601 PROGNOSTIC SIGNIFICANCE OF RESECTION BIOPSY OF THE TUMOR BED DURING TUR-B FOR SUPERFICIAL TRANSITIONAL BLADDER CANCER

601

Prognostic significance of resection biopsy of the tumor bed during TUR-B for superficial transitional bladder cancer

Forster T.H.1, Shahin O.2, Weltzien B.1, Werthemann P.1, Maurer P.2, Schürch L.2, Wyler S.1, Ruszat R.1, Gasser T.C.1, Bachmann A.1 University Hospital Basel, Urologic University Clinic, Basel, Switzerland, 2Hospital Liestal, Urologic University Clinic, Basel, Switzerland 1

Introduction & Objectives: The guidelines (GL) of the German urologic association (DGU) recommend an additional resection biopsy of the tumor bed (RBoTB) after the TUR-B has been completed. This histology gives important diagnostic information whether the tumor could be resected completely. Furthermore, the additional resection may have therapeutic effects. We sought to investigate whether the resection-bed biopsy during TUR-B for superficial transitional bladder cancer has prognostic significance. Material & Methods: Since 2003 we try to follow the GL proposed by the DGU while doing TUR-B. Whenever possible a RBoTB after TUR-B was done. Al relevant clinical and histological data including follow up are continuously entered in a database. From January 2003 to December 2005 169 TUR-B were performed with RBoTB. The tumor characteristics were: 66% primary tumors, 33% recurrences; 81% pTa, 19% pT1 cancers; 80% G1-2, 20% G3 tumors; concomitant carcinoma in situ was found in 8%; morphology was papillary in 96% and solid in 4%; unifocality and multifocality was found to be 64% and 36%, respectively. The average follow-up time was 12 months. Results: A tumor bed biopsy with residual tumor was found in 33% of the cases. Only G3 tumors (50% vs. 29%) were associated with a significantly (p<0.05) higher incidence of a positive tumor-bed histology but not recurrence-status, tumor stage, morphology, concomitant carcinoma in situ or multifocality. In an univariate Kaplan Meier analysis recurrent tumors, multifocality and residual tumor in the RBoTB were significantly associated with recurrence (p<0.01). In a multivariate Cox proportional hazard analysis including the following covariates (stage, grade, morphology, multifocality, recurrencestatus, concomitant carcinoma in situ, intraoperative Epirubicin, and tumor bed positivity) only a recurrence-status (HR: 0.5 (95% confidence interval: 0.3-1.0), solid (0.2 (0.1-1.0)) and multifocal (2.8 (1.1-4.6) morphology and a positive tumor bed biopsy (0.4 (0.2-1.0) were significantly associated with recurrence (p<0.05).



602

Simultaneous TURB-TURP in patients with bladder cancer and BPH: a prospective randomized trial on relapses occurrence and treatment-related quality of life Dellabella M., D’Anzeo G., Milanese G., Fabiani A., Muzzonigro G. Polytechnic University of the Marche Region, Urology, Ancona, Italy

Introduction & Objectives: The simultaneous execution of TURB and TURP is not indicated as a standard procedure for treatment of patients with bladder cancer and urinary symptoms related to BPH, because of an increased risk of recurrence on bladder neck and prostatic urethra. The aim of this study was to evaluate the differences on bladder cancer recurrences between patients treated with TURB+TURP and patients treated only with TURB. Moreover, we investigated patients-QoL in both groups. Material & Methods: From 1998 to 2003 we randomised 80 pts (40 underwent TUB and 40 TURP+TURB) affected by urinary symptoms related to BPH and bladder cancer with prostatic volume up to 50 ml. For each patient we considered features of the primary bladder cancer, prostatic volume, Qmax, PVR, IPSS; we never positioned a suprapubic trocar. The resections were performed by 2 surgeons (G.Mu. and M.D.) with similar surgical experience. Patients were followed-up with cistoscopy (every 3 months), CT scans and eventually bladder biopsy or Re-TURB. 16 patients from TURB group and 21 from TURB+TURP group underwent endovescical adjuvant therapy with epirubicin. Patients from TURB grou were treated with alpha-blockers after resection. All patients were asked with FACT-BRM, a validated instrument for QoL investigation in bladder cancer. Our endpoints were incidence, localization and timing of bladder cancer recurrences and quality of life related to follow-up and treatment. Results: We evaluated 37 pts in TURB group and 38 in TURB+TURP group (5 lost in follow-up); both groups were similar for their initial features. We observed 17 recurrences in TURB group and 10 in TURB+TURP group (p>0,05), 6 and 7 respectively on bladder neck/prostatic urethra (p>0,05) with median time to recurrence of 16,6 and 17,7 months, respectively (p>0,05). The multifocality of primary bladder tumor seems to be the only indipendent predictive factor of recurrence (OR= 6,7, IC 1,5-26,4). The FACT BRM score showed a difference between the 2 groups (18,6 for TURB – 10,95 for TURB+TURP, p=0,004).

