The value of a second transurethral resection for T1 bladder cancer

Oncological and Survival Outcomes of Pelvic Lymph Node Dissection in Patients with Nonmuscle Invasive Bladder Cancer Undergoing Radical Cystectomy Using the National Cancer Database

OBJECTIVE

To evaluate the role of pelvic lymph node dissection (PLND) in patients diagnosed with high-risk nonmuscle-invasive bladder cancer (NMIBC) undergoing radical cystectomy (RC) using a national cohort of NMIBC patients.

METHODS

A cohort of patients diagnosed with NMIBC cancer with urothelial carcinoma from the National Cancer Database (NCDB) between 2004 and 2019 was utilized. The cohort consists of patients who have not received BCG and underwent upfront radical cystectomy or pelvic exenteration. Kaplan-Meier analysis was utilized to assess overall survival (OS) outcomes. Cox regression was also utilized to identify independent predictors of OS.

RESULTS

The cohort of 9399 patients was stratified by clinical T stage and then subdivided by pathological outcome. For patients with cTa, a majority received a lymph node dissection 97.74% (941/1019), amongst the entire cohort, a minority had node positive disease 3.3% (34/1019). For cTis, most patients received a lymph node dissection 94.08% (482/507), and a minority had node positive disease 5.1% (26/507). For cT1, most patients had a lymph node dissection 95.62% (6,060/6,337), and a 13.1% (832/6337) of patients had a positive lymph node. Amongst patients with cT1 disease who underwent PLND, KMA demonstrated better OS compared to patients who did not undergo PLND (P < .001).

CONCLUSION

The data suggests an OS benefit in patients with later stage (cT1) NMIBC. Thus, our findings support the existing clinical guidelines of pelvic lymph node dissection in patients with high-risk nonmuscle invasive bladder cancer.

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.

Artificial Intelligence in the Advanced Diagnosis of Bladder Cancer-Comprehensive Literature Review and Future Advancement

Artificial intelligence is highly regarded as the most promising future technology that will have a great impact on healthcare across all specialties. Its subsets, machine learning, deep learning, and artificial neural networks, are able to automatically learn from massive amounts of data and can improve the prediction algorithms to enhance their performance. This area is still under development, but the latest evidence shows great potential in the diagnosis, prognosis, and treatment of urological diseases, including bladder cancer, which are currently using old prediction tools and historical nomograms. This review focuses on highly significant and comprehensive literature evidence of artificial intelligence in the management of bladder cancer and investigates the near introduction in clinical practice.

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.

Presence and predominance of histological grade 3 define cT1HG bladder cancer prognostic groups

PURPOSE

Current World Health Organization/International Society of Urological Pathology (2004 WHO/ISUP) grading of bladder urothelial carcinoma relies on the highest pathologic grade of the specimen and does not reflect the inherent qualitative and quantitative heterogeneity of disease.

MATERIALS AND METHODS

We retrospectively studied consecutive urothelial high-grade cT1 (cT1HG) carcinomas submitted to adjuvant bacille Calmette-Guérin between 2008 and 2015 to evaluate the prognostic potential of grade 3 (presence or predominance) according to the 1973 WHO system concerning disease progression and cancer-specific death.

RESULTS

Among 253 patients, grading distribution was 34.4% 1+2, 7.5% 2+1, 20.2% 2+2, 19.0% 2+3, 5.1% 3+2, and 13.8% 3+3. Recurrence was diagnosed in 115 (45.5%), progression in 83 (32.8%), and cancer-specific death in 50 patients (19.8%). Mean time to recurrence, progression, and death from disease were 35.9±31.7, 47.6±44.5, and 51.2±50.4 months, respectively. Grade 3 presence (2+3, 3+2, or 3+3) occurred in 96 (37.9%) and independently predicted time to progression (p<0.001; hazard ratio [HR], 3.11; 95% confidence interval [CI], 1.88-5.14). Grade 3 predominance (3+2 or 3+3) occurred in 48 (18.9%) and independently predicted time to disease-specific death.

CONCLUSIONS

Grade 3 presence and predominance are independent predictors of progression and disease-specific death and occur in about 40% and 20% of cT1HG, respectively. Describing qualitative and quantitative heterogeneity in urothelial carcinoma grading might improve the stratification of patients. This gives three prognostic high-grade groups based on WHO/ISUP 1973: prognostic grade group I (grade 3 absence), prognostic grade group II (grade 3 presence), and prognostic grade group III (grade 3 predominance).

