of Radiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Haruhito Azuma
- Department of Urology, Osaka Medical College, Takatsuki, Osaka, Japan
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Quan Y, Jeong CW, Kwak C, Kim HH, Kim HS, Ku JH. Dose, duration and strain of bacillus Calmette-Guerin in the treatment of nonmuscle invasive bladder cancer: Meta-analysis of randomized clinical trials. Medicine (Baltimore) 2017; 96:e8300. [PMID: 29049231 PMCID: PMC5662397 DOI: 10.1097/md.0000000000008300] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Intravesical bacillus Calmette-Guerin (BCG) instillation is widely used as an adjuvant therapy after transurethral resection of bladder tumor (TURBT) in patients with intermediate- and high-risk nonmuscle invasive bladder cancer (NMIBC). However, the effective dose, duration, and strain of BCG have not yet been clearly determined. We aimed to elucidate the relationship between dose, duration, and strain of BCG and clinical outcomes in NMIBC patients treated with TURBT. METHODS We conducted a literature search in Embase, Scopus, and PubMed databases for all relevant articles published up to October 2016 in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. The relative risks of clinical outcomes, including recurrence, progression, cancer-specific mortality, and all-cause mortality according to dose (standard vs low), duration (induction vs maintenance), and strain of BCG were presented as the pooled risk ratio (RR) and 95% confidence interval (CI). RESULTS Nineteen studies meeting the inclusion criteria were finally selected in this meta-analysis. The risk of recurrence was significantly highly observed in case of low-dose BCG (RR, 1.17; 95% CI 1.06-1.30) and induction BCG (RR, 1.33; 95% CI 1.17-1.50) only group without heterogeneity among the included studies. Although there were no significant differences between dose or duration and other clinical outcomes. On direct comparison in each study comparing BCG strains, the Tice stain showed a relatively high probability of recurrence compared with the Connaught (RR, 1.29; 95% CI 1.01-1.64) and RIVM (RR, 2.04, 95% CI 1.28-3.25) strains. Funnel plot testing revealed no significant publication bias. CONCLUSION The use of standard dose and maintenance BCG instillation may be effective to reduce recurrence rate after TURBT for NMIBC. Further large scale, well-designed, and prospective studies, with stratification of the patients into risk group at randomization, will be required to determine the optimal guideline of BCG use to improve clinical outcomes in NMIBC.
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Affiliation(s)
- Yongjun Quan
- Department of Urology, Seoul National University Hospital, Seoul
| | - Chang Wook Jeong
- Department of Urology, Seoul National University Hospital, Seoul
| | - Cheol Kwak
- Department of Urology, Seoul National University Hospital, Seoul
| | - Hyeon Hoe Kim
- Department of Urology, Seoul National University Hospital, Seoul
| | - Hyung Suk Kim
- Department of Urology, Dongguk University Ilsan Medical Center, Goyang, Korea
| | - Ja Hyeon Ku
- Department of Urology, Seoul National University Hospital, Seoul
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