Initial Transurethral Resection Of Bladder Tumor Research Articles

Impact of resident involvement in endoscopic bladder cancer surgery on pathological outcomes

Objective: Transurethral resection of bladder tumor (TURBT) pathology specimens which lack muscle are associated with clinical upstaging and may necessitate repeat resections, potentially delaying curative treatment. This study evaluated whether resident involvement in TURBT is associated with suboptimal perioperative outcomes. Materials and methods: All TURBTs performed at a Canadian healthcare institution from November 2011 to June 2014 were reviewed. Multivariable logistic regression models assessed associations between intraoperative resident involvement and TURBT muscle presence. Among high-risk patients (high grade, ≥ T1 or carcinoma in situ) who underwent cystectomy, time from TURBT to cystectomy was compared between resident and attending urologists with the log-rank test. Results: In total, 463 TURBTs were identified. In multivariable analyses, residents were less likely to obtain muscle in specimens for all TURBTs [adjusted odds ratio (aOR) 0.59, p = 0.03] and the subset of 275 high-risk TURBTs (aOR 0.41, p = 0.006). Among patients who underwent cystectomy, time to cystectomy was delayed by a median of 23 days when residents were involved in the initial high-risk TURBT compared with attending urologists only (p = 0.024). Conclusions: In this single academic center series, intraoperative resident involvement was associated with a decreased rate of muscle presence in TURBT specimens and a prolonged time to cystectomy.

MP13-11 HIGH SPECIFICITY OF DIFFUSION-WEIGHTED MRI IN DIFFERENTIATING RESIDUAL BLADDER CANCER FROM POSTOPERATIVE CHANGES

You have accessJournal of UrologyBladder Cancer: Non-Invasive I1 Apr 2016MP13-11 HIGH SPECIFICITY OF DIFFUSION-WEIGHTED MRI IN DIFFERENTIATING RESIDUAL BLADDER CANCER FROM POSTOPERATIVE CHANGES Yuki Nakamura, Soichiro Yoshida, Hiroshi Tanaka, Masaharu Inoue, Masaya Ito, Minato Yokoyama, Junichiro Ishioka, Yoh Matsuoka, Noboru Numao, Kazutaka Saito, Yasuhisa Fujii, and Kazunori Kihara Yuki NakamuraYuki Nakamura More articles by this author , Soichiro YoshidaSoichiro Yoshida More articles by this author , Hiroshi TanakaHiroshi Tanaka More articles by this author , Masaharu InoueMasaharu Inoue More articles by this author , Masaya ItoMasaya Ito More articles by this author , Minato YokoyamaMinato Yokoyama More articles by this author , Junichiro IshiokaJunichiro Ishioka More articles by this author , Yoh MatsuokaYoh Matsuoka More articles by this author , Noboru NumaoNoboru Numao More articles by this author , Kazutaka SaitoKazutaka Saito More articles by this author , Yasuhisa FujiiYasuhisa Fujii More articles by this author , and Kazunori KiharaKazunori Kihara More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2492AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In managing bladder cancer, the significant risk of residual cancer after initial transurethral resection of bladder tumor (TURBT) is a big concern, and repeat TURBT is recommended in selected patients. The ability of magnetic resonance imaging (MRI) to detect bladder cancer at diagnosis is excellent. However, differentiating residual cancer from changes after the initial TURBT remains challenging. Growing evidence has emerged showing the usefulness of Diffusion-weighted MRI (DW-MRI) as an imaging biomarker for characterizing the pathophysiology of bladder cancer. In this study, we evaluated the diagnostic ability of DW-MRI in parallel with T2-weighted MRI (T2W-MRI) and dynamic contrast-enhanced MRI (DCE-MRI) in differentiating residual cancer from postoperative changes after initial TURBT. METHODS Between January 2013 and August 2015, a total of 67 patients underwent repeat TURBT at our institute. Of these 67 patients, 25 who underwent high-quality multi-sequence MRI including DCE-MRI and DW-MRI after initial TURBT and prior to repeat TURBT were retrospectively evaluated in the current study. Two urologists independently interpreted the images. Bladder wall thickening on T2W-MRI, early enhancement on DCE-MRI, and high signal intensity on DW-MRI with a b-value of 1000 s/mm2 were assigned to positive findings. Discrepancies were resolved by consensus. In the 25 eligible patients, 32 lesions were histologically evaluated in repeat TURBT. We analyzed the diagnostic abilities of each imaging sequence. RESULTS The interobserver agreement was excellent for T2W-MRI (κ = 0.840) and DW-MRI (κ = 0.936), and good for DCE-MRI (κ = 0.784). Of the 32 lesions, 16 were confirmed histologically to be a residual cancer (pTa/T1/T2 = 2/6/8). The sensitivity/specificity/accuracy of T2W, DCE, and DW-MRI were 94/13/52%, 100/13/58% and 100/81/91%, respectively. The specificity/accuracy of DW-MRI were significantly higher than that of T2W-MRI (p < 0.01/p < 0.01) and DCE-MRI (p < 0.01/p < 0.01). CONCLUSIONS The feasibility of DW-MRI in differentiating bladder cancer from postoperative change after initial TURBT was shown. The findings of DW-MRI showing high specificity can be a useful adjunct for selecting patients who can avoid repeat TURBT. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e138 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Yuki Nakamura More articles by this author Soichiro Yoshida More articles by this author Hiroshi Tanaka More articles by this author Masaharu Inoue More articles by this author Masaya Ito More articles by this author Minato Yokoyama More articles by this author Junichiro Ishioka More articles by this author Yoh Matsuoka More articles by this author Noboru Numao More articles by this author Kazutaka Saito More articles by this author Yasuhisa Fujii More articles by this author Kazunori Kihara More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Can immediate second resection be an alternative to standardized second transurethral resection of bladder tumors?