Raman Imaging and Fluorescence Lifetime Imaging Microscopy for Diagnosis of Cancer State and Metabolic Monitoring

Hurdles for effective tumor therapy are delayed detection and limited effectiveness of systemic drug therapies by patient-specific multidrug resistance. Non-invasive bioimaging tools such as fluorescence lifetime imaging microscopy (FLIM) and Raman-microspectroscopy have evolved over the last decade, providing the potential to be translated into clinics for early-stage disease detection, in vitro drug screening, and drug efficacy studies in personalized medicine. Accessing tissue- and cell-specific spectral signatures, Raman microspectroscopy has emerged as a diagnostic tool to identify precancerous lesions, cancer stages, or cell malignancy. In vivo Raman measurements have been enabled by recent technological advances in Raman endoscopy and signal-enhancing setups such as coherent anti-stokes Raman spectroscopy or surface-enhanced Raman spectroscopy. FLIM enables in situ investigations of metabolic processes such as glycolysis, oxidative stress, or mitochondrial activity by using the autofluorescence of co-enzymes NADH and FAD, which are associated with intrinsic proteins as a direct measure of tumor metabolism, cell death stages and drug efficacy. The combination of non-invasive and molecular-sensitive in situ techniques and advanced 3D tumor models such as patient-derived organoids or microtumors allows the recapitulation of tumor physiology and metabolism in vitro and facilitates the screening for patient-individualized drug treatment options.

Dysuria therapeutic agents as an independent prognostic factor for the primary recurrence of non-muscle invasive bladder cancer: a propensity score matching study

OBJECTIVE

To investigate if the use of therapeutic agents for dysuria is a risk factor for the primary recurrence of non-muscle invasive bladder cancer (NMIBC).

METHODS

First, patients with NMIBC were divided into two groups: the non-recurrence group and the recurrence group. Patient characteristics were compared between both groups. The risk factors of recurrence that were statistically different between the two groups were identified by multivariate analysis. Second, we divided the patients into risk and non-risk groups, and differences in the recurrence-free survival (RFS) between the two groups were analyzed before and after propensity score matching (PSM).

RESULTS

A total of 162 patients were included, with 84 patients in the non-recurrence group and 78 patients in the recurrence group. In the multivariate analysis, the intake of dysuria agents and bacillus Calmette-Guérin (BCG) therapy were independent factors. The RFS results in terms of the intake of dysuria agents were statistically significant before and after PSM analysis, but no factors were significantly different between the BCG and non-BCG groups after PSM.

CONCLUSIONS

Therapeutic agents for dysuria might be at an independent risk factor for NMIBC recurrence. This trial is registered with the UMIN Clinical Trials Registry under the number UMIN000036097 (https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno = R000041122).

Artificial intelligence in urological oncology: An update and future applications

There continues to be rapid developments and research in the field of Artificial Intelligence (AI) in Urological Oncology worldwide. In this review we discuss the basics of AI, application of AI per tumour group (Renal, Prostate and Bladder Cancer) and application of AI in Robotic Urological Surgery. We also discuss future applications of AI being developed with the benefits to patients with Urological Oncology.

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.

Utilization of imaging for staging in bladder cancer: is there a role for MRI or PET-computed tomography?

PURPOSE OF REVIEW

Accurate staging of bladder cancer is essential to guide appropriate management. In this review, we discuss the principles, applications and performance of multiparametric MRI (mpMRI) and PET-computer tomography (PET-CT) for local and distant staging of bladder cancer.

RECENT FINDINGS

Bladder mpMRI has a high diagnostic performance in local staging of bladder cancer, superior to other imaging modalities. It can accurately differentiate muscle invasive bladder cancer (MIBC) from non-MIBC (NMIBC), as well as ≤T2 from ≥T3 stages. mpMRI can be used to assess pelvic lymph nodes, although its sensitivity is relatively low. For the assessment of the upper urinary tract, CT urography is the imaging modality of choice. magnetic resonance urography is a viable alternative to CT in selected cases. Although PET-CT is accurate for nodal and distant staging of bladder cancer, there is no clear evidence on its superior diagnostic performance compared with contrast-enhanced CT.

SUMMARY

mpMRI is the most accurate imaging modality for local staging of bladder cancer, capable to accurately distinguish MIBC from NMIBC. Nodal and distant staging relies primarily on contrast-enhanced CT.

Value of separate tumor base biopsy in transurethral resection of bladder tumors

Introduction

The aim of our study was to evaluate whether a biopsy from the tumor base after transurethral resection of bladder tumor (TURBT) has an impact on subsequent management of patients with bladder tumors. While tumor base biopsy at the completion of TURBT is a common practice, there is no definition of its role within the major international professional guidelines.

Material and methods

We retrospectively reviewed the records of consecutive patients undergoing TURBT between 2015 and 2019 at our institution. We recorded demographic and tumor characteristics of initial TURBT, tumor base biopsy and restaging TURBT pathology outcomes. The pathologic outcomes were correlated to assess the additional value of a separate tumor base biopsy.

Results

A total of 532 patients underwent TURBT. A separate tumor base biopsy after completion of TURBT was performed in 154 patients. The mean patient's age was 72.8 ±11.7 years (range 48–94) and 119 (77.2%) were men. In 40 patients (25.9%) muscle was absent in the pathological specimen of the tumor resection. Muscle was present in all but 6 (3.9%) tumor base biopsies. Of the 33 patients who underwent repeated transurethral resection for pT1 tumors, 2 had residual low-grade pTa, 1 had residual high-grade pT1, and 3 patients were upstaged to pT2.

