Second transurethral resection in T1G3 bladder tumors - Selectively avoidable?

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.

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.

When to Avoid a Restaging Procedure for Non-muscle Invasive Bladder Cancer? Inferences from a Tertiary Care Center

The increasing incidence of urinary bladder carcinoma is alarming. Approximately seventy percent of these patients are non-muscle invasive bladder cancer (NMIBC). Restage transurethral resection of bladder tumor (TURBT) is the current recommendation for any T1 and or high-grade non muscle invasive bladder cancers (NMIBC) to accurately stage the malignancy. The question whether a second surgery is always required as a restage procedure is still unanswered. The patient's concern about completeness, morbidity, and financial considerations of a major surgery cannot be overlooked. Moreover, it also puts a strain on the already overburdened healthcare system. To answer this question, whether it is oncologically sound to omit a second resection, the current study evaluated the outcomes of patients undergoing restage TURBT, and analyzed the preoperative factors predicting a change in the staging of this malignancy. The study design was a prospective observational including NMIBC patients from September 2018 to February 2020. A total of 72 patients underwent restage TURBT. Their demographic data, imaging and cystoscopic findings, and histopathological data were recorded. The objective was to study the clinico-pathological correlations and factors predicting recurrence and upstaging of tumor in NMIBC patients undergoing restage TURBT. A total of 101 patients were found eligible for restage TURBT. Eventually, 72 underwent restage TURBT. Twelve (16.7%) patient had recurrence at restage while 3(4.16%) were upstaged to T2. Presence of lower urinary tract symptoms (LUTS) was independently associated with the risk of recurrence of same stage compared to no recurrence (p-0.025, OR-8.793, 95% CI-1.316-98.773). Chemical exposure (p-0.042) was also significantly associated with the same. Presence of lymphadenopathy on CT was independently associated with the risk of upstaging compared to no recurrence (p-0.032, OR-18.25, 95% CI-1.292-257.85). The study concluded that in the presence of a well-performed and adequate initial TURBT, restage TURBT could be skipped for further management. However, in small subgroup of patients with lymphadenopathy on preoperative imaging having a higher risk of tumor recurrence and upstaging, and patients with a history of chemical exposure and previous lower urinary tract symptoms having a high risk of recurrence alone, restage TURBT should still be performed to accurately stage the disease. Further studies with large patient cohort are needed to confirm and reinforce the facts proposed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-022-01516-8.

Utility of restage transurethral resection of bladder tumor

Introduction:

Transurethral resection of bladder tumor (TURBT) aims at complete resection of all the visible tumors. Existing guidelines recommend restage TURBT in all patients with T1 and high-grade tumors, to avoid under-staging. However, restage TURBT may not be plausible/feasible at all the times. This study was performed with an aim to better define the utility of restage TURBT in a tertiary care hospital of India.

Methods:

Patients with high grade/T1 tumors at the first TURBT were prospectively enrolled. Their demographic profile, previous cystoscopic findings, and histological reports were recorded. The primary objective was to assess the tumor detection and stage up-migration rates at restage TURBT. The secondary objectives was to identify factors predicting presence of tumor at restage TURBT. Patients were followed up to detect recurrence and progression for a minimum of 3 months.

Results:

Of 128 prospective patients’ enrolled, 29 patients were lost to follow-up and 11 patients did not undergo restage. A total of eighty-eight patients underwent restage TURBT of which twenty-eight patients (31.8%) had tumor at their second TURBT with five of these patients being upstaged to T2. The risk of having a tumor at restage was significantly higher in patients with solid tumors (56.2% vs. 26.4%, P = 0.02, 95% confidence interval: 0.035–0.024) but was independent of the tumor size (P = 0.472), number of growths (P = 0.267), grade of tumor (P = 0.441), presence or absence of muscle at the initial TURBT (P = 0.371) and place of initial TURBT (P = 0.289). There was a significant difference in the recurrence and progression rates in patients who had tumor at restage as compared to those who did not (recurrence; 33.3% and 23.8%, P = 0.022, respectively vs. progression; 11.1% and 3.7% respectively, P = 0.07; mean follow-up = 10.8 months).

Conclusions:

We conclude that restage TURBT is necessary in patients with solid looking tumors and the presence of tumor at restage confers a higher risk of recurrence and progression.

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.

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.

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.