This study analyzed the impact of an immediate second transurethral resection of bladder tumor (TURBT) protocol on residual tumor status at the initial TURBT session and the recurrence rate in the primary resection area. We prospectively evaluated and randomized 47 consecutive patients who underwent TURBT sessions for bladder cancer. In accordance with the inclusion criteria, of the 47 consecutive patients, 19 (Group I) underwent immediate second resection of the tumor bed after complete TUR and 28 (Group II) did not. After standard TURBT, Group I underwent a second cystoscopy and resection of the bed of the tumor or an ignored tumor, which was performed by a different urologist. After 4–6 weeks, delayed second TURB was performed, and all pathological results were evaluated. Tumors were detected in two patients during the immediate second resection. Of these, one was a misdiagnosed tumor, whereas the other was diagnosed at the bed of the tumor by pathological examination. Tumors were detected in nine patients at the delayed second TURB, of which only one was part of Group I, while the others were part of Group II (p = 0.04). The results of this study demonstrated that residual tumors may remain after initial TURB, either in the tumor bed or in a different location within the bladder. Although this was a pilot study enrolling only a small number of patients, our initial results supported the assertion that immediate second resection can be an alternative to standard second TURBT.

Evaluation of second-look transurethral resection in the management of superficial bladder tumors

Objectives The aim of the present study was to evaluate the role of second-look transurethral resection of bladder tumors (TURBT) in the management of non-muscle-invasive bladder cancer (NMIBC). Background Bladder cancer is the ninth most common cancer diagnosis worldwide. Second-look TURBT ensures adequate evaluation of the muscularis propria while detecting and treating residual tumors. Patients and methods Thirty-one NMIBC patients underwent a second-look TURBT 2 weeks after the initial TURBT. The procedures carried out included reassessment of the bladder for the detection of residual lesions after initial resection, and the resection of the base of the previous resection site for restaging. Results Thirty-one NMIBC patients underwent second-look TURBT 2 weeks after the initial TURBT. Residual tumors were found in 28% of the patients with Ta tumors and 54.2% of the patients with T1 tumors (P = 0.445). The overall percent of residual tumors was 48.4% for all patients. Patients with Ta tumors had no upstaging to a higher stage or grade. On the other hand, in patients with T1 tumors we found that 50% of them were upstaged to T2. Thus, the overall upstaging to T2 was 38.7% of all NMIBC patients (P = 0.413). Conclusion Second-look TURBT is highly desirable in patients with high-grade T1 disease and large tumor size (>2-5 cm), especially if deep muscle is not found in the primary resection because of the significant risk for detecting muscle-invasive disease and missed residual tumors.