Conclusions

Although tumor base biopsy at the completion of TURBT is a common practice, our analysis fails to demonstrate any tangible benefit in the staging of bladder tumors. In our experience tumor base biopsy did not change the management in patients with superficial or muscle invasive disease.

Efficacy of pirarubicin for nonmuscle invasive bladder cancer: A protocol of systematic review and meta-analysis

BACKGROUND

This study will aim to appraise the efficacy and safety of pirarubicin for the treatment of patients with nonmuscle invasive bladder cancer (NMIBC).

METHODS

We will perform a comprehensive literature search in MEDLINE, EMBASE, Cochrane Library, Scopus, PsycINFO, Web of Science, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure from their beginning to the February 29, 2020. All randomized controlled trials of pirarubicin for NMIBC will be included regardless limitations related to the language and publication time. Two researchers will independently select studies from searched records, extract data from included randomized controlled trials, and assess study quality using Cochrane risk of bias tool. Any differences between them will be solved with the help of another researcher. RevMan 5.3 software will be utilized for statistical analysis.

RESULTS

This study will provide a synthesis of current evidence to investigate the efficacy and safety of pirarubicin for NMIBC using overall survival, progression-free survival, recurrence-free survival, quality of, rates of recurrence, and adverse events.

CONCLUSION

This study will explore whether or not pirarubicin can be used as an effective and safety treatment for patients with NMIBC.

REGISTRATION NUMBER

INPLASY202040113.

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.

Diagnostic accuracy of photodynamic diagnosis with 5-aminolevulinic acid, hexaminolevulinate and narrow band imaging for non-muscle invasive bladder cancer

Objective: To assess the diagnostic test accuracy (DTA) of photodynamic diagnosis with 5-aminolaevulinic acid (5-ALA), hexylaminolevulinate (HAL) and narrow band imaging (NBI) for non-muscle-invasive bladder cancer (NMIBC), with white light-guided cystoscopy (WLC) as reference standard. Materials and Methods: A systematic review and narrative synthesis was performed in accordance with PRISMA. Major electronic databases were searched until 20th May 2019. All studies assessing the DTA of 5-ALA, HAL and NBI compared with WLC at patient and lesion-level were included. Relevant sensitivity analyses and risk of bias (RoB) assessment were undertaken. Results: 26 studies recruiting 3979 patients were eligible for inclusion. For patient-level analysis, NBI appeared to be the best (median sensitivity (SSY) 100%, median specificity (SPY) 68.45%, median positive predictive value (PPV) 90.75%, median negative predictive value (NPV) 100% and median false positive rate (FPR) 31.55%), showing better DTA outcomes than either HAL or 5-ALA. For lesion-level analysis, median SSY across NBI, HAL and 5-ALA were 93.08% (IQR 87.04-98.81%), 93.16% (IQR 91.48-97.04%) and 94.42% (IQR 82.37-95.73%) respectively. As for FPR, median values for NBI, HAL and 5-ALA were 20.40% (IQR 13.68-27.36%), 17.43% (IQR 12.79-22.40%) and 28.12% (IQR 22.08-42.39%), respectively. Sensitivity analyses based on studies with low to moderate RoB and studies with n>100 patients show similar findings. Conclusions: NBI appears to outperform 5-ALA and HAL in terms of diagnostic accuracy. All three modalities present high FPR, hence indicating the ability to detect additional cases and lesions beyond WLC.

Apaziquone for Nonmuscle Invasive Bladder Cancer: Where Are We Now?

Apaziquone is an interesting drug for intravesical use in patients with nonmuscle invasive bladder cancer; however, more research is needed to prove its actual benefit. Although the apaziquone trials demonstrate the potential of this new drug, the singular phase 3 trials did not reach their primary endpoint. To date, no new trials are recruiting, so the development of apaziquone seems to have stopped.

Diagnostic performance of image technique based transurethral resection for non-muscle invasive bladder cancer: systematic review and diagnostic meta-analysis

OBJECTIVE

To explore the diagnostic performance of image technique based transurethral resection for bladder cancer, with white light-guided cystoscopy (WLC) as the reference standard.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed/MEDLINE, Web of Science, the Cochrane Library, Central Register of Controlled Trials and Embase from inception to 31 March 2018.

METHODS

Included studies reported the diagnostic performance of photodynamic diagnosis (PDD) with 5-aminolevulinic acid (5-ALA), PDD with hexaminolevulinic acid (HAL) or narrow band imaging (NBI), with WLC as the reference standard at the patient or lesion level. The studies' risk of bias (RoB) was assessed using Quality Assessment of Diagnostic Studies-2. Data were pooled using a random effect diagnostic meta-analysis, and subgroup analyses were performed.

RESULTS

Twenty-six studies comprising a total of 3979 patients were included in this diagnostic meta-analysis. Pooled sensitivity (SSY), specificity (SPY), diagnostic OR (DOR) and area under the receiver operating characteristic curve (AUROC) values were calculated per group for NBI, HAL and 5-ALA at the lesion or patient level. NBI showed significant diagnostic superiority compared with WLC at the lesion level (SSY 0.94, 95% CI 0.82 to 0.98; SPY 0.79, 95% CI 0.73 to 0.85; DOR 40.09, 95% CI 20.08 to 80.01; AUROC 0.88, 95% CI 0.85 to 0.91). NBI presented the highest DOR (358.71, 95% CI 44.50 to 2891.71) in the patient level. Subgroup analyses were performed on studies with low to moderate RoB and at least 100 patients at the lesion level. These results were consistent with those of the overall analysis.

