The role of repeat transurethral resection in the management of high-risk superficial transitional cell bladder cancer

The clinical significance of a second transurethral resection for T1 high-grade bladder cancer: Results of a prospective study

Purpose

This study was designed to estimate the value of a second transurethral resection of bladder tumor (TURBT) procedure in patients with initially diagnosed T1 high-grade bladder cancer.

Materials and Methods

Between August 2009 and January 2013, a total of 29 patients with T1 high-grade bladder cancer prospectively underwent a second TURBT procedure. Evaluation included the presence of previously undetected residual tumor, changes to histopathological staging or grading, and tumor location. Recurrence-free and progression-free survival curves were generated to compare the prognosis between the groups with and without residual lesions by use of the Kaplan-Meier method.

Results

Of 29 patients, 22 patients (75.9%) had residual disease after the second TURBT. Staging was as follows: no tumor, 7 (24.1%); Ta, 5 (17.2%); T1, 6 (20.7%); Tis, 6 (20.7%); Ta+Tis, 1 (3.4%); T1+Tis, 1 (3.4%); and ≥T2, 3 (10.3%). The muscle layer was included in the surgical specimen after the initial TURBT in 24 patients (82.7%). In three patients whose cancer was upstaged to pT2 after the second TURBT, the initial surgical specimen contained the muscle layer. In the group with residual lesions, the 3-year recurrence-free survival and 3-year progression-free survival rates were 50% and 66.9%, respectively, whereas these rates were 68.6% and 68.6%, respectively, in the group without residual lesions. This difference was not statistically significant.

Conclusions

Initial TURBT does not seem to be enough to control T1 high-grade bladder cancer. Therefore, a routine second TURBT procedure should be recommended in patients with T1 high-grade bladder cancer to accomplish adequate tumor resection and to identify patients who may need to undergo prompt cystectomy.

Second transurethral resection and prognosis of high-grade non-muscle invasive bladder cancer in patients not receiving bacillus Calmette-Guérin

OBJECTIVE

To define the natural history of T1G3 bladder tumor not receiving intravesical Bacillus Calmette-Guerin (BCG) and assess the diagnostic and therapeutic value of a second transurethral resection (Re-TUR) in these patients.

PATIENTS AND METHODS

Retrospective study on the natural history of 210 patients treated at two institutions for T1G3 bladder carcinoma without associated CIS. In no case was BCG administered; 79 (37.6%) received TUR alone, and 131 (62.4%) Re-TUR 4 to 6 weeks later; 23 (12.4%) underwent cystectomy for tumor progression.

RESULTS

Median follow-up was 55 (78 IQR) months, male/female ratio 8/1, and mean age 70.6+11.8 (range 37-93). 19.5% were free of recurrence at 10 years, and 61.9% free of progression. Independent prognostic factors for progression were solid pattern (HR: 2.71; P=.0004), multiplicity (HR: 2.26; P=.003), and recurrence at 3 months (HR: 3.4; P=.003). Cancer-specific survival was 81.5% at 5 and 69% at 10 years. Independent predictors of survival were: progression during the first year (HR: 17.9; P<.0001), solid pattern (HR: 2.13; P=.02), multiplicity (HR: 2.05; P=.03), and age>65 years (HR: 2.9; P=.03). Re-TUR avoided under-staging (7.4%), detected T1G3 residual disease (10.7%), reduced recurrence rate at 3 months (11.4 to 4.6%; P=.06), and rate of progression on the 1st year (13.9 to 3.8%; P=.0075). However, in these patients the risk remains and no differences were detected in the long term in terms of recurrence (log-rank, P=.14), progression (P=.91), or cancer death (P=.21) in patients treated with Re-TUR.

CONCLUSION

The recurrence in the first 3 months of a T1G3 tumor not receiving BCG is the main risk factor for progression, and progression of this type of tumors within the first year is the main factor of cancer death. The Re-TUR improves both variables but it does not change the long-term prognosis.

Prophylactic effects of Bacille Calmette-Guérin intravesical instillation therapy: time period-related comparison between Japan and Western countries

Guidelines change every few years regarding the prophylactic use of Bacille Calmette-Guérin (BCG) against non-muscle invasive bladder cancer. We performed a retrospective comparison to clarify the differences in BCG efficacy, based on time period, between Japan and Western countries . Published literature on 18 Japanese and 28 Western patient studies were compared to evaluate differences in BCG efficacy. Additionally, Internet searches were performed to obtain comparative Japanese and Western data. BCG efficacy in Japanese literature tended to show decreasing non-recurrence rates by time period. Non-recurrence rates in Western countries increased each year. This discrepancy may stem from a number of factors, including changes in accepted BCG indications, the introduction of restaging transurethral resection (re-TUR), the concept of BCG maintenance, and the evolution of histopathological diagnostic criteria.

