Restaging Transurethral Resection of HG Ta Bladder Tumors: A Risk-Adapted Approach

Abstract

The AUA and EAU Guidelines recommend patients with high grade (HG) Ta bladder tumors undergo restaging transurethral resection (reTUR) if categorized as ‘High Risk’ or in the absence of muscle in the specimen, respectively. These statements were generated from a paucity of data. We investigated the role of reTUR in BCG response to create a risk-adapted approach to the management of HG Ta lesions. Review of patients with HG Ta bladder cancer at index transurethral resection (TUR) who received induction BCG at our institution from 2000-2018 was performed. Patients were stratified by (1) presence of residual disease on reTUR and (2) use of AUA Guideline-driven reTUR. Of the 209 patients with primary HG Ta bladder cancer who received BCG, 95 underwent reTUR which identified residual disease in 42 patients (44%). Factors associated with residual disease on reTUR included tumor multifocality (67% in residual disease group vs. 38% in no residual disease, P=0.004) and carcinoma in situ (CIS, 47% vs. 15%, P=0.001). Index TUR performed at our institution and use of peri-operative chemotherapy were both associated with no residual disease on reTUR (14% vs. 34%, P=0.024; 5% vs. 25%, P=0.009, respectively). Higher EORTC nomogram scores and AUA risk stratification were associated with residual disease on reTUR, but the CUETO risk score was not predictive. When comparing patients categorized as AUA Hight Risk with HG Ta tumors, those who underwent guideline-based reTUR (n=66) had similar outcomes compared to those who did not (n=75). When evaluating for BCG response, we found no difference in recurrence-free survival or progression-free survival between patients who underwent reTUR vs. those who did not, nor between those who had residual disease at reTUR vs. those who did not. We identified risk factors predicting presence of residual disease at reTUR for HG Ta lesions. However, neither the presence of residual disease on reTUR nor the omission of reTUR in High Risk lesions resulted in adverse response to BCG. We propose that routine reTUR in HGTa patients may be omitted for the sake of cost and morbidity savings without detriment to oncologic outcome in selected patients receiving adequate induction BCG.