CONCLUSIONS

Pooled data indicated that image technique based transurethral resection (NBI, HAL and 5-ALA) showed diagnostic superiority compared with WLC. Moreover, NBI is potentially the most promising diagnostic intervention, showing the best diagnostic performance outcomes. Further prognostic outcomes of novel imaging technologies compared with those WLC should be explored in addition to current diagnostic performance analysis.

Multiparametric Cystoscopy for Detection of Bladder Cancer Using Real-time Multispectral Imaging

BACKGROUND

Various imaging modalities can be used in addition to white light (WL) to improve detection of bladder cancer (BC).

OBJECTIVE

To use real-time multispectral imaging (rMSI) during urethrocystoscopy to combine different imaging modalities to achieve multiparametric cystoscopy (MPC).

DESIGN, SETTING, AND PARTICIPANTS

The rMSI system consisted of a camera with a spectral filter, a multi-LED light source, a microcontroller, and a computer for display and data acquisition. MSI with this system was achieved via temporal multiplexing.

SURGICAL PROCEDURE

MPC was performed in ten patients with a diagnosed bladder tumor.

MEASUREMENTS

We gathered evidence to prove the feasibility of our approach. In addition, experienced urologists performed post-interventional evaluation of images of individual lesions. Images were independently rated in a semiquantitative manner for each modality. A statistical model was built for pairwise comparisons across modalities.

RESULTS AND LIMITATIONS

Overall, 31 lesions were detected using the rMSI set-up. Histopathology revealed malignancy in 27 lesions. All lesions could be visualized simultaneously in five modalities: WL, enhanced vascular contrast (EVC), blue light fluorescence, protoporphyrin IX fluorescence, and autofluorescence. EVC and photodynamic diagnosis images were merged in real time into one MP image. Using the recorded images, two observers identified all malignant lesions via MPC, whereas the single modalities did not arouse substantial suspicion for some lesions. The MP images of malignant lesions were rated significantly more suspicious than the images from single imaging modalities.

CONCLUSIONS

We demonstrated for the first time the application of rMSI in endourology and we established MPC for detection of BC. This approach allows existing imaging modalities to be combined, and it may significantly improve the detection of bladder cancer.

PATIENT SUMMARY

Real-time multispectral imaging was successfully used to combine different imaging aids for more comprehensive illustration of bladder tumors for surgeons. In the future, this technique may allow better detection of bladder tumors and more complete endoscopic resection in cases of cancer.

Blue light flexible cystoscopy with hexaminolevulinate in non-muscle-invasive bladder cancer: review of the clinical evidence and consensus statement on optimal use in the USA - update 2018

Blue light cystoscopy (BLC) with hexaminolevulinate (HAL) during transurethral resection of bladder cancer improves detection of non-muscle-invasive bladder cancer (NMIBC) and reduces recurrence rates. Flexible BLC was approved by the FDA in 2018 for use in the surveillance setting and was demonstrated to improve detection. Results of a phase III prospective multicentre study of blue light flexible cystoscopy (BLFC) in surveillance of intermediate-risk and high-risk NMIBC showed that 20.6% of malignancies were identified only by BLFC. Improved detection rates in the surveillance setting are anticipated to lead to improved clinical outcomes by reducing future recurrences and earlier identification of tumours that are unresponsive to therapy. Thus, BLFC has a role in surveillance cystoscopy, and determining which patients will benefit from BLFC and optimal and cost-effective ways of incorporating this technology into surveillance cystoscopy must be developed.

Therapeutic benefit of second-look transurethral resection of bladder tumors for newly diagnosed T1 bladder cancer: a single-center experience

PURPOSE

In recent years, second-look transurethral resection of bladder tumors (TURBT) has been recommended for patients with stage T1 bladder cancer after the initial TURBT for restaging and deciding the subsequent treatment. However, we believe that second-look TURBT has therapeutic benefits, such as low incidence of recurrence and progression. Therefore, we compare the differences in long-term outcome between patients who did and did not accept second-look TURBT for stage T1 bladder cancer.

METHODS

We assessed 504 patients diagnosed with urothelial carcinoma who underwent initial TURBT between January 2012 and December 2016 at a single medical center; of these patients, 177 were diagnosed with T1 bladder cancer during the initial TURBT, and we excluded no muscle from the specimen in the initial TURBT. The patients were categorized into groups 1 and 2 based on the acceptance of second-look TURBT, which was performed within 4-14 weeks after the initial TURBT. Group 1 underwent second-look TURBT, but group 2 did not. Both groups were followed-up for recurrence-free survival (RFS) and progression-free survival (PFS), and the risk factors for recurrence and progression were analyzed.