PD25-10 RESIDENT INVOLVEMENT IN ENDOSCOPIC BLADDER CANCER SURGERY IS ASSOCIATED WITH INADEQUATE PATHOLOGY SPECIMENS AND PROLONGED TIME TO CYSTECTOMY

You have accessJournal of UrologyBladder Cancer: Detection and Screening II1 Apr 2015PD25-10 RESIDENT INVOLVEMENT IN ENDOSCOPIC BLADDER CANCER SURGERY IS ASSOCIATED WITH INADEQUATE PATHOLOGY SPECIMENS AND PROLONGED TIME TO CYSTECTOMY Derek Bos, Christopher Allard, Shawn Dason, Vladimir Ruzhynsky, Anil Kapoor, and Bobby Shayegan Derek BosDerek Bos More articles by this author , Christopher AllardChristopher Allard More articles by this author , Shawn DasonShawn Dason More articles by this author , Vladimir RuzhynskyVladimir Ruzhynsky More articles by this author , Anil KapoorAnil Kapoor More articles by this author , and Bobby ShayeganBobby Shayegan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1659AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Transurethral resection of bladder tumor (TURBT) specimens lacking detrusor muscle are associated with clinical upstaging and the need for additional procedures which may delay curative treatment. We evaluated whether resident involvement in TURBTs is associated with adequacy of pathology specimens and time to cystectomy at a single academic centre in Ontario, Canada. METHODS We identified all TURBTs performed at St. Joseph's Healthcare Hamilton from November 2011 to June 2014. Charts were reviewed to determine baseline characteristics, resident involvement, and pathologic findings including presence of detrusor muscle. Logistic regression was used to assess associations between resident involvement and adequacy of tumor specimens. Among patients who underwent cystectomy, we assessed the time to cystectomy from initial high risk TURBT (high grade, ≥T1, or CIS), excluding patients with subsequent low risk TURBTs, BCG, or neoadjuvant chemotherapy. Associations between resident involvement with pathologic outcomes and time to cystectomy were determined with Chi−square and log rank tests, respectively. RESULTS A total 664 TURBTs were performed on 471 patients during the study period. Patient and tumor characteristics were comparable for TURBTs performed by attendings and residents. Attendings were more likely to obtain muscle in specimens for all TURBTs (OR1.68 [95%CI 1.09, 2.59], p=0.018) and for the subset of 275 high risk TURBTs (OR1.99 [95%CI 1.11, 3.55], p=0.019). Senior residents (PGY3−5) had higher odds of muscle in all (OR1.91 [95%CI 1.12, 3.25], p=0.017) and high risk (OR2.9 [95%CI 1.43, 5.9], p=0.003) specimens compared with juniors. In multivariate analysis adjusting for covariates patient age, sex, and tumor size, resident involvement was associated with inadequate tumor specimens among all patients (p=0.032) and only high risk tumors (p=0.049). Resident involvement was associated with a non-significant increased need for repeat TURBT. The median time from initial high risk TURBT to cystectomy was 73.3 (IQR 51.8, 131.4) and 49.4 (IQR 31.4, 65.7) days for residents and attendings, respectively (p=0.024). CONCLUSIONS Resident involvement during TURBTs is associated with inconclusive pathology and delayed time to cystectomy. Future studies should assess educational tools to improve endoscopic surgical training techniques minimizing effects of resident learning on patient outcomes. Further studies are needed to clarify the impact of resident involvement on long-term patient outcomes. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e564 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Derek Bos More articles by this author Christopher Allard More articles by this author Shawn Dason More articles by this author Vladimir Ruzhynsky More articles by this author Anil Kapoor More articles by this author Bobby Shayegan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The clinical significance of a second transurethral resection for T1 high-grade bladder cancer: Results of a prospective study

