Initial TUR Research Articles

Do we need a re-TUR after en bloc resection of T1 stage bladder cancer?

BackgroundA second look trans-urethral resection of the bladder (re-TUR) is recommended after the diagnosis of T1 high grade (T1HG) bladder cancer. Few studies have evaluated the results of re-TUR after a first en bloc resection (EBR) and none of them have specifically reported the pathological results on the field of previous T1 disease.ObjectiveTo report the rate of upstaging and the rate of residual disease (RD) on the field of T1HG lesions resected with EBR.Materials and methodsBetween 01/2014 and 06/2022, patients from 2 centers who had a re-TUR after an EBR for T1HG urothelial carcinoma were retrospectively included. Primary endpoint was the rate of RD including the rate of upstaging to T2 disease on the scar of the primary resection. Secondary endpoints were the rate of any residual disease outside the field.ResultsSeventy-five patients were included. No muscle invasive bladder cancer lesions were found after re-TUR. Among the 16 patients who had a RD, 4 were on the resection scar. All of these lesions were papillary and high grade. RD outside the field of the first EBR was observed in 12 patients.ConclusionAfter EBR of T1HG disease, none of our patients had an upstaging to MIBC. However, the rate of RD either on and outside the field of the EBR remains quite significant. We suggested that predictive factors of residual papillary disease (number of tumors at the initial TUR and concomitant CIS) might be suitable to select patient who will benefit of the re-TUR.

Could We Safely Avoid a Second Resection in Selected Patients With T1 Non-Muscle-Invasive Bladder Cancer? Preliminary Results of Cost-Effectiveness Study From HUmanitas New Indications for ReTUR (HuNIRe) Multicenter Prospective Trial.

ObjectivesThe aim of this study is to assess whether restaging transurethral resection (ReTUR) could be safely replaced with urine cytology (UC) and in-office fiexible cystoscopy in selected T1 non-muscle-invasive bladder cancer (NMIBC).Materials and MethodsThis is an ongoing prospective multicenter trial enrolling patients diagnosed with T1 BC from 5 Italian centers. Patients with a macroscopically incomplete initial resection or absence of detrusor muscle were subjected to ReTUR according to European Association of Urology (EAU) guidelines. Conversely, those with a complete tumor resection at initial TUR underwent UC at 3–4 weeks and in-office fiexible white-light and narrow-band cystoscopy at 4–6 weeks. In case of positive UC, or evidence of recurrence at cystoscopy, ReTUR was performed within 2 weeks. Otherwise, patients started Bacillus Calmette–Guérin (BCG) induction course without ReTUR. The primary endpoint was to determine the feasibility and the clinical utility of not performing ReTUR in selected T1 NMIBC patients. The secondary endpoint was to perform a cost–benefit analysis of this alternative approach.ResultsSince May 2020, among 87 patients presenting with T1, 76 patients were enrolled. Nineteen (25%) patients underwent standard ReTUR after initial resection, 10 (13.2%) due to the absence of the detrusor muscle and 9 (11.8%) due to a macroscopically incomplete initial TUR. Overall, 57 (75%) patients initially avoided immediate ReTUR and underwent UC plus in-office flexible cystoscopy. Among them, 38 (66.7%) had no evidence of residual disease and immediately started the BCG induction course. Nineteen patients (33.3%) underwent “salvage” ReTUR due to either positive UC (7; 12.3%) or suspicious cystoscopy (12; 21%). Considering only the patients who initially avoided the ReTUR, disease recurrence was observed in 10/57. The saving of resource for each safely avoided ReTUR was estimated to be 1,759 €. Considering the entire sample, we estimated a saving of 855 € per patient if compared with the EAU guideline approach.ConclusionThe preliminary results of our trial suggested that ReTUR might be safely avoided in highly selected T1 BC patients with a complete resection at first TUR. Longer follow-up and larger sample size are needed to investigate the long-term oncological outcomes of this alternative approach.

Restaging transurethral resection in ta high-grade nonmuscle invasive bladder cancer: a systematic review.

The role of a re-transurethral resection (TUR) is clearly demonstrated in T1 high-grade nonmuscle invasive bladder cancer. However, its role remains controversial for Ta high-risk tumors and the recent European guidelines stated that the second look procedure could be avoided for these patients despite harboring a high-risk of both disease recurrence and progression. We aimed to evaluate the added benefit on staging, response to bacillus Calmette-Guérin and oncological outcomes of re-TUR in patients with Ta high-grade nonmuscle invasive bladder cancer. Overall, we identified 15 studies, including 3912 patients from which 743 harbored Ta high-grade disease. Delay between first and second TUR was ranging from 2 to 12 weeks (median 5.6 weeks). The rate of residual disease was 52.8% (range 17-67%). The rate of overall upstaging to T1 and muscle-invasive disease were 10.9 and 4.7%, respectively. Although there was a trend toward improvement of recurrence-free survival outcomes, no definitive conclusions can be drawn due to the retrospective design of the studies included. Residual tumor is common after initial TUR for Ta high-grade. Re-TUR is useful in reducing the rates of residual disease, may improve staging, response to bacillus Calmette-Guérin and oncological outcomes.