Repeated white light transurethral resection of the bladder in nonmuscle-invasive urothelial bladder cancers: systematic review and meta-analysis

BACKGROUND AND PURPOSE

Transurethral resection of the bladder (TURB), the first step in treatment of patients with urothelial bladder cancers, is limited by technicalities, surgeon skill, and random chance. When high-risk superficial diseases are discovered, a repeated TURB is indicated. We reviewed current literature and performed a meta-analysis of the role of repeated TURB in the management of nonmuscle-invasive bladder cancers.

METHODS

PubMed, MEDLINE, ISI Web of Knowledge, EBSCO, EMBASE, and Biomed Central databases were searched for reports in English from 1980 to June 2010. The end point was prevalence of persistent urothelial bladder cancer of any stage and grade at repeated TURB, assessed separately for T(a) and T(1) lesions at TURB. Persistence was presence at repeated TURB of same or lower stage cancer as at TURB; upstaging was presence of higher stage.

RESULTS

There were 2327 original articles and 562 reviews retrieved. Data from 15 studies were pooled and analyzed. Prevalence of T(1) was reported in all and of T(a) in 8. Persistence rate prevalence at repeated TURB was 0.39 (95% confidence interval [CI]=0.26 to 0.54) for T(a) and 0.47 (95% CI=0.41 to 0.53) for T(1). Persistence was 19.4% to 56% and 15.2% to 55%, and upstaging occurred in 0% to 14.3% of T(a) and 0% to 24.4% of T(1) at repeated TURB, respectively.

CONCLUSION

High percentages of persistence and upstaging confirm a repeated TURB is needed in patients with high-risk nonmuscle-invasive bladder cancer. Further investigation is encouraged taking risk stratification into consideration to evaluate the role of repeated TURB in low- and mid- risk diseases.

Evidence-based clinical practice guidelines for bladder cancer (summary - JUA 2009 Edition)

In Japan, until now, the treatment of bladder cancer has been based on guidelines from overseas. The problem with this practice is that the options recommended in overseas guidelines are not necessarily suitable for Japanese clinical practice. A relatively large number of clinical trials have been conducted in Japan in the field of bladder cancer, and the Japanese Urological Association (JUA) considered it appropriate to formulate their own guidelines. These Guidelines present an overview of bladder cancer at each clinical stage, followed by clinical questions that address problems frequently faced in everyday clinical practice. In this English translation of a shortened version of the original Guidelines, we have abridged each overview, summarized each clinical question and its answer, and only included the references we considered of particular importance.

A Randomized Trial of Radical Radiotherapy for the Management of pT1G3 NXM0 Transitional Cell Carcinoma of the Bladder

PURPOSE

We conducted a multicenter randomized trial in the United Kingdom to determine the efficacy of radical radiotherapy in reducing the incidence of progression of pT1G3 transitional cell carcinoma of the bladder to muscle invasive disease and subsequent disease fatality.

MATERIALS AND METHODS

Patients with a new diagnosis of pT1G3 NXM0 transitional cell carcinoma with unifocal disease and no carcinoma in situ (group 1), or with multifocal disease and/or carcinoma in situ (group 2) were eligible for the trial. Patients in group 1 were randomized between observation and radiotherapy to the bladder, and in group 2 between intravesical therapy and radiotherapy.

RESULTS

From September 1991 to February 2003 a total of 210 patients from 37 centers in the United Kingdom were entered into the study. There were 77 patients in group 1 and 133 patients in group 2, and 6 patients were excluded from analysis because they were found to have pT2 disease by the reference pathologist. No evidence of an advantage with radiotherapy was found in terms of progression-free interval (hazard ratio 1.07; 95% CI 0.65, 1.74; p = 0.785), progression-free survival (hazard ratio 1.35; 95% CI 0.92, 1.98; p = 0.133) or overall survival (hazard ratio 1.32; 95% CI 0.86, 2.04; p = 0.193).

CONCLUSIONS

To our knowledge this is the largest randomized trial performed in patients with pT1G3 disease for which 210 patients were recruited during 11 years. There is no evidence that radiotherapy is better than more conservative treatment. The prognosis of this group of patients appears to be poor irrespective of treatment and new treatment strategies need to be investigated.