PurposeThis study was designed to estimate the value of a second transurethral resection of bladder tumor (TURBT) procedure in patients with initially diagnosed T1 high-grade bladder cancer.Materials and MethodsBetween August 2009 and January 2013, a total of 29 patients with T1 high-grade bladder cancer prospectively underwent a second TURBT procedure. Evaluation included the presence of previously undetected residual tumor, changes to histopathological staging or grading, and tumor location. Recurrence-free and progression-free survival curves were generated to compare the prognosis between the groups with and without residual lesions by use of the Kaplan-Meier method.ResultsOf 29 patients, 22 patients (75.9%) had residual disease after the second TURBT. Staging was as follows: no tumor, 7 (24.1%); Ta, 5 (17.2%); T1, 6 (20.7%); Tis, 6 (20.7%); Ta+Tis, 1 (3.4%); T1+Tis, 1 (3.4%); and ≥T2, 3 (10.3%). The muscle layer was included in the surgical specimen after the initial TURBT in 24 patients (82.7%). In three patients whose cancer was upstaged to pT2 after the second TURBT, the initial surgical specimen contained the muscle layer. In the group with residual lesions, the 3-year recurrence-free survival and 3-year progression-free survival rates were 50% and 66.9%, respectively, whereas these rates were 68.6% and 68.6%, respectively, in the group without residual lesions. This difference was not statistically significant.ConclusionsInitial TURBT does not seem to be enough to control T1 high-grade bladder cancer. Therefore, a routine second TURBT procedure should be recommended in patients with T1 high-grade bladder cancer to accomplish adequate tumor resection and to identify patients who may need to undergo prompt cystectomy.

Delays in the diagnosis and treatment of muscle invasive bladder cancer: A pilot project mapping the pathway

Background: The patient pathway for muscle invasive bladder cancer (MIBC) is multidisciplinary. Trans-urethral resection of bladder tumour (TURBT) counts as the first definitive treatment and subsequent definitive therapy thereafter is often delayed, which may adversely affect outcome. We elected to scrutinise the management pathway in detail to understand these delays and improve the patient experience. Method: A retrospective mapping analysis was conducted on 17 patients with MIBC. The causes of any delays and measures to avoid these were identified. A prospective study of 17 patients with MIBC was then undertaken to see if the strategies used to re-engineer the patient care pathway had been effective. Result: The median time from GP referral to first appointment was 9 days (range: 1–37) and from TURBT to subsequent radical treatment was 75 days (range: 27–105) in keeping with published literature. The median time for a referral letter from urology to oncology following MDT was 15 days. We therefore modified the MDT proforma to use as a formal referral, and a project manager proactively managed the patient pathway. Capacity issues were addressed by protecting clinical slots for bladder patients and establishing monthly evening clinics. After implementing the strategies, the median days from first appointment to TURBT improved from 31 to 23 days and time from TURBT to subsequent treatment improved from 75 to 66 days. The time from MDT referral to being seen by an oncologist or urologist significantly reduced from 32 to 15 days. Conclusion: Retrospective analysis identified delays between initial TURBT to definitive therapy and strategies adopted to reduce these were effective. TURBT is a diagnostic process and if acknowledged as first treatment results in delays of what is the definitive treatment. We found the initial diagnostic pathway to work well but non-muscle invasive bladder cancer (NMIBC) and MIBC are then managed very differently and warrant two separate pathways.

S093: Can immediate second resection be an alternative for standardized second transurethral resection of bladder tumor?

This study analyzed the impact of an immediate second transurethral resection of bladder tumor (TURBT) protocol on residual tumor status at the initial TURBT session and the recurrence rate in the primary resection area. We prospectively evaluated and randomized 47 consecutive patients who underwent TURBT sessions for bladder cancer. In accordance with the inclusion criteria, of the 47 consecutive patients, 19 (Group I) underwent immediate sec- ond resection of the tumor bed after complete TUR and 28 (Group II) did not. After standard TURBT, Group I underwent a second cystoscopy and resection of the bed of the tumor or an ignored tumor, which was performed by a different urologist. After 4e6 weeks, delayed second TURB was performed, and all pathological results were evaluated. Tumors were detected in two patients during the immediate second resection. Of these, one was a misdiagnosed tumor, whereas the other was diagnosed at the bed of the tumor by pathological examination. Tumors were detected in nine patients at the delayed second TURB, of which only one was part of Group I, while the others were part of Group II (p Z 0.04). The results of this study demon- strated that residual tumors may remain after initial TURB, either in the tumor bed or in a different location within the bladder. Although this was a pilot study enrolling only a small number of patients, our initial results supported the assertion that immediate second resection can be an alternative to standard second TURBT. Copyright a 2016, Kaohsiung Medical University. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/

Measuring the dimension of invasive component in pT1 urothelial carcinoma in transurethral resection specimens can predict time to recurrence