RECURRENCE RATE AFTER REPEAT TRANSURETHRAL RESECTION AMONG PATIENTS WITH NEWLY DIAGNOSED T1 BLADDER CANCER

Background: Transurethral resection of the bladder tumor (TURBT) is the cornerstone of diagnosis and TURBT followed by selective adjuvant intravesical chemotherapy or immunotherapy is the gold standard of treatment for the patients with non-muscle invasive bladder cancer (NMIBC). Even after complete resection of the tumor there is high risk of residual tumor and subsequent recurrence and progression of the disease. The recurrence of T1 tumor is found to be around 71 % within 5 years and High grade T1 lesions recur in more than 80% of the cases and progress in 50% of the patients within 3 years. Disease status at 3 months after initial resection is an important predictor of subsequent recurrence and progression. To assess the tumor recurrence rat Objective: e among patients with newly diagnosed T1 bladder cancer between repeat transurethral resection group and single TURBT group. Ra Type of study: ndomized controlled trial. Place of study: Department of urology, BSMMU, Dhaka, Bangladesh. This Randomi Materials And Methods: zed Controlled Trial was conducted in urology department of BSMMU, Dhaka, Bangladesh from February 2017 till September 2018. A total of 50 patients, diagnosed as a case of T1 bladder cancer and who fulll the selection criteria were randomly divided in two groups consisting of 25 patients in each group. After informed consent, repeat TUR was done after 4 weeks of the initial TURBT for only 22 patients in group I since 3 of the patients did not show up on the scheduled date of surgery. Whereas, repeat TUR was not done for other 25 patients in group II. All the patients in both the groups were further treated with intravesical therapy according to the histopathological report. The patients in both the groups were followed up at 3 months and 6 months of the initial intervention where detailed history was taken, relevant investigations were done and check cystoscopy was done. TURBT was done for recurrent tumors. Out of 22 patients in group I, 2 patients were excluded for follow up on the basis of repeat TUR ndings. Whereas in group II, 2 patients missed the follow up and one of them missed the normal scheduled dose of intravesical therapy. Hence, 22 patients completed the study in group II. The baseline variables like age and Results: sex were similar in both the groups with higher male predominance. There was no statistical signicant difference in tumor characteristics such as size, number and grade of the tumor between the two groups. Out of 22 patients in group I who underwent repeat TUR at 4 weeks of initial TUR, residual disease was found in 8 (36.36%) patients. One of the patient was found to have T2 disease and 1 patient had CIS during repeat TUR. These 2 patients were not followed up since the treatment strategy changed after the results of repeat TUR. After 6 months of follow up of all the patients, 2 (10%) out of 20 patients in group I were found to have tumor recurrence however, in group II, 9 (40.9%) patients had tumor recurrence. The tumor recurrence rate between the two groups was found to be statistically signicant (p=0.023). In the light of ndings of this Conclusion: study, it can be concluded that performing repeat transurethral resection in patients with newly diagnosed T1 bladder cancer at 4 weeks of initial TURBT, helps to detect signicant number of residual tumor and reduce early recurrence rate of the tumor.

Preoperative predictive factors of carcinoma in situ in the normal-appearing mucosa in patients who underwent an initial transurethral resection for non-muscle-invasive bladder cancer under white light cystoscopy.

BackgroundAlthough few studies evaluated the significance of random biopsies under white light cystoscopy (WLC) in patients with non‐muscle‐invasive bladder cancer (NMIBC), the findings are controversial.AimThis aim of this study was to evaluate what kind of preoperative covariates were useful as predictive factors in detecting carcinoma in situ (CIS) from normal‐appearing mucosa using random bladder biopsies under WLC.Methods and ResultsA total of 229 patients with NMIBC underwent initial TUR followed by random biopsies under WLC at Red Cross Takayama Hospital between 2007 and 2016. These patients underwent TUR with complete resection of intravesical visible tumors followed by random biopsies of normal‐appearing mucosa. In this study, random bladder biopsies of normal‐appearing urothelial mucosa, excluding abnormal mucosa, were carried out with a cold punch in the selected intravesical sites. The covariates included age, gender, the urine cytology result, presence of an abnormal mucosa, number of tumors, size of the largest tumors, configuration of the tumor, and tumor type. Abnormal mucosa was defined as reddish or mossy areas at the time of TUR under WLC. The primary endpoint was to determine what kind of preoperative covariates were useful as predictive factors in detecting CIS from normal‐appearing mucosa using random bladder biopsies under WLC. Finally, 212 patients were evaluated, and 67 patients (31.6%) were diagnosed with CIS from normal‐appearing mucosa. In univariate analysis, positive urine cytology, abnormal mucosa, and the number of tumors were significantly associated with concomitant CIS. On multivariate analysis, positive urine cytology and abnormal mucosa were significantly associated with CIS.ConclusionThe patients who were diagnosed with positive urine cytology or abnormal mucosa by WLC are ideal candidates for TUR followed by random biopsy of normal‐appearing mucosa.

Short-term efficacy and predictive factors of BCG instillation in high risk non-muscle invasive bladder cancer