RESULTS

In total, 93 (52.5%) patients in group 1 underwent second-look TURBT, and 84 (47.5%) in group 2 did not. The 2-year RFS rates were 74.6% and 60.0% and the PFS rates were 91.2% and 87.5% in groups 1 and 2, respectively.

CONCLUSION

This study demonstrated higher recurrence-free and progression-free survival rates for patients who underwent second-look TURBT. This result emphasizes the importance of second-look TURBT in stage T1 bladder cancer not only for restaging but also for therapeutic benefit.

Evaluation of the Dwell-Time and Dose Difference in Intravesical Bacillus Calmette-Guèrin Therapy

Objective:

Bacillus Calmette-Guèrin (BCG) intravesical therapy is currently established using a low dose because of the high incidence of side-effects. Moreover, shortening the dwell time of BCG is conducted in some facilities owing to the complications associated with a long dwell time after injection. The method of BCG administration varies in each facility and even with each doctor. We evaluated whether the dwell-time and dose differences in patients who underwent intravesical BCG therapy is related to completion rates, adverse effects, and nonrecurrence rates.

Methods:

From November 2006 to April 2016, a total of 173 patients who received intravesical BCG therapy after transurethral resection of bladder tumor or transurethral biopsy were evaluated retrospectively. We allocated them into 4 groups based on the dose (40 or 80 mg BCG) and the dwell time (1 or 2 hours). Completion rate, side effects, and nonrecurrence rates were evaluated.

Results:

No significant improvement in the completion rate or reduction in side-effects was observed in any of the regimens. Although nonrecurrence rates for the 1-hour dwell time tended to be lower than the 2-hour dwell time, the difference was not significant.

Conclusion:

Our study suggests that reducing the BCG dose or shortening the dwell time does not reduce adverse effects or affect the nonrecurrence rate.

Surface-Enhanced Raman Scattering Nanoparticles for Multiplexed Imaging of Bladder Cancer Tissue Permeability and Molecular Phenotype

Bladder cancer has the highest recurrence rate of all cancers due in part to inadequate transurethral resection. Inadequate resection is caused by the inability of cystoscopes to detect invisible lesions during the resection procedure. To improve detection and resection of nonmuscle invasive bladder cancer, we quantified the ability of a surface-enhanced Raman nanoparticle and endoscope system to classify bladder tissue as normal or cancerous. Both antibody-based (active) and tissue permeability-based (passive) targeting mechanisms were evaluated by topically applying nanoparticles to ex vivo human bladder tissue samples. Multiplexed molecular imaging of CD47 and Carbonic Anhydrase 9 tumor proteins gave a receiver operating characteristic area under the curve (ROC AUC of 0.93 (0.75, 1.00). Furthermore, passively targeted nanoparticles enabled tissue classification with an ROC AUC of 0.93 (0.73, 1.00). Passively targeted nanoparticles penetrated 5-fold deeper and bound to tumor tissue at 3.3-fold higher concentrations in cancer compared to normal bladder urothelium, suggesting the existence of an enhanced surface permeability and retention effect in human bladder cancer.

Predictors of Residual T1 High Grade on Re-Transurethral Resection in a Large Multi-Institutional Cohort of Patients with Primary T1 High-Grade/Grade 3 Bladder Cancer

The aim of this multi-institutional study was to identify predictors of residual high-grade (HG) disease at re-transurethral resection (reTUR) in a large cohort of primary T1 HG/Grade 3 (G3) bladder cancer patients. A total of 1155 patients with primary T1 HG/G3 bladder cancer from 13 academic institutions that underwent a reTUR within 6 weeks after first TUR were evaluated. Logistic regression analysis was performed to assess the association of predictive factors with residual HG at reTUR. Residual HG cancer was found in 288 (24.9%) of patients at reTUR. Patients presenting residual HG cancer were more likely to have carcinoma in situ (CIS) at first resection (p<0.001), multiple tumors (p=0.02), and tumor size larger than 3 cm (p=0.02). Residual HG disease at reTUR was associated with increased preoperative neutrophil-to-lymphocytes ratio (NLR) (p=0.006) and body mass index (BMI)>=25 kg/m². On multivariable analysis, independent predictors for HG residual disease at reTUR were tumor size >3cm (OR = 1.37; 95% CI: 1.02-1.84, p=0.03), concomitant CIS (OR 1.92; 95% CI: 1.32-2.78, p=0.001), being overweight (OR= 2.08; 95% CI: 1.44-3.01, p<0.001) and obesity (OR 2.48; 95% CI: 1.64-3.77, p<0.001). A reTUR in high grade T1 bladder cancer is mandatory as about 25% of patients, presents residual high grade disease. Independent predictors to identify patients at risk of residual high grade disease after a complete TUR include tumor size, presence of carcinoma in situ, and BMI >=25 kg/m².

Bladder cancer local staging: multiparametric MRI performance following transurethral resection

PURPOSE

To evaluate the performance of multiparametric MRI (mpMRI) for the local staging of bladder cancer following transurethral resection of bladder tumor.

