Conservative Management of Low Risk Superficial Bladder Tumors

Abstract

The most common approach for nonmuscle invasive urothelial cancers of the bladder is transurethral resection of the bladder tumor, often under regional or general anesthesia. Due to the high rate of recurrence, many such patients experience the potential risks and morbidity of frequent surgical intervention, despite the often slow growth rate and low risk of progression of such tumors. Recent experiences have suggested that some patients with low grade superficial tumors may be treated expectantly. We report on our experience with expectant management of low risk superficial bladder tumors. We retrospectively evaluated 173 patients with superficial bladder cancer who are currently actively treated at our institution and who have complete clinical information. From this population we identified 22 cases (12.7%) under expectant management for bladder tumors in the last 12 months. Demographic and clinical information on this cohort are described as well as clinical and pathological outcomes, and disease interventions on followup. All patients had a prior history of recurrent low risk (Ta, low grade) bladder tumors. The mean followup was 25 months. Of the 22 patients 8 had no growth, 9 had minimal growth and 5 had moderate growth of their tumors. Fifteen patients have required no intervention, 3 have undergone office fulguration and 4 have undergone repeat transurethral bladder tumor resection. Two men (9%) had evidence of grade progression on followup transurethral bladder tumor resection, and 1 of these men (4.5%) had stage progression (T1 disease). Both men had evidence of moderate tumor growth and suspicious/malignant cytology which resulted in the repeat transurethral bladder tumor resection. Interestingly, these 2 men had a 6 and 11 year history of recurrent Ta, low grade disease before progression and had been under expectant management for 18 and 12 months before progression. Interestingly all smokers had a recurrence during the surveillance period and this represented a 3.3-fold increased rate of recurrence over nonsmokers. Expectant management of recurrent bladder tumors may be an appropriate option for some patients with a history of Ta, low grade tumors, especially those who are older and with significant medical comorbidities. Such a strategy may avoid potential risks and morbidities associated with frequent, repeat transurethral bladder tumor resection. However, under such an expectant management strategy, patients should remain under careful cystoscopic and cytologic surveillance as there remains some risk for grade and stage progression in this patient population.