Review – Bladder CancerRepeat Transurethral Resection in Non–muscle-invasive Bladder Cancer: A Systematic Review☆
Introduction
Bladder cancer (BC) is the fourth commonest male malignancy worldwide [1] and one of the most expensive cancers to manage [2]. Initial treatment for most BCs involves transurethral resection (TUR) of tumours to remove all possible tumours and obtain material for histological examination. Following resection, patients are started on treatment pathways that reflect the nature and potential of their disease (typically determined by histological grade and tumour-node-metastasis stage). Treatment for primary high-risk non–muscle-invasive BCs (NMIBC), such as high-grade (HG) or grade 3, Ta, or T1 cancers, often commences with a repeat TUR (reTUR) of bladder tumours within 2–6 wk of initial resection [3]. A reTUR is recommended by the European Association of Urology (EAU) guidelines if the first resection was incomplete, if detrusor muscle was not present in the initial specimen, if the clinical suspicion is of worse disease than reported by the pathologist, or to ensure the absence of muscle invasion [4]. These scenarios are in consensus across the major international guideline panels (Table 1). The reTUR should remove any residual disease and resample the initial resection area. Residual tumour at reTUR has been described in up to 75% of Ta and T1 patients [5], [6]. Even more profound is the rate of upstaging from Ta to ≥T1 or T1 to ≥T2 at reTUR, which has been observed in up to 28% of initial T1 [5], [7] and 9.5% of initial Ta-HG tumours [8], respectively. This is even more striking in cases where muscularis propria is missing in the first transurethral resection of bladder tumour (TURBT) specimens; here, upstaging to muscle-invasive disease has been reported in up to 45% of T1 patients undergoing a reTUR [9]. The reTUR may also have a therapeutic role. It may increase recurrence-free (RFS) [10], [11], progression-free (PFS) [10], cancer-specific (CSS), and overall (OS) survival [10] after intravesical Bacillus Calmette-Guérin (BCG) immunotherapy and provide valuable prognostic information [8].
However, recent studies have questioned the benefit of reTUR. These reports, including patients with T1BC treated with/without BCG (according to study), did not show any improvement in PFS and CSS of patients undergoing a reTUR when detrusor muscle was included in the primary TURBT [12], [13]. These authors suggest that reTUR may not be necessary for this group of patients, if muscle was present in the primary TURBT.
The aim of this systematic review (SR) was two-fold. Patient Intervention Comparator Outcome (PICO) 1 was to evaluate the surgical practice of reTUR (including the presence of detrusor muscle in the primary resection), percentage of residual tumours found at reTUR (same site, different site, any site), and upstaging of disease pathology at reTUR. PICO 2 was to assess the therapeutic benefit of reTUR regarding disease recurrence, progression, OS, and CSS.
Section snippets
Systematic review
We searched PubMed/Medline and Web of Science in December 2016 and again in October 2017, for all original articles, with no language or time limits applied. We used string terms “re”, “second”, “restaging”, “repeat”, “early” AND “transurethral resection”, “TUR”, “TURB”, “reTUR” AND “bladder” AND “cancer”, “tumor”, “tumour”, “neoplasm”, and “carcinoma” (Fig. 1). Manuscripts included were original articles investigating the role of reTUR and disease recurrence, progression, or survival data in
Evidence synthesis
Abstracts from 15 209 reports (Fig. 1) were reviewed by two researchers (M.G.C. and B.F.) independently. Five articles were excluded as they were in languages that none of the authors could translate (Japanese, Chinese, Russian, and Hungarian), and 99 full-text manuscripts were obtained. Of these, 68 were excluded because they either did not report data as stratified into different histological subtypes or contained <50 study participants, or the papers were not available. In total, we
Conclusions
Residual tumour is common after TUR for high risk NMIBC. The reTUR helps in the diagnosis of this residual cancer and may improve outcomes for cancers initially staged as T1.
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Cited by (218)
Natural History of Multiple Recurrences in Intermediate-Risk Non-Muscle Invasive Bladder Cancer: Lessons From a Prospective Cohort
2023, UrologyCitation Excerpt :However, maintenance BCG was found to be associated with a reduction in multiple recurrences and this consistent with guidelines considering maintenance BCG for IR-NMIBC2. A systematic review of re-TURBT found that only one study examined the prognostic value of re-TURBT in high grade Ta tumors to prevent multiple recurrences.22 We found that re-resection does not improve initial recurrence-free survival for HG Ta IR-NMIBC.
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These authors shared first authorship.