METHODS

This Institutional Review Board-approved, retrospective study identified 45 patients with pathology-proven bladder cancer who underwent transurethral resection followed by mpMRI between August 2011 and October 2016. Two radiologists reviewed each MRI independently and assigned T and N stage. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for the presence of muscle invasion (T2 or higher), peri-vesical invasion (T3 or higher), and regional nodal disease compared to findings at cystectomy as the reference standard. Inter-observer agreement was measured using Cohen's κ coefficient.

RESULTS

Of 45 patients, 13% were stage T2, 27% T3, 16% T4; of 40 patients, 28% had regional nodal disease. Sensitivity, specificity, PPV, NPV, and accuracy of mpMRI for readers 1 and 2, respectively, were muscle invasion, 92% and 88%, 74% and 84%, 81% and 88%, 88% and 84%, 84% and 86%; peri-vesical invasion, 72% and 67%, 92% and 92%, 87% and 86%, 81% and 79%, 83% and 81%; regional nodal disease, 45% and 45%, 93% and 90%, 71% and 63%, 82% and 81%, 80% and 78%. Inter-observer agreement was good using all sequences.

CONCLUSIONS

mpMRI was both sensitive and specific in the detection of muscle invasive bladder cancer, and was specific but not sensitive for both peri-vesical invasion and nodal involvement. mpMRI may have a role at locally staging bladder cancer following transurethral resection.

The use of blue light flexible cystoscopy with hexaminolevulinate & the diagnosis of bladder cancer

Blue light cystoscopy improves the detection of bladder cancer at time of transurethral resection of bladder tumor for nonmuscle-invasive bladder cancer. This has translated to decreased tumor recurrence. Given this improvement in rigid cystoscopy, the question remains whether the use of blue light flexible cystoscopy (BLFC) in the surveillance setting provides the same benefits. This review aims to evaluate the recently reported Phase III prospective multicenter study of BLFC which evaluated the detection of bladder cancer during surveillance, which in its earliest reporting demonstrated improved detection of bladder cancer. This study evaluated 304 patients with findings of 63 confirmed malignancies, with 13 (20.6%) only identified by BLFC (p < 0.0001). The question still remains whether the improved detection rate will translate to improved clinical outcomes. Further, studies will be necessary to determine which patients will benefit from BLFC, optimal ways to incorporate into surveillance strategies and cost-effectiveness.

Intravesical bacillus Calmette-Guerin therapy after second transurethral resection for primary T1 bladder cancer

BACKGROUND

To evaluate the effect of intravesical bacillus Calmette-Guerin (BCG) instillation therapy after second transurethral resection (TUR) on primary T1 bladder cancer.

METHODS

The subjects were 180 patients diagnosed with T1 bladder cancer at our university and at affiliated hospitals between January 1990 and December 2015. Tumor residual rate, intravesical recurrence rate, and risk factors for intravesical recurrence were investigated.

RESULTS

The median follow-up period was 26 (1-175) months. Of the 180 patients, 78 (43%) underwent a second TUR. Residual tumors were detected in 42 patients (53.8%), and no up-staging cases were observed. Within the whole group, 42 patients were treated with intravesical BCG therapy following a second TUR (group 1), 36 were treated with second TUR alone (group 2), 28 were treated with intravesical BCG therapy alone (group 3), and 74 were treated without second TUR or intravesical BCG therapy (group 4). The 1- and 5-year recurrence-free survival rates of the four groups were 80.7 and 59.7% (group 1), 69.0 and 26.3% (group 2), 76.3 and 56.6% (group 3), 64.6 and 48.6% (group 4), respectively. There was no significant difference between group 1 and group 3 (p = 0.401). Intravesical BCG therapy was the only factor preventing intravesical recurrence (p = 0.013).

CONCLUSIONS

Intravesical BCG therapy alone showed a significant preventive effect with regard to intravesical recurrence. In our cohort, however, second TUR did not improve recurrence-free survival in those individuals who underwent BCG instillation.

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.

Wide-field autofluorescence-guided TUR-B for the detection of bladder cancer: a pilot study

PURPOSE

The aim of this pilot study was to assess the feasibility and value of wide-field autofluorescence imaging (AFI) for the detection of bladder cancer during transurethral resection of the bladder (TUR-B).

METHODS

For imaging, the D-Light/AF System (Karl Storz GmbH, Tuttlingen, Germany) and a customized band pass filter (≈ 480-780 nm) at the eyepiece of the endoscope were used. The excitation light wavelength was 440 nm. Representative spectral measurements of tissue autofluorescence (AF) were performed using a spectrometer attached behind the AF band pass filter in selected patients. During TUR-B, cystoscopy was performed in white light (WL) followed by wide-field AFI. Lesions were classified as suspicious or normal using either modality.

RESULTS

Representative spectral measurements using excitation at a wavelength of 440 nm resulted in significantly lower fluorescence intensity of malignant versus non-malignant tissue. Overall, 56 lesions (30 cancerous and 26 non-malignant) in 25 patients were assessed and classified by wide-field AFI. Papillary tumors as well as flat lesions lacked the green fluorescence seen in normal urothelium, thus emerging as "brown-reddish" areas. When compared with histopathological findings, the pooled per-lesion sensitivity and specificity for AF were 96.7 and 53.8%, respectively. For WL these values were 86.7 and 69.2%, respectively.