Recurrences of nonmuscle-invasive urothelial bladder cancer are very common following resection. Predictive histopathologic variables in transurethral resection of bladder tumor (TURBT) specimens are of particular importance especially in determining the behavior of lamina propria-invasive tumors (high grade T1 stage). A total of 110 patients who underwent TURBT for urothelial carcinoma (1997-2005) from a single institution were retrospectively reviewed. Amount of tumor invasion by urothelial carcinoma was assessed in terms of percentage, focality (focal vs multifocal), and dimension (DI, aggregate length of invasion). Of 110 patients, 39 (35%) were found to have invasive high-grade urothelial carcinoma, including 9 females. Mean age was 70 years (range, 56-94 years). Twenty-three patients with high-grade T1 urothelial carcinoma had available follow-up information. Recurrence rate in these 23 patients was 96% (22/23). Nearly all of the recurences (221/22, 95%) occurred within 1 year of the initial TURBT. There was an inverse correlation of DI with time to recurrence (P < .05; correlation coefficient, -0.47). Urothelial carcinoma with a greater DI (>0.5 cm) had a mean time to recurrence of less than 6 months. Percentage of tumor invasion and focality was not associated with recurrence. The aggregate length of invasion may be a prognostic variable for high-risk nonmuscle-invasive bladder cancer. Measuring "aggregate length of invasive tumor," if further validated in larger studies, could provide a practical alternative in substaging pT1 tumors in TURBT specimens.

Destruction of the bladder by single dose Mitomycin C for low‐stage transitional cell carcinoma (TCC) – avoidance, recognition, management and consent

To identify a cohort of patients under our care who have had significant and in some cases irreparable damage to their bladders after Mitomycin C (MMC) instillation. To highlight the importance of avoidance and recognition of bladder perforations during transurethral resection of bladder tumour (TURBT) and explore the issue of consent regarding MMC given the serious complications that may occur after its instillation. Patients referred to our tertiary centre for a second opinion to manage their complications after a suspected MMC leak was identified from the departmental database between January 2000 and December 2010. After collection of all the records, we established a cohort of six patients. All patients had their initial tumour resection elsewhere and were referred for specialist management thereafter. Details of the operating surgeon and cystoscopic findings were known only in half of the cases. Retrospective analysis of their notes including documentation from the referring centre was undertaken. This included a review of all the histology and imaging. All patients had immediate severe pelvic pain on instillation of the MMC. Four of the six continue to have chronic pelvic pain. Two patients had urinary retention and three had severe lower urinary tract symptoms. One patient developed a frozen pelvis. Initial treatment was with an indwelling catheter for a period of 2-52 weeks to aid healing. Two patients had reconstructive surgery, one with success and the other with failure, as an intestinal patch failed to close the fistula and he continues with a catheter. One patient had an ileal conduit. No patient was warned of such complications. Although rare, prophylactic MMC can have devastating consequences. Patients should be aware of such major risks. Strong emphasis should be placed on the quality of the initial TURBT coupled with the judgement of an experienced surgeon before to MMC instillation. The real clinical benefit could be reviewed and intravesical MMC offered only to patients who have a good chance of benefit.

Time between First and Second Transurethral Resection of Bladder Tumors in Patients with High-Grade T1 Tumors: Is It a Risk Factor for Residual Tumor Detection?

Purpose: We evaluated the risk factors for residual tumor detection after transurethral resection of bladder tumors (TURBT) in patients with newly diagnosed high-grade T1 transitional cell carcinoma of the bladder. Patients and Methods: Overall 132 patients underwent TURBT for primary bladder tumors and were diagnosed as high-grade T1 bladder cancer. Patients with incomplete resections were excluded from the study. Clinical and pathologic characteristics of the patients were compared and multivariate analysis was performed to determine independent prognostic factors. Results: Residual tumor was demonstrated in 57 (43.1%) of the patients. The residual tumor rate was significantly lower in patients with solitary tumors, tumors <3 cm in diameter, muscle presence in the initial TURBT pathologic sample and treated by an expert surgeon. In patients with solitary bladder tumors, tumors at the dome and posterior wall of the bladder exhibited higher rates of residual tumor (p < 0.0001). The time elapsed between first and second TURBT was significantly shorter in patients without residual tumor compared to patients with residual tumor at second TURBT (32.6 ± 9.1 vs. 39.3 ± 10.9 days, respectively, p = 0.001). Multivariate analysis demonstrated that time elapsed between first and second TURBT is the most important parameter for residual tumor detection. Conclusion: Our study revealed that multiple tumors, tumors >3 cm in size, absence of detrusor muscle in the initial TURBT specimen, TURBT performed by trainees and finally, as a new finding, prolonged interval between first and second TURBT are independent predictors for residual tumor detection in patients with high-grade T1 tumors.

