Is RE-TURB always necessary?
Bladder Cancer (BC) is the most common malignancy of the urinary tract and the seventh most common cancer in men and the 17th in women. The world global age standardised mortality rate is 3 for men versus 1 per 100,000 for women. Approximately 70% of patients with BC present with a disease that is confined to the mucosa (stage Ta, CIS) or submucosa (stage T1) and approximately 30% of patients present a muscle-invasive bladder cancer (T2 or more)1. According to current European Association of Urology (EAU) guidelines, a routine second transurethral resection (TUR) is mandatory in Ta high grade and T1 tumours, but the scientific evidence is weak. The aim of this study was to valuate the usefulness of a second transurethral resection for high grade non muscle-invasive bladder tumor.
Materials and Methods
From January 2010 to December 2013, 118 patients with high grade non muscle-invasive bladder cancer underwent second TURB at our hospital. First TURB was performed in white light (WL TURB), and was apparently complete and performed until perivesical fat2. None of these patients had adjuvant chemotherapy. A RE-TURB at 6-8 weeks after initial resection was applied to the scar of the first resection and other suspicious lesions in the bladder2. We evaluated the recurrence rate at initial site of resection and the recurrence rate at another site in the bladder. All patients had a follow-up cystoscopy at 3, 6 and 12 month from RE-TURB2.
Of the 118 cases 107 (91%) had no tumors in bladder during RE-TURB and 11 (9%) had tumors; in particular 2 of the tumors were found at others sites in the bladder, instead 9 of the tumors ( 2 CIS and 7 high grade non muscle-invasive) were found at initial site of resection. Of 9 patients 7 had a cancer bigger than 3 cm at first TURB. The recurrence rate was 3% (2/107) in patients followed at 3 months after RE-TURB, 6% (6/107) in patients followed at 6 months and 9% (10/107) in patients followed at 12 months. In none of the 18 cases, cancer appeared on the scar of first resection at 3-6 and 12 months.
Concerning RE-TURB, or second-look TURB, there is a significant disagreement within the scientific community. There is evidence in the literature that a RE-TURB at 6 weeks after initial resection is appropriate to confirm complete resection of the original tumor, to control residual invasive tumor, to detect silent muscle invasion and to provide a better evalutation of clinical stage3,4 . Our findings show that positivity of RE-TURB is very low and only 7 % of the patients had tumor at initial site of resection at RE-TURB and 80% of these had a cancer bigger than 3 cm at first TURB. The absence of muscle in the initial resection specimen is an important risk factor for understaging. Therefore in our opinion, a RE-TURB is mandatory in these cases5. On the other hand, when a complete TURB has been performed until perivesical fat and the muscularis propria is tumor free, we consider that a systematic RE-TURB is not necessary and it is just indicated in selected patients, even more if we consider that the RE-TURB is not exempt from complications. Nowdays, in the “spending review period”, we are wondering if the costs of operatory room for standard RE-TURB at 6 weeks are justified.
A second transurethral resection could be not mandatory in all high grade non muscle-invasive bladder tumor when resection was complete and performed until perivescial fat, particulary when lesion was single (or less than 7 lesions) and lower than 3 cm (EORTC risk tables)6 . Photodynamic diagnosis and narrow band imaging improve non-muscle invasive bladder cancer detection, including carcinoma in situ, enabling more complete resection and fewer residual tumors, but they have the disadvantages of a higher false-positive rate. They can improve bladder cancer detection and characterization, and transurethral resection quality and can further help to reduce RE-TURB positivity at initial site of resection and at another site in the bladder 7-8. Nevertheless a good cost-effectiveness analysis must be carry out about these new technologies.
1-.A. Witjes et all., Guidelines on Muscle-invasive and Metastatic Bladder Cancer;2014
2- M. Babjuk et all.; EAU Guidelines on Non-muscle-invasive Bladder Cancer (Ta, T1 and CIS);2014
3-Herr HW et all.; The value of a second transurethral resection in evaluating patients with bladder tumors. J Urol. 1999 Jul;162(1):74-6.
4-Miladi M1 et all.; The value of a second transurethral resection in evaluating patients with bladder tumoursEur Urol. 2003 Mar;43(3):241-5.
5-Gaya JM1 et all.; [A second transurethral resection could be not necessary in all high grade non-muscle-invasive bladder tumors].Actas Urol Esp. 2012 Oct;36(9):539-44.
6-Sylvester RJ et all. Predicting recurrence and progression in individual patients with stage Ta T1 bladder cancer using EORTC risk tables: a combined analysis of 2596 patients from seven EORTC trials. Eur Urol. 2006 Mar;49(3):466-5.
7-Herr HW1.; Randomized Trial of Narrow-band Versus White-light Cystoscopy for Restaging (Second-look) Transurethral Resection of Bladder Tumors .Eur Urol. 2014 Jul 17.
8- Rink M. et all; Hexyl aminolevulinate-guided fluorescence cystoscopy in the diagnosis and follow-up of patients with non-muscle-invasive bladder cancer: a critical review of the current literature. Eur Urol. 2013 Oct;64(4):624-38.