CONCLUSION

Wide-field AFI imaging during TUR-B is simple and easy to use. Our preliminary data suggest that AFI has the potential to increase the detection rates of bladder tumors compared with WL without the need of intravesical instillation prior to the procedure.

Image-Guided Transurethral Resection of Bladder Tumors - Current Practice and Future Outlooks

Transurethral resection of bladder tumor (TURBT) under white light cystoscopy (WLC) is the cornerstone for the diagnosis, removal and local staging of non-muscle invasive bladder cancer (NMIBC). Despite technological improvements over the decades, significant shortcomings remain with WLC for tumor detection, thereby impacting the surgical quality and contributing to tumor recurrence and progression. Enhanced cystoscopy modalities such as blue light cystoscopy (BLC) and narrow band imaging (NBI) aid resections by highlighting tumors that might be missed on WLC. Optical biopsy technologies such as confocal laser endomicroscopy (CLE) and optical coherence tomography (OCT) characterize tissue in real-time to ensure a more thorough resection. New resection techniques, particularly en bloc resection, are actively under investigation to improve the overall quality of resections and aid pathologic interpretation. Moreover, new image processing computer algorithms may improve perioperative planning and longitudinal follow-up. Clinical translation of molecular imaging agents is also on the horizon to improve optical diagnosis of bladder cancer. This review focuses on emerging technologies that can impact the quality of TURBT to improve the overall management of NMIBC.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Transurethral Resection of Bladder Tumors: Improving Quality Through New Techniques and Technologies

PURPOSE OF REVIEW

Cystoscopy with transurethral resection of bladder tumors (TURBT) is essential in the diagnosis of bladder cancer as well as the management of non-muscle-invasive disease yet remains a comparatively imprecise procedure secondary to variability among patients, tumors, and surgeons alike. We will review evolving technologies and techniques used to enhance safety and efficacy of TURBT performance and education in the management of bladder cancer.

RECENT FINDINGS

Though a generally safe procedure, efficacy of TURBT in terms of complete tumor excision, appropriate pathologic diagnosis, and absence of complications can vary significantly with direct impact on patient outcomes. Application of new techniques including bipolar electrocautery and photodynamic enhancement continues to shape endoscopic management of bladder cancer and improve safety, tumor excision rates, and downstream outcomes. High-quality bladder tumor resection is essential for effective bladder cancer management. Technologies such as bipolar electrocautery and photodynamic visualization improve safety and tumor eradication. Improved education and surgical technique will further standardize high-level outcomes for patients undergoing TURBT.

MicroRNA Expression Profile Identifies High Grade, Non-Muscle-Invasive Bladder Tumors at Elevated Risk to Progress to an Invasive Phenotype

The objective of this study was to identify a panel of microRNAs (miRNAs) differentially expressed in high-grade non-muscle invasive (NMI; TaG3-T1G3) urothelial carcinoma that progress to muscle-invasive disease compared to those that remain non-muscle invasive, whether recurrence happens or not. Eighty-nine high-grade NMI urothelial carcinoma lesions were identified and total RNA was extracted from paraffin-embedded tissue. Patients were categorized as either having a non-muscle invasive lesion with no evidence of progression over a 3-year period or as having a similar lesion showing progression to muscle invasion over the same period. In addition, comparison of miRNA expression levels between patients with and without prior intravesical therapy was performed. Total RNA was pooled for microarray analysis in each group (non-progressors and progressors), and qRT-PCR of individual samples validated differential expression between non-progressive and progressive lesions. MiR-32-5p, -224-5p, and -412-3p were associated with cancer-specific survival. Downregulation of miR-203a-3p and miR-205-5p were significantly linked to progression in non-muscle invasive bladder tumors. These miRNAs include those implicated in epithelial mesenchymal transition, previously identified as members of a panel characterizing transition from the non-invasive to invasive phenotype in bladder tumors. Furthermore, we were able to identify specific miRNAs that are linked to postoperative outcome in patients with high grade NMI urothelial carcinoma of the bladder (UCB) that progressed to muscle-invasive (MI) disease.

How do we manage high-grade T1 bladder cancer? Conservative or aggressive therapy?

High-grade T1 bladder cancer has a poor prognosis due to a higher incidence of recurrence and progression than other nonmuscle invasive bladder cancer; thus patients with high-grade T1 have to be carefully monitored and managed. If patients are diagnosed with high-grade T1 at initial transurethral resection (TUR), a second TUR is strongly recommended regardless of whether muscle layer is present in the specimen because of the possibility of understating due to incomplete resection. Since high-grade T1 disease shows diverse clinical courses, individual approaches are recommended for treatment. In cases with low risk of progression, cystectomy could represent overtreatment and deteriorate quality of life irreversibly, while, in those with high risk, bacillus Calmette-Guérin (BCG) therapy may worsen survival by delaying definitive therapy. Therefore, a strategy for predicting prognosis based on the risk of progression is needed for managing high-grade T1 disease. Molecular risk classifiers predicting the risk of progression and response to BCG may help identify the optimal management of high-grade T1 disease for each individual.