The value of extended transurethral resection of bladder tumour (TURBT) in the treatment of bladder cancer

Transurethral resection of bladder tumour (TURBT) is the 'gold standard' in the diagnosis and therapy of non-muscle-invasive bladder cancer. To improve the quality of this technique an additional TUR (after 4-6 weeks) or a simultaneous photodynamic diagnosis is often offered. The present study shows different variables that influence, to a greater or lesser extent, the accuracy of the TUR diagnosis and the success of the operation. This is very important for the further management of bladder cancer, be it in tumour follow-up or in preparation for more invasive therapies. To analyse the impact of a standardised extended transurethral resection of bladder tumour (TURBT) protocol on the determination of the residual tumour status at initial TURBT session and recurrence rate in the primary resection area. Despite, the fact that there is a clear consensus on the aims of TURBT, there is little agreement on how to perform TURBT to achieve that goal. We retrospectively evaluated 221 consecutive patients, who underwent 305 TURBT sessions for bladder cancer, including patients with recurrent tumours. All the TURBTs were extended by taking additional deep and marginal specimens, according to a standardised protocol. Clinical and histopathological data were retrieved from the patients' records. Across all tumour stages, residual tumour (pR1) was found in 38% of the additionally taken specimens. There was a significant association of pR1 status with tumour stage, grade, and size. Also in the group of non-muscle-invading tumours, the rate of R1 resection was rather high at 22%. There was no association with focality and the training status of the surgeon. At follow-up, of all the patients with a unifocal primary tumour there was recurrence in the same area as the primary in 5.1%. Extended TURBT provides detailed information about the horizontal and vertical extent of the bladder tumour. The implementation of standardised TURBT procedures, such as our protocol of an extended TURBT, is greatly needed to improve local tumour control. Whether a diagnostic re-TUR may be restricted to those cases with positive margins or ground specimens remains to be studied.

“Complete Transurethral Resection of Bladder Tumor”: Are the Guidelines Being Followed?

To determine how often complete eradication of all visible tumors during transurethral resection of bladder tumor (TURBT) is accomplished in a referral setting. The American Urological Association guidelines recommend complete eradication whenever possible. We retrospectively reviewed the records of patients who underwent a second TURBT within 4 weeks of being referred to us. Relevant data such as residual tumor location, number, stage, and grade were collected and analyzed. Patients with muscle invasive tumor or known incomplete resection were excluded. Forty-seven patients met the inclusion criteria. Mean age was 75 years. In the initial TURBT, 35 (75%) had a high grade tumor and 12 (25%) had low grade tumors. Twenty-four (52%) were Ta and 23 (48%) were T1 tumors. Of the 47 patients who satisfied the criteria, 33 (70%) had an initial incomplete resection. Of these, 10 (30%) had macroscopic residual tumor at the resection site. Twenty-three (70%) had at least 1 unresected tumor away from the previous resection site. There were 39 unresected or partially resected tumors. Thirteen (33%) tumors were located in the anterior wall, 12 (31%) in the posterior wall and trigone, 10 (26%) in the lateral wall, 3 (7.5%) in the dome, and 1 (2.5%) in the prostatic urethra. Although TURBT is a commonly performed operation, in this selected series, the incidence of unresected and gross residual tumor after initial TURBT is high. This indicates a need to emphasize the guidelines for a complete resection and to emphasize the use of a proper technique in this commonly performed urological procedure.

