MANAGEMENT OF NON-MUSCLE INVASIVE UROTHELIAL CARCINOMA OF BLADDER AND THE NECESSITY FOR ADHERENCE TO STANDARD GUIDELINES: A LOCAL STUDY

Abstract

Background
 Bladder cancer is a very common urological malignancy affecting human being, it is the disease related to environment and aging. The biologic behavior or bladder cancer is unpredictable, but the issue of recurrence, progression in relation to morbidity and mortality are well recognized. NMIBC (Non-Muscle Invasive Bladder Cancer); compromise Ta, T1 and Cis with great difference in their management and prognosis. It is found early recurrence and progression of NMIBC as a clinical marker carries a poor prognosis.
 Objectives 
 To detect the rate of early recurrence, progression, and to evaluate the clinical behavior and final outcome of 44 patients diagnosed with NMIBC.
 Materials and Methods
 This is a prospective study conducted between June 2013 and December 2014 in Sulaimani Surgical Teaching and Hewa Teaching hospitals. Fourty four patients who had been managed for primary NMIBC were reviewed for their medical records, clinical parameters including patients age ,gender, physical examination, investigations, the operations, tumor morphology and adjuvant therapy were entered into database. Patients were called back for reviewing their course of the disease and to complete their managements.The outcomes of re-resection, recurrence rate , progression and overall survival were recorded in relation to initial management and follow up.
 Results
 Of 44 patients with primary NMIBC, male: female ratio is 6:1, the mean age is 55 years. Index TURBT revealed 47.7% was Ta, 45.45% was T1 and 6.8% unknown stage with no CIS detection. Grading showed; 18.1% was PUNLMP, 34.1% G1, 13.6% G2, 27.27% G3, and 6.8% was unknown. Tumor size was; 9.09% < 1 cm, 40.9% size was 1-3 cm, and 50% was > 3 cm. The multiplicity; 36.36% was solitary tumor, 31.8% multiple, and 31.8% the multiplicity was not recorded. Initial treatment was 18.2% TURBT alone, 18.2% second TURBT, 4.5% TURBT and immediate intravesical MMC, 61.36% TURBT and 6weeks course of MMC, 6.8% underwent TURBT and 6 weeks’ course of BCG. Mean time to recurrence was 5.6 months and 7 months for progression. Using multivariate analysis, the P value for tumor size and grade of tumor were 0.001 and 0.008 respectively, which are statistically significant for both recurrence and progression.
 Conclusion
 The biological behavior of NMIBC remained elusive in term of curability, recurrence, progression and mortality. Lack of documentation and irregular follow up schedules were observed obviously. Deviations from the standard guideline management strategy can threaten the life of patients.