Objective To investigate the short-term efficacy, safety and factors affecting the efficacy of BCG intravesical therapy in high risk non-muscle-invasive bladder cancer (NMIBC) patients. Methods A total of 161 high-risk non-muscle invasive bladder cancer (NMIBC) patients were reviewed in our hospital from March 2014 to December 2017. They were all treated with BCG instillation after transurethral resection of bladder tumor (TURBT). There were 121 males (75.2%) and 40 females (24.8%). Median age was 65 years old, including 17 cases (10.6%) <50 years old, 23 cases (14.3%) within 50-59 years old, 72 cases (44.7%) within 60-69 years old, 49 cases ≥70 years old (30.4%). There were 112 patients (69.6%) with primary bladder cancer and 49 (30.4%) patients with recurrent bladder cancer. 56 cases (34.8%) had single tumor and 105 cases (65.2%) had multiple tumors. The tumors size in 106 cases (65.8%) was less than 3 cm, and tumor size in 55 cases (34.2%) was more than 3 cm. 43 patients (26.7%) suffered carcinoma in situ. 10 patients (6.2%) suffered urothelial carcinoma with variant types. According to the American Joint Commission for Cancer (AJCC) version 7 TNM staging system, 25 cases (15.5%) were classified into Ta stage, 129 cases (80.1%) were classified into T1 stage, and 7 cases (4.3%) were classified into Tis stage. There were 8 cases (5%) with low-grade cancer and 153 cases (95%) with high-grade cancer. 69 patients (42.9%) received chemo-instillation before. 43 cases were directly perfused without re-TURBT and 118 cases were perfused after re-TURBT. They were all treated with BCG instillation after transurethral resection of bladder tumor (TURBT). The 120 mg BCG were dissolved into 50 ml saline for instillation and were kept for 2 hours. Induction scheme of six-weekly and three fortnightly instillations started two weeks after the initial TUR or re-TUR. Maintenance instillations were then be offered in a scheme of ten monthly instillations. During treatment, patients were offered cystoscopy and cytology every three months, while CT and chest radiographs were reviewed every 6-12 months. Recurrence status and adverse effects were recorded. Univariate and multivariate regression analyses were performed to predict risk factors for failure of BCG instillation in bladder cancer. Results A total of 161 patients were followed up. The median follow-up time was 13 months, ranging 7-22 months. The overall recurrence rate was 26.1% (42/161) and the 1-year recurrence-free survival rate was 79.0%. On univariate analysis, recurrence history, history of instillation chemotherapy application and history of re-staging transurethral resection influenced recurrence. Multivariate regression analysis showed recurrence status was an independent prognostic factor regarding recurrence-free survival. The incidence of adverse events in all 161 instillation patients was 40.4% (26/65). Grade 1, grade 2 and grade 3 adverse events accounted for 53.8%(35/65), 40.0%(26/65) and 6.2%(4/65) respectively. 6 cases (3.7%) reduced the dose of BGC and 1 case stop the instillation due to the intolerance of BCG. Conclusion Short-term efficiency and safety were confirmed in BCG-treated high-risk NMIBC patients. And recurrence status was an independent prognostic factor for recurrence-free survival. Key words: Bacillus Calmette-Guerin; Bladder cancer; Intraversical instillation

MP58-02 GENOMIC DIFFERENCES BETWEEN “PRIMARY” AND “SECONDARY” MUSCLE INVASIVE BLADDER CANCER: IMPLICATIONS FOR NEOADJUVANT CHEMOTHERAPY

You have accessJournal of UrologyBladder Cancer: Invasive V1 Apr 2017MP58-02 GENOMIC DIFFERENCES BETWEEN “PRIMARY” AND “SECONDARY” MUSCLE INVASIVE BLADDER CANCER: IMPLICATIONS FOR NEOADJUVANT CHEMOTHERAPY Eugene Pietzak, Aditya Bagrodia, Hikmat Al-Ahmadie, Harry Herr, Emily Zabor, David Barron, Qiang Li, Francois Audenet, Samuel Funt, Ahmet Zehir, Maria Arcila, Priscilla Baez, Michael Berger, Nikolaus Schultz, David Solit, Dean Bajorin, Jonathan Rosenberg, Eugene Cha, Bernard Bochner, and Gopa Iyer Eugene PietzakEugene Pietzak More articles by this author , Aditya BagrodiaAditya Bagrodia More articles by this author , Hikmat Al-AhmadieHikmat Al-Ahmadie More articles by this author , Harry HerrHarry Herr More articles by this author , Emily ZaborEmily Zabor More articles by this author , David BarronDavid Barron More articles by this author , Qiang LiQiang Li More articles by this author , Francois AudenetFrancois Audenet More articles by this author , Samuel FuntSamuel Funt More articles by this author , Ahmet ZehirAhmet Zehir More articles by this author , Maria ArcilaMaria Arcila More articles by this author , Priscilla BaezPriscilla Baez More articles by this author , Michael BergerMichael Berger More articles by this author , Nikolaus SchultzNikolaus Schultz More articles by this author , David SolitDavid Solit More articles by this author , Dean BajorinDean Bajorin More articles by this author , Jonathan RosenbergJonathan Rosenberg More articles by this author , Eugene ChaEugene Cha More articles by this author , Bernard BochnerBernard Bochner More articles by this author , and Gopa IyerGopa Iyer More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1797AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We recently reported that patients with secondary muscle-invasive bladder cancer (MIBC) have substantially worse outcomes with neoadjuvant chemotherapy compared to primary MIBC (Pietzak, et al. AUA 2016). We subsequently used next-generation sequencing to investigate genetic differences between primary and secondary MIBC specimens. METHODS We examined MIBC specimens from the Cancer Genome Atlas (TCGA) (n=131), our institutional genomic research database (n=569), and a prospective clinical sequencing protocol (n=214) to identify 342 chemotherapy-naive urothelial MIBC specimens (270 primary and 72 secondary) that underwent whole-exome or targeted exon-capture sequencing. Primary and secondary MIBC specimens were compared for genomic alterations in 341 known cancer genes. Primary MIBC was defined as clinical stage ≥T2 on either initial or re-staging TUR on first bladder tumor diagnosis. Patients with a history of NMIBC (Tis, Ta, or T1 with uninvolved detrusor muscle in specimen) confirmed by a second cystoscopy prior to the eventual diagnosis of clinical stage ≥T2 were considered to have secondary MIBC. RESULTS We compared 270 primary and 72 secondary MIBC specimens for differences in genomic alterations in 341 cancer-associated genes. We identified significantly different rates of ERCC2, APC, and FGFR3 alterations. FGFR3-activating mutations (S249C, Y373C) occurred more frequently in secondary MIBC specimens (18% [13/72] vs. 9% [24/270], p=0.03). APC mutations were only seen in primary MIBC specimens (5% [14/270] vs. 0% [0/72], p=0.047). Surprisingly, ERCC2 missense mutations, which are associated with extreme sensitivity to cisplatin chemotherapy, only occurred in primary MIBC specimens (12% [32/270] vs. 0% [0/72], p<0.001). After adjusting for multiple comparisons using the Benjamini-Hochberg false discovery rate method, only ERCC2 mutations remained significant (adjusted p =0.016). CONCLUSIONS ERCC2 is involved in repair of cisplatin-induced DNA damage, and mutations in ERCC2 are associated with clinical responses to cisplatin. ERCC2 mutations occurred exclusively in primary MIBC patients and may account for their improved outcomes with neoadjuvant chemotherapy compared to secondary MIBC patients. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e772-e773 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Eugene Pietzak More articles by this author Aditya Bagrodia More articles by this author Hikmat Al-Ahmadie More articles by this author Harry Herr More articles by this author Emily Zabor More articles by this author David Barron More articles by this author Qiang Li More articles by this author Francois Audenet More articles by this author Samuel Funt More articles by this author Ahmet Zehir More articles by this author Maria Arcila More articles by this author Priscilla Baez More articles by this author Michael Berger More articles by this author Nikolaus Schultz More articles by this author David Solit More articles by this author Dean Bajorin More articles by this author Jonathan Rosenberg More articles by this author Eugene Cha More articles by this author Bernard Bochner More articles by this author Gopa Iyer More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP13-02 IS RE-RESECTION NECESSARY? RE-RESECTION OF NON-MUSCLE INVASIVE BLADDER CANCER AT A TERTIARY CARE CENTER