Relook TURBT in superficial bladder cancer: Its importance and its correlation with the tumor ploidy

Objective To evaluate various prognostic factor predictors of residual growth in Relook transurethral resection of bladder tumor (TURBT) in superficial bladder cancer. Also, to evaluate the role of Relook TURBT along with the ploidy for prediction of recurrence and stage progression in these patients. Material and Methods Fifty patients with superficial bladder cancer underwent TURBT after complete evaluation. Ploidy of the tumor specimen was evaluated by flow cytometry. After 4 to 6 weeks of initial TURBT, these patients underwent Relook TURBT. Final treatment was given after the results of the histological evaluation of these specimens. Patients who underwent bladder sparing treatment were followed-up. Results Of the patients, 28.5% had residual tumor in Relook TURBT. Growth was found to be at the same site in 66.7% and at a different site 33.3%; 75% had single while 25% had multiple residual growth. Residual malignant tissue had a statistically significant correlation with size of the tumor (>3 cm), appearance (solid tumor), number (>3), grade (high), and multiple previous resections. Overall, the up-migration of stage and grade leads to change in treatment in 41.6%; 5 underwent radical cystectomy and 1 opted for radiotherapy; in 2 patients, intravesical BCG was given. In follow-up of mean 11.5 months, 16.6% had recurrence. Presence of residual growth in Relook TURBT along with number, size, morphology, and multiple previous resections were found to have significant correlation with the recurrence in these patients. Ploidy and grade of the tumor were not found to have correlation. Conclusions Multiple, more than 3 cm, solid high grade tumor with > 3 previous resections were predictors of presence of residual tumor in Relook TURBT. Presence of residual growth is a significant risk factor for recurrence. Ploidy was not found to be significantly correlated with recurrence.

Clinical outcome of conservative therapy for stage T1, grade 3 transitional cell carcinoma of the bladder.

The objective of this study was to retrospectively investigate the effectiveness of transurethral resection of bladder tumor (TURBT) and intravesical instillation therapy for stage T1, grade 3 (T1G3) transitional cell carcinoma (TCC) of the urinary bladder. Between January 1995 and December 1997, 97 patients with T1G3 TCC of the urinary bladder were treated by TURBT and adjuvant intravesical instillation with bacillus Calmette-Guérin (BCG) or other anticancer agents. The recurrence-free survival rates were evaluated according to several clinicopathological factors. The cases that progressed to muscle invasive disease were also analysed. In this series, the median follow-up period was 25 months (range, 5- 41) after the initial TURBT. Intravesical recurrence was noted in 44 patients (45%), and the 1, 2, and 3 year recurrence-free survival rates were 72%, 58%, and 42%, respectively. Multivariate analyses revealed that the risk of intravesical recurrence was significantly higher for patients who did not receive BCG therapy, irrespective of age, gender, tumor size, multiplicity, pathological stage, concomitant carcinoma in situ, and lymphovascular involvement. Moreover, after a median of 10 months, disease progression occurred in seven patients (7%), of which only one patient was treated by BCG therapy after initial TURBT. These findings suggest that intravesical instillation with BCG combined with TURBT is an effective conservative treatment for T1G3 TCC of the bladder. Patients with negative prognostic factors should be treated by BCG rather than other anticancer agents after TURBT.

Conservative therapy for stage T1b, grade 3 transitional cell carcinoma of the bladder

Objectives. To retrospectively evaluate the usefulness of transurethral resection of bladder tumor (TURBT) and intravesical instillation for pT1bG3 transitional cell carcinoma of the urinary bladder. Methods. Between May 1984 and May 1997, 45 patients with pT1bG3 transitional cell carcinoma of the urinary bladder underwent TURBT and intravesical instillation with bacillus Calmette-Guérin (BCG) or other anticancer agents. Random biopsy was carried out in 37 patients. The recurrence-free survival rate was determined by tumor size, number of tumors, lymphovascular invasion, and drugs used for intravesical instillation. The median follow-up period was 63 months (range 4 to 145) after the initial TURBT. Results. Of 37 patients who underwent random biopsy, concomitant carcinoma in situ was detected in 18 patients (48.6%). The incidence of concomitant CIS was significantly higher in patients with multiple tumors ( P = 0.029). Vesical recurrence was noted in 16 patients (35.6%). The overall 1-, 3-, and 5-year recurrence-free survival rates were 88.5%, 66.7%, and 66.7%, respectively. Progression (muscular invasion) occurred in only 2 patients (4.4%). Total cystectomy was performed in 4 patients, including the 2 patients with progressive disease, and 2 patients with recurrent CIS that resisted BCG therapy. None of the patients died of bladder cancer. Conclusions. Our results suggest that aggressive attempts at initial or subsequent TURBT combined with BCG therapy achieved good control of pT1bG3 transitional cell carcinoma of the urinary bladder.