An Immediate Instillation after Transurethral Resection of Bladder Tumor in Non–Muscle-Invasive Bladder Cancer: Has the Evidence Changed?

Abstract

In the last year, three papers [1–3] have been published suggesting that an immediate instillation after transurethral resection of bladder tumor (TURBT) should be abandoned in multiple or high-grade non–muscle-invasive bladder tumors and that it is clinically meaningless in lowrisk tumors. Are their arguments correct? The European Association of Urology (EAU) guidelines on non–muscle-invasive urothelial carcinoma of the bladder (and, to a lesser extent, the American Urological Association guidelines) recommend that an immediate instillation of chemotherapy be given after TURBT in all patients with non–muscle-invasive bladder cancer [4,5]. The one exception is in patients with an extended TURBT, for whom there is a risk of bladder perforation and extravasation of the drug. The basis for these recommendations is a meta-analysis published in 2004 (1476 patients) that showed a reduction of 39% in the odds of recurrence in patients who received one immediate instillation as the sole treatment after TURBT [6]. There was a clear effect in patients with a single tumor (odds ratio [OR]: 0.61, p = 0.0005; 849 patients from four studies) and a strong suggestion of an effect in patients with multiple tumors (OR: 0.44, p = 0.06; 111 patients from two studies). It was emphasized that an immediate instillation was, by itself, insufficient treatment in patients with multiple tumors who are at high risk of recurrence. Studies that have been published after themeta-analysis [6] have not contradicted the conclusions of the metaanalysis or the EAU guidelines. Berrum-Svennung et al confirmed the results of the meta-analysis and found that a single instillation of epirubicin as the only treatment after TURBT significantly delayed the time to first recurrence during the 2-yr study period ( p = 0.02) [1]. Gudjonsson et al