You have accessJournal of UrologyBladder Cancer: Non-Invasive I1 Apr 2016MP13-02 IS RE-RESECTION NECESSARY? RE-RESECTION OF NON-MUSCLE INVASIVE BLADDER CANCER AT A TERTIARY CARE CENTER Rano Matta, Ashraf Al Matar, Bimal Bhindi, Alexander Zlotta, Neil Fleshner, Michael Jewett, Robert Hamilton, Antonio Finelli, and Girish Kulkarni Rano MattaRano Matta More articles by this author , Ashraf Al MatarAshraf Al Matar More articles by this author , Bimal BhindiBimal Bhindi More articles by this author , Alexander ZlottaAlexander Zlotta More articles by this author , Neil FleshnerNeil Fleshner More articles by this author , Michael JewettMichael Jewett More articles by this author , Robert HamiltonRobert Hamilton More articles by this author , Antonio FinelliAntonio Finelli More articles by this author , and Girish KulkarniGirish Kulkarni More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2483AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Re-staging transurethral resection (re-TUR) of T1 bladder tumors provides more accurate staging, and is associated with better local control. Re-TUR has been included in guidelines for management of non-muscle invasive bladder cancer since 2007. However, in practice, re-TUR has been questioned in the setting of perceived complete resection at initial TUR, amongst other patient and surgeon specific factors. We aimed to understand the practice patterns of re-TUR of T1 urothelial carcinoma at our center and its predictors. We also determined outcomes associated with re-TUR at a Canadian tertiary care center. METHODS We retrospectively identified 358 consecutive patients with pT1 high grade urothelial carcinoma of the bladder who were treated at the University Health Network, Toronto, from 2000 to 2012. We excluded those who had metastatic disease on diagnosis, those treated primarily with cystectomy or chemotherapy/radiation after TURBT. Those treated with early cystectomy or chemotherapy/radiation after re-TUR were not included in the final cohort. Patients who did not undergo immediate/early cystectomy were offered adjuvant BCG therapy. The remaining 270 patients were included in the final analysis. We compared re-TUR rates in the pre- (2000-2008) and post-guideline (2009-2012) era. End points were time to recurrence, time to progression (defined as stage T2 or higher), and mortality. Univariate and multivariate analyses were used to determine any significant effect of patient specific factors (age, gender) and disease specific factors (associated CIS, muscle sampled, immediate chemotherapy) on proceeding for re-TUR. We also performed Cox-proportional hazard models to determine risk factors for recurrence, progression, and survival. RESULTS The median age of the cohort was 68.9 years (18-97) with a mean follow up 3.3 years (0.08-13.3 years). Re-TUR was performed in 109 patients (40%). The average re-TUR rate increased after 2008 from 31.6% to 51.3% (p=0.038). There was residual tumor in 70% of re-TUR cases. Upstaging to T2 disease on re-TUR was seen in 16.5% of patients. There was residual pT1 in 29.4% of cases. Residual T1 disease at re-TUR was a significant risk factor for progression (HR 38.1; CI 5.9-246.6). Re-TUR was not a significant risk factor for recurrence, progression or mortality. CONCLUSIONS Overall, re-TUR is an important therapy, decision-making and prognostication tool in NMIBC. However, in terms of the effectiveness of re-TUR on recurrence and progression, further prospective studies will provide more definitive information. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e134 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Rano Matta More articles by this author Ashraf Al Matar More articles by this author Bimal Bhindi More articles by this author Alexander Zlotta More articles by this author Neil Fleshner More articles by this author Michael Jewett More articles by this author Robert Hamilton More articles by this author Antonio Finelli More articles by this author Girish Kulkarni More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP52-17 ENDOSCOPIC TREATMENT OF POSTERIOR URETHRAL STRICTURES FOLLOWING SIMPLE AND RADICAL PROSTATECTOMY: SUCCESS AND INCONTINENCE RATES