Bacillus Calmette-Guerin therapy after the second transurethral resection significantly decreases recurrence in patients with new onset high-grade T1 bladder cancer

Background

The purpose of this study was to assess the efficacy of Bacillus Calmette-Guerin (BCG) therapy after a second transurethral resection (TUR) in new onset high-grade T1 bladder cancer.

Methods

From January 2008 to September 2013, 207 patients with new onset high-grade T1 bladder cancer after an initial TUR were treated at our university and at affiliated hospitals. Residual cancer rate, intravesical recurrence-free survival (RFS), and risk factors for intravesical recurrence were analyzed.

Results

Among a total of 207 patients, 42 patients were treated with BCG therapy following a second TUR (group 1), 23 were treated with second TUR alone (group 2), 72 were treated with BCG alone (group 3), and 70 were treated without a second TUR or BCG. The median patients’ age was 72.0 years, and the median follow-up period was 33.5 months. The second TUR revealed that 34 patients (52 %) had residual cancer. Between groups 1 and 2 and groups 1 and 3, the differences in RFS were statistically significant (p = 0.002 and 0.045, respectively). In addition, BCG therapy was the most significant factor to predict RFS after the second TUR. Among the 31 patients whose pathology of the second TUR was pT0, only 1 of 12 patients (8 %) in group 1 and 11 of 19 patients (58 %) in group 2 had a recurrence.

Conclusions

BCG instillation following a second TUR decreases intravesical recurrence, even if the pathology of the second TUR is pT0.

Results of second transurethral resection for high-grade T1 bladder cancer

Background:

The aim of this study was to examine the histological outcome and potential therapeutic benefit of second transurethral resection (TUR) for high-grade T1 bladder cancer.

Patients and Methods:

The subjects were 171 patients who underwent initial TUR between January 1993 and December 2013, and were diagnosed with high-grade T1 bladder cancer. Second TUR was performed within 4–6 weeks after the initial resection. Intravesical recurrence, invasive intravesical recurrence, and disease-free, progression-free, and overall survival were examined between second TUR group and no second TUR group.

Results:

Of the 171 patients, 79 (46.2%) underwent second TUR. Histological findings from second TUR were no cancer in 33 (41.8%), carcinoma in situ in 18 (22.9%), Ta in 15 (19.0%), T1 in 12 (15.2%), and muscle invasive bladder cancer (T2) in 1 case (1.3%). The 5- and 10-year intravesical recurrence-free survival rates were 72.0% and 57.4%, respectively, and the disease-free survival rates at these times were 69.7% and 49.6%, respectively. Second TUR had no influence on intravesical recurrence, regardless of the use of Bacillus Calmette–Guerin (BCG) therapy. No BCG therapy and recurrent cancer were significantly associated with intravesical recurrence in multivariate analysis. Recurrent cancer was also a significant risk factor for invasive intravesical recurrence. BCG therapy significantly improved disease-free survival. Second TUR was a significant factor in overall survival. In the histological results for second TUR, no cancer and Tis cases had reduced intravesical recurrence compared to Ta and T1 cases.

Conclusion:

Second TUR allows more accurate staging and pT0 cases in second TUR have a better outcome, indicating a possible therapeutic benefit of the procedure.

Is intravesical Bacillus Calmette-Guérin therapy superior to chemotherapy for intermediate-risk non-muscle-invasive bladder cancer? An ongoing debate

The objective of this study was to evaluate the risk of recurrence in patients with intermediate-risk non-muscle-invasive bladder cancer (NMIBC) after intravesical instillation with chemotherapeutic agents or Bacillus Calmette-Guérin (BCG) therapy. A cohort of 746 patients with intermediate-risk NMIBC comprised the study group. The primary outcome was time to first recurrence. The recurrence rates of the transurethral resection (TUR) alone, chemotherapy, and BCG groups were determined using Kaplan-Meier analysis. Risk factors for recurrence were identified using Cox regression analysis. In total, 507 patients (68.1%), 78 patients (10.5%), and 160 (21.4%) underwent TUR, TUR+BCG, or TUR+chemotherapy, respectively. After a median follow-up period of 51.7 months (interquartile range=33.1-77.8 months), 286 patients (38.5%) developed tumor recurrence. The 5-yr recurrence rates for the TUR, chemotherapy, and BCG groups were 53.6%±2.7%, 30.8%±5.7%, and 33.6%±4.7%, respectively (P<0.001). Chemotherapy and BCG treatment were found to be predictors of reduced recurrence. Cox-regression analysis showed that TUR+BCG did not differ from TUR+chemotherapy in terms of recurrence risk. Adjuvant intravesical instillation is an effective prophylactic that prevents tumor recurrence in intermediate-risk NMIBC patients following TUR. In addition, both chemotherapeutic agents and BCG demonstrate comparable efficacies for preventing recurrence.