Conclusions: In terms of recurrence RboTB positivity is an independent adverse prognostic marker in superficial bladder cancer. It is advisable to follow the GL of the DGU and to consider a second TUR-B in case of a positive RboTB.

Conclusions: Our results did not show differences in terms of bladder cancer recurrence on bladder neck/ prostatic urethra between the two groups. Patients who underwent additional TURP showed a better tolerance of endoscopic follow-up and intravescical therapy, probably because of a reduced post-void-residual and a better bladder emptying.





603

Bipolar transurethral resection of bladder cancer: pathomorphologic advantages Meneghini A.1, Borghi L.2, Ballotta M.R.2, Pizzarella M.1

S. Maria della Misericordia Hospital, Urology, Rovigo, Italy, 2S. Maria della Misericordia Hospital, Clinical Pathology, Rovigo, Italy 1

Introduction & Objectives: Bipolar electrosurgery technology is a well established practice in urological endoscopy. Compared to monopolar electrosurgery, bipolar TURB offers many clinical advantages. We evaluated the pathomorphologic impact of this technique on 81 cases of transurethral resected bladder cancer patients Material & Methods: From September 2003 to September 2006 81 patients (65 males, 16 females) underwent bipolar TURB with the ACMI Vista CTR device at our Department. Median age was 67 years (range 45 – 94). Multifocal (> 3) neoplasia was present in 44/81 patients (54.3%). Mean cumulative diameter of the neoplasia was 26 mm (range 9 – 75). Median operative time was 12’ (range 5 – 60). All the specimens were immediately formalin fixed and subjected to standard paraffin embedding and H & E staining. Results: No significant postoperative complications were reported. TNM classification results were as follow. Stage

G1

G2

G3

Total

Negative

-

-

-

5

Ta

7

26

4

37

T1

-

7

12

19

Tis

-

-

13

13

Infiltrating

-

2

5

6

No thermal damage or artifact was evident in all the specimens. A common feature of urothelial CIS is lacking of intercellular cohesion, resulting in extensive denudation of the epithelium in tissue sections (“denuding cystitis”) or in residual individual neoplastic cells attached to the surface referred to as “clinging CIS”. In such case the pathologist should not refer the specimen as negative and missing information should be obtained by examining remnant epithelial cells for cytologic anaplasia. The absence of thermal artifacts in these specimens greatly improved this diagnostic capability. In lower stage tumors grade, configuration, depth of eventual muscle penetration, blood vessel and lymphatic invasion and changes in adjacent mucosa were better evaluated as well.

Bipolar transurethral resection of superficial bladder cancer: Results after resection of the ureteral orifice

604

Brunken C., Tauber R. Asklepios Klinik St. Georg, Urology, Hamburg, Germany Introduction & Objectives: For complete removal of superficial bladder cancer the resection of the ureteral orifice is sometimes necessary. Vesicoureteral reflux or stricture of the ureter are possible complications. We evaluated the results after resection of the orifice in TURIS (transurethral resection in saline) technique in a consecutive series performed by a single surgeon. Material & Methods: Between November 2004 and June 2006 complete resection of an orifice for total removal of a superficial bladder cancer was performed on 28 patients. None of the patients had preoperative hydronephrosis. An Olympus SurgMaster System with a 26 Ch OES Pro Resectoscope was used for the procedures. After the resection the stump of the ureter was wide open and easy to identify in all cases. Close to the ureter coagulation was avoided. At the beginning of the series temporary DJ-stenting was performed in 36% of the patients. In the last 15 patients stents weren’t used at all. 25% of the patients received Mitomycin early instillation. Results: After the resection none of the patients showed hydronephrosis. All DJ-stents were removed shortly after resection. Clinically significant reflux wasn’t found in any of the patients. Conclusions: Resection of the orifice in TURIS technique is safe. DJstenting is not necessary.

Conclusions: The effectiveness and clinical safety of bipolar electrosurgery is further enhanced by the improved pathomorphologic evaluation of the specimen. Extensive papillary disease, non papillary bladder lesions, short term follow up of high grade tumors and critical patients should be considered for bipolar TURB, even considering cost / effectiveness ratio.

Eur Urol Suppl 2007;6(2):173