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) II1 Apr 2016MP52-17 ENDOSCOPIC TREATMENT OF POSTERIOR URETHRAL STRICTURES FOLLOWING SIMPLE AND RADICAL PROSTATECTOMY: SUCCESS AND INCONTINENCE RATES Clemens M. Rosenbaum, Tim A. Ludwig, Philip Reiss, Georg Salomon, Margit Fisch, and Sascha A. Ahyai Clemens M. RosenbaumClemens M. Rosenbaum More articles by this author , Tim A. LudwigTim A. Ludwig More articles by this author , Philip ReissPhilip Reiss More articles by this author , Georg SalomonGeorg Salomon More articles by this author , Margit FischMargit Fisch More articles by this author , and Sascha A. AhyaiSascha A. Ahyai More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.493AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Vesicourethral stenosis (VUS) after radical prostatectomy (RP) and bladder neck contracture (BNC) after simple prostatectomy (SP) are the most common cause for posterior urethral strictures. Our study objective is to compare outcomes of endoscopic treatment for patients treated for VUS and BNC. METHODS A retrospective analysis of patients who underwent TUR for VUS after RP or for BNC after SP between 2009 and 2014 at our institutions was performed. Patients with BNC after primary radiation therapy for prostate cancer without any history of prostate surgery were excluded. All patients who returned a self-administered standardized non-validated questionnaire were additionally interviewed by telephone. Primary end point was the treatment specific success rate (no history of further surgery or catheterisation). Secondary endpoint was new onset incontinence after TUR. Patients were stratified in two groups (TUR for VUS vs. TUR for BNC). For statistical calculation descriptive as well as univariate logistic regression were applied. RESULTS 103 patients required 135 procedures. In 86 cases TUR was performed for VUS, in 49 cases TUR was done for BNC. Median FU was 27 and 24 month, respectively. Groups did not differ in age, preoperative uroflowmetric assesment, time between initial therapy and first TUR and time to recurrence after TUR. Overall succes rate was 38.4% in patients with VUS vs 53.1% in patients with BNC. Results were not significantly different (p=0.07). Patients who underwent TUR for VUS had to undergo significantly more often radiation therapy (p= 0.01) prior TUR. New onset incontinence occurred significantly more often in patients undergoing TUR for VUS (14% vs 2%, p=0.019). These results remained significant after excluding patients with history of radiotherapy (p<0.05). In patients with TUR for VUS recurrence rates and incontinence were not significantly influenced by adjuvant radiotherapy. CONCLUSIONS TUR for VUS and BNC are two different entities and should not be lumped together. Recurrence rate and postoperative incontinence rate are higher in patients undergoing TUR for VUS after RP compared to patients treated for BNC after SP. Adjuvant radiation therapy does not have an influence on success rate or incontinence. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e695 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Clemens M. Rosenbaum More articles by this author Tim A. Ludwig More articles by this author Philip Reiss More articles by this author Georg Salomon More articles by this author Margit Fisch More articles by this author Sascha A. Ahyai More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Factors that predict residual tumors in re-TUR patients

IntroductionThe first and foremost rule in the treatment of superficial bladder cancer is correct and complete resection of the tumor. Histopathological analysis of the resected tumor will help to define the correct tumor stage, thus delaying or, ideally, avoiding tumor recurrence and progression. ObjectivesTo examine the prognostic factors for residual tumors in the tumor base or in another area of the bladder in patients subjected to repeat transurethral resection (re-TUR). Patients and methodsBetween September 2009 and August 2014, 188/221 patients advised to undergo re-TUR for stage T1 tumors were subjected to the procedure. The following data were collected for this retrospective study: patients’ age and sex, information on whether initial TUR was carried out for a primary tumor/primary tumors, tumor number, tumor size and tumor grade, as well as information on whether muscularis propria was found in the resected specimens of initial TUR, whether there was carcinoma in situ and whether single-dose intracavitary chemotherapy was administered following initial TUR. ResultsOn re-TUR, new tumors outside of the previous resection area were found in 34 (18%) and residual tumors in the initial resection area in 48 (25.5%) patients. 61.7% of the patients diagnosed with new tumors outside of the previous tumor area and 62.5% of those with residual tumors in the initial resection area had initially undergone TUR for multifocal tumors. Both univariate and multivariate analysis revealed a significant relationship between male sex, multifocal primary tumors and the detection of residual tumors in the previous resection area during re-TUR. ConclusionFor the reasons mentioned above, we believe that re-TUR will influence the treatment strategies and have an impact on T1-tumor progression, especially with regard to multifocal tumors.

PD41-02 A NEW PROPOSAL FOR T1, HIGH GRADE (HG) BLADDER CANCER (BCA) MICRO-STAGING DEFINITION

You have accessJournal of UrologyBladder Cancer: Staging1 Apr 2015PD41-02 A NEW PROPOSAL FOR T1, HIGH GRADE (HG) BLADDER CANCER (BCA) MICRO-STAGING DEFINITION Rodolfo Fausto Hurle, Carlo Patriarca, Luisa Pasini, Pier Giuseppe Colombo, Giario Natale Conti, Massimo Freschi, Fabio Capogrosso, Marco Moschini, Lucia Ferrari, Massimo Maffezzini, Maurizio Colecchia, Tiziana Magnani, Andrea Conti, and Renzo Colombo Rodolfo Fausto HurleRodolfo Fausto Hurle More articles by this author , Carlo PatriarcaCarlo Patriarca More articles by this author , Luisa PasiniLuisa Pasini More articles by this author , Pier Giuseppe ColomboPier Giuseppe Colombo More articles by this author , Giario Natale ContiGiario Natale Conti More articles by this author , Massimo FreschiMassimo Freschi More articles by this author , Fabio CapogrossoFabio Capogrosso More articles by this author , Marco MoschiniMarco Moschini More articles by this author , Lucia FerrariLucia Ferrari More articles by this author , Massimo MaffezziniMassimo Maffezzini More articles by this author , Maurizio ColecchiaMaurizio Colecchia More articles by this author , Tiziana MagnaniTiziana Magnani More articles by this author , Andrea ContiAndrea Conti More articles by this author , and Renzo ColomboRenzo Colombo More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2410AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Histological T1 sub-staging has been advocated as a potential prognostic factor. However, the absence of a standardized method, the inter-observers variability and the absence of a clear clinical validation prevent the spreading of T1 sub-staging in routine practice. This study was aimed to assess both feasibility and prognostic reliability of a new procedure (ROL) for the assessment of the T1 sub-staging in comparison to the other well known sub-staging methods METHODS The ROL sub-staging was defined as ROL 1: < 1 PF (20x) corresponding to 1mm of lamina propria thickness invasion and as ROL 2: > 1 PF (20x) or multifocality sizing more than 1mm of lamina propria invasion. Multiple slides of a series of consecutive patients with T1HG (2004-WHO classification) BCa at initial TUR were revised by uro-pathologists of four different centers. Both feasibility and prognostic reliability of ROL method were compared to those of T1a/T1b,c subdivision (above or under the muscolaris mucosae) and T1m/T1e subdivision (< 1 HPF 40x vs > 1 HPF 40x or multifocality), according to Angulo and to van Rhijn methods, respectively. Progression free survival (PFS) and recurrence-free survival (RFS) were analyzed by KM estimation. Univariable Cox regression analyses were used to test the risk factors associated with a detrimental effect on survival RESULTS Out of a total of 318 patients, 250 patients who received a second-TURB were confirmed as T1HG and entered the study. Mean age was 71 years and 40 patients were female. At a mean follow up of 45 months, 116 patients (36.5%) have a recurrence, 36 (11.3%) have a progression and 52 underwent radical cystectomy. The ROL methods was feasible in 99.7% of cases compared to 72.3% for Angulo and 99.7% for van Rhijn, respectively. RFS was 74% and 26% for T1a and T1b/c, 41% and 59 for T1m and T1e and 53.4% and 46.6% for ROL 1 and ROL 2 method, respectively (all p>0.2). PFS survival at 3 year follow-up was 94% and 76% for T1a and T1b,c (p=0.04), 91% and 92% for T1m and T1e (p=0.2), and 95% and 90% for ROL 1 and ROL 2 (p=0.04), respectively CONCLUSIONS According to the results of this retrospective study, the new threshold of sub-staging (ROL 1/2) of pT1HG was documented to be feasible in all cases, easy to report and reproducible due to its objective standardized definition. In addition, the ROL sub-staging resulted as a reliable predictor of oncologic outcomes also when compared to other sub-staging systems. These results may have a great impact in clinical practice and deserve to be confirmed in prospective multicentric investigations © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e840 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rodolfo Fausto Hurle More articles by this author Carlo Patriarca More articles by this author Luisa Pasini More articles by this author Pier Giuseppe Colombo More articles by this author Giario Natale Conti More articles by this author Massimo Freschi More articles by this author Fabio Capogrosso More articles by this author Marco Moschini More articles by this author Lucia Ferrari More articles by this author Massimo Maffezzini More articles by this author Maurizio Colecchia More articles by this author Tiziana Magnani More articles by this author Andrea Conti More articles by this author Renzo Colombo More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

942 Should second TUR be performed in the first 2–6 weeks after the initial TUR necessarily in high risk non-muscle invasive bladder cancer patients receiving maintanance BCG? Multicenter trial of Turkish Society of Urooncology

942 Should second TUR be performed in the first 2–6 weeks after the initial TUR necessarily in high risk non-muscle invasive bladder cancer patients receiving maintanance BCG? Multicenter trial of Turkish Society of Urooncology

Tumour stage on re-staging transurethral resection predicts recurrence and progression-free survival of patients with high-risk non-muscle invasive bladder cancer.

To identify patients who should be considered for early radical cystectomy, we evaluated the clinical and pathological variables affecting the outcome of patients with high-risk non-muscle invasive bladder cancer (NMIBC) who underwent re-staging transurethral resection (re-TUR). We reviewed the clinical data of 453 patients treated for urothelial carcinoma between 2006 and 2010. In total, 94 patients underwent re-TUR after their initial TUR. Of these, 72 were not upstaged to muscle invasive disease and were therefore included in our study. On re-TUR, 31 patients had no residual tumour (T0) and 41 patients had residual NMIBC. A statistically significant difference was noted between patients with pT0 and patients with residual NMIBC on re-TUR in regard to tumour recurrence and progression (39% vs. 83%, p < 0.001) (6% vs. 34%, p = 0.005), respectively. On multivariate analysis, tumour stage on re-TUR and the regimen of intravesical bacillus Calmette-Guérin (BCG) therapy (induction vs. maintenance) remained independent predicting factors for recurrence-free survival (RFS) (p = 0.001, hazard ratio [HR]: 1.77), (p < 0.001 HR: 0.16) and progression-free survival (PFS) (p = 0.014, HR: 2.11), (p = 0.008, HR: 0.097), respectively. The presence of T0 on re-TUR is associated with better RFS and PFS and could be a predictive factor for candidates for conservative management. Patients with persistent NMIBC on re-TUR require close follow-up and, in some cases, could be considered for early cystectomy. Maintenance intravesical BCG therapy can improve RFS and PFS in patients with high-risk NMIBC. This study is limited by its retrospective nature and the relatively small number of patients in the cohort.

Scoring system development for prediction of extravesical bladder cancer

Staging of bladder cancer is crucial for optimal management of the disease. However, clinical staging is not perfectly accurate. The aim of this study was to derive a simple scoring system in prediction of pathological advanced muscle-invasive bladder cancer (MIBC). Logistic regression and bootstrap methods were used to create an integer score for estimating the risk in prediction of pathological advanced MIBC using precystectomy clinicopathological data: demographic, initial transurethral resection (TUR) [grade, stage, multiplicity of tumors, lymphovascular invasion (LVI)], hydronephrosis, abdominal and pelvic CT radiography (size of the tumor, tumor base width), and pathological stage after radical cystectomy (RC). Advanced MIBC in surgical specimen was defined as pT3-4 tumor. Receiving operating characteristic (ROC) curve quantified the area under curve (AUC) as predictive accuracy. Clinical usefulness was assessed by using decision curve analysis. This single-center retrospective study included 233 adult patients with BC undergoing RC at the Military Medical Academy, Belgrade. Organ confined disease was observed in 101 (43.3%) patients, and 132 (56.7%) had advanced MIBC. In multivariable analysis, 3 risk factors most strongly associated with advanced MIBC: grade of initial TUR [odds ratio (OR) = 4.7], LVI (OR = 2), and hydronephrosis (OR = 3.9). The resultant total possible score ranged from 0 to 15, with the cut-off value of > 8 points, the AUC was 0.795, showing good discriminatory ability. The model showed excellent calibration. Decision curve analysis showed a net benefit across all threshold probabilities and clinical usefulness of the model. We developed a unique scoring system which could assist in predicting advanced MIBC in patients before RC. The scoring system showed good performance characteristics and introducing of such a tool into daily clinical decision-making may lead to more appropriate integration of perioperative chemotherapy. Clinical value of this model needs to be further assessed in external validation cohorts.

A second transurethral resection could be not necessary in all high grade non-muscle-invasive bladder tumors

ObjectivesTo evaluate the rate of residual tumor, understaging and perioperative complications in patients with high grade non-muscle-invasive bladder cancer who underwent second transurethral resection (re-TUR). Materials and methodsA retrospective review of 47 patients with high grade non-muscleinvasive bladder cancer who underwent second TUR from January 2007 to December 2009 at our institution. We evaluated the rate of residual tumor and understaging detected by re-TUR, complications, and the cost of the surgery. ResultsTwenty-two patients underwent second TUR because of the absence of muscle in the initial resection specimen (cTx). We observed residual disease in 8/47 patients (17%) and understaging in 2 cases (4.2%); in only 2 patients understaged, muscularis propria was not present in the sample of initial TUR. The other 20 cTx (90%) were cT0 in the re-TUR. We did not identify any case of cT1 understaged in the re-TUR (≥cT2). Six patients (12.6%) reported complications related with the second TUR (one urethral stricture, two patients required reintervention because of bleeding, one febrile urinary infection and two bladder perforations). ConclusionsOur findings show that the absence of muscle in the initial resection specimen is the only risk factor for understaging. Therefore, we consider re-TUR is mandatory in these cases. On the other hand, when complete TUR has been performed and the muscularis propria is present and tumor free (cTa-T1), we consider that systematic re-TUR is not necessary and only indicated in selected patients, even more if we consider that re-TUR is not exempt from complications.

La re-resección transuretral puede no ser necesaria en todos los tumores vesicales no músculo-invasivos de alto grado

ObjectivesEvaluate the rate of residual tumor, understaging and perioperative complications in patients with high grade non-muscle-invasive bladder cancer who underwent second transurethral resection (re-TUR). Material and methodsA retrospective review of 47 patients with high grade non-muscle-invasive bladder cancer who underwent second TUR from January 2007 to December 2009 at our institution. We evaluated the rate of residual tumor and understaging detected by re-TUR, complications, and the cost of the surgery. ResultsTwenty-two patients underwent second TUR because of the absence of muscle in the initial resection specimen (cTx). We observed residual disease in 8/47 patients (17%) and understaging in 2 cases (4.2%), the only 2 patients understaged muscularis propria was not present in the sample of initial TUR. The other 20 cTx (90%) were cT0 in the re-TUR. We did not identify any case of cT1 understaged in the re-TUR (≥cT2). Six patients (12.6%) reported complications related with the second TUR (one urethral stricture, two patients required reintervention because of bleeding, one febrile urinary infection and two bladder perforations). ConclusionsOur findings show that the absence of muscle in the initial resection specimen is the only risk factor for understaging. Therefore, we consider re-TUR is mandatory in these cases. On the other hand, when complete TUR has been performed and the muscularis propria is present and tumor free (cTa-T1), we consider systematic re-TUR is not necessary and only indicated in selected patients, even more if we consider that re-TUR is not exempt from complications.

1784 “THE IMPACT OF EARLY RE-RESECTION ON UPSTAGING AND UPGRADING IN PATIENTS WITH HIGH GRADE NON-MUSCLE INVASIVE BLADDER CANCER”

You have accessJournal of UrologyBladder Cancer: Superficial II1 Apr 20121784 “THE IMPACT OF EARLY RE-RESECTION ON UPSTAGING AND UPGRADING IN PATIENTS WITH HIGH GRADE NON-MUSCLE INVASIVE BLADDER CANCER” Nikhil Vasdev, Jose Domineuz-Escrieg, Mark Johnson, Garret Durkan, and Andrew Thorpe Nikhil VasdevNikhil Vasdev Newcastle upon Tyne, United Kingdom More articles by this author , Jose Domineuz-EscriegJose Domineuz-Escrieg Newcastle upon Tyne, United Kingdom More articles by this author , Mark JohnsonMark Johnson Newcastle upon Tyne, United Kingdom More articles by this author , Garret DurkanGarret Durkan Newcastle upon Tyne, United Kingdom More articles by this author , and Andrew ThorpeAndrew Thorpe Newcastle upon Tyne, United Kingdom More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1801AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Our objective is to evaluate the impact of early re-resection on the incidence of recurrence and progression in patients with HG-NMIBC. METHODS From 1998 to 2008, 486 consecutive patients were diagnosed with HG-NMIBC. Retrospective data was collected which included patient demographics,histological parameters including the presence of detrusor muscle at initial TUR and at re-resection, adjuvant intravesical therapy and recurrence and progression rates. Early re-resection was performed within 8 weeks of initial TUR. Patients comprised of those who underwent an early re-resection (Group-A) and those who did not (Group-B). Group A consisted of 172 patients and Group B consisted of 314 patients. RESULTS At initial TUR detrusor muscle was present in 61% of patients in group A and 76% of patients in group B. At early re-resection detrusor muscle was present in 77.9% of cases. The incidence of residual tumour was 54.6% with the incidence of up-grading and up-staging being 20.2% and 12.7%, respectively. The overall incidence of tumour recurrence was 35% in group A and 42% in group B. The rate of upstaging was 3.3% of tumours in group A vs. 14.4% in group B (p<0.05), with a rate of upgrading of 8.3% and 26% in group A and B, respectively (p<0.05). CONCLUSIONS Our results confirm the benefits of this approach and highlight a significant reduction in tumour up-staging in recurrences following re-resection. We hence advocate the implementation of an early re-resection in this subset of patients. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e720 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nikhil Vasdev Newcastle upon Tyne, United Kingdom More articles by this author Jose Domineuz-Escrieg Newcastle upon Tyne, United Kingdom More articles by this author Mark Johnson Newcastle upon Tyne, United Kingdom More articles by this author Garret Durkan Newcastle upon Tyne, United Kingdom More articles by this author Andrew Thorpe Newcastle upon Tyne, United Kingdom More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Restaging Transurethral Resection of Bladder Tumor for High-risk Stage Ta and T1 Bladder Cancer

Bladder cancer is the most common malignancy of the urinary tract. About 75%-85% of patients present with non-muscle-invasive bladder cancer (NMIBC). However, patients with pT1 tumors, as well as all those with high-grade disease, make up a subset with a high-risk of recurrence and disease progression. Although still regarded as the gold standard, clinical evidence from contemporary published series clearly demonstrates that transurethral resection of tumor (TUR) is a procedure far from optimal, highlighting its limitations and the need for further diagnostic accuracy. Routine use of a restaging TUR (re-TUR), supported by the American Urological Association and European Association of Urology guidelines, detects residual tumor in a significant number of cases after initial TUR. It provides a more accurate staging of the disease and, consequently, helps to guide its treatment. Recent years have seen rapid development of novel optical techniques aimed to optimize resection. Routine implementation of these novel techniques in the context of re-TUR is promising and may potentially result in more tumors being identified and completely resected, leading to significantly lower residual tumor rates than with the standard white-light TUR. This article will focus on re-TUR in the management of high-risk NMIBC, with an up-to-date review of the available literature and detailed analysis of the published series.

MP-15.17: Comparison of efficacy of post-TURBT adjuvant intravesical mitomycin C therapy in preventing the recurrence of intermediate risk superficial TCC: peri-operative single dose versus delayed multi-dose regimen, short- versus long-term result

Superficial bladder TCC especially G.I-II could be effectively managed by initial TUR with adjuvant intravesical therapy using Mitomycin C. To date, there is no worldwide consensus regarding the universally accepted protocol of MMC. Different studies claim better result with conventional delayed multi-dose regimen while others claim superior results with single peri-operative instillation. In the background of controversy we have designed a prospective study in the department of Urology, BSMMU, Dhaka, to compare the efficacy of adjuvant intravesical therapy of MMC, single peri-operative dose versus delayed multi-dose regimen in preventing the recurrence of intermediate risk superficial TCC.

The Role of the Surgeon and Transurethral Resection in the Treatment of Superficial Bladder Cancer

Non-muscle invasive bladder cancers are a heterogeneous group of cancers whose spectrum includes low grade Ta lesions and high-grade T1 lesions. Accurate staging and grading during initial evaluation and TUR ensures appropriate treatment and prevents the risk of understaging. TUR should be ideally performed under spinal anesthesia, with a continuous flow video resectoscope to maintain a stable bladder capacity, and a video monitor. The entire bladder must be visualized, with both 30- and 70-degree lenses, and all abnormal areas must be resected, with separate biopsies from each tumor's base. Repeat TUR is recommended for all high grade tumors and T1 tumors, especially if muscle was not present in the initial specimen. Immediate instillation of single dose chemotherapy agents following TUR is highly recommended to reduce the risk of tumor recurrences.