- Email: [email protected]
Is a Second Transurethral Resection Necessary for Newly Diagnosed pT1 Bladder Cancer?
Is a Second Transurethral Resection Necessary for Newly Diagnosed pT1 Bladder Cancer? ¨ mı˙t Yildirim, As¸kin Erog˘lu, Ferruh Zorlu and Haluk Özen Taner Dı˙vrı˙k,* U From the Department of Urology, SSK Tepecik Teaching Hospital, I˙zmir (TD, UY, AE, FZ), and the Department of Urology, Hacettepe University, Ankara (HO), Turkey
Purpose: We evaluated the potential benefit of a second transurethral resection in patients with newly diagnosed pT1 transitional cell carcinoma of the bladder. Materials and Methods: Between January 2001 and May 2003, 80 patients with stage T1 bladder cancer were included in this protocol in which all patients prospectively received second TUR within 2 to 6 weeks following the initial resection. Patients with incomplete resections were excluded from study. The pathological findings of the second TUR were reviewed. Results: Of the 80 patients who underwent second resection, 18 (22.5%) had macroscopic tumors before resection. However, with the addition of microscopic tumors, overall residual disease was determined in 27 (33.8%) patients. Of the 27 patients 7 had pTa, 14 had pT1, 3 had pT1⫹pTis and 3 had pT2 disease. Residual cancers were detected in 5.8%, 38.2% and 62.5% in G1, G2 and G3 tumors, respectively. The risk of residual tumor directly correlated with the grade of the initial tumor (p ⫽ 0.009). Conclusions: Although second TUR dramatically changed the treatment strategy in a small percentage of cases, we strongly recommend performing second TUR in all cases of primary pT1 disease, especially in high grade cases. Key Words: mycobacterium bovis, bladder neoplasms
ransurethral resection of bladder tumors is the mainstay approach in the diagnosis and the treatment of bladder cancer. The first and the most important rule is the complete resection of the superficial bladder cancer. This procedure is not only mandatory for adequate staging but also serves as the completion of TURB for most of the superficial tumors. Recent studies have suggested that initial TURB may be incomplete in a significant number of cases.1– 6 In this prospective study we evaluated the necessity of a second TUR in patients with newly diagnosed pT1 bladder cancer.
T
MATERIALS AND METHODS From January 2001 to May 2003, a total of 80 patients with newly diagnosed T1 tumors underwent second TUR and prospectively evaluated to document the number of the patients with residual tumors and adequacy of clinical staging in our institution. The mean age was 62.2 years (range 37 to 87, SD 10.4) and 7 of all patients were women. The initial resection of all cases was performed in our institution by 4 experienced surgeons. Patients who were considered to have undergone incomplete resection and specimens of patients not having muscle tissue to evaluate tumor invasion were excluded from this study. During this period we have ex-
Submitted for publication January 17, 2005. Nothing to disclose. * Correspondence: 1394 Sk. No: 11/13, Alsancak-I˙zmir, Turkey (telephone: ⫹90 232 4650888; FAX: ⫹90 232 4646050; e-mail: [email protected], [email protected]).
0022-5347/06/1754-1258/0 THE JOURNAL OF UROLOGY® Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION
cluded 26 patients from this study, 22 because of the lack of muscle tissue in the specimen and an additional 3 patients with incomplete resection and a further patient with perforation. All visible tumors, tumor bed and the margins were resected separately. Cold cup biopsies from normal mucosa were not routinely obtained. All of the tumors were depicted on a bladder map by the surgeon immediately after the operation. Second TUR was routinely performed within 2 to 6 weeks following the initial resection if the histopathological evaluation revealed T1 tumor. Tumors were classified according to the TNM system of the UICC7 and were graded according to the WHO classification. If there were no residual tumor or it was superficial intravesical chemotherapy was planned. However, if muscle invasive residual tumor or Tis were detected subsequent treatment strategy was planned as radical cystoprostatectomy or intravesical bacillus Calmette-Guerin treatment, respectively. Statistical evaluation was performed using the Pearson chi-square test. Informed consent for the treatment strategy was obtained from each patient. RESULTS Of 80 patients with primary T1 tumor, 18.8% were solitary and less than 3 cm and the rest (81.2%) were multiple and/or
Editor’s Note: This article is the first of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 1582 and 1583.
1258
Vol. 175, 1258-1261, April 2006 Printed in U.S.A. DOI:10.1016/S0022-5347(05)00689-0
SECOND TRANSURETHRAL RESECTION FOR NEWLY DIAGNOSED pT1 BLADDER CANCER TABLE 1. Solitary and multifocality after initial TUR, percent residual tumor at second TUR
Macroscopic Appearance
No. After Initial TUR (%)
Solitary, less than 3 cm Solitary, greater than 3 cm Multifocal, less than 3 cm Multifocal, greater than 3 cm
15 (18.8) 27 (33.8) 22 (27.5) 16 (20.0)
No. Residual Tumor After Second TUR (%) 3 (20) 24 (37)
1259
TABLE 3. Grade distribution as assessed during first and second TUR
G1 G2 G3 Overall
No. After First TUR (%)
No. After Second TUR (%)
17 (21.3) 55 (68.7) 8 (10.0) 80 (100)
1 (5.8) 21 (38.2) 5 (62.5) 27 (33.8)
p ⫽ 0.009.
more than 3 cm in diameter (table 1). Regarding the grading of the tumors resected by the first TURB, 21.3%, 68.7% and 10% had G1, G2 and G3 transitional cell carcinoma, respectively. Cystoscopy performed 2 to 6 weeks after initial resection showed that 18 (22.5%) patients had visible tumors. Our protocol dictated TUR of the previously resected areas even if there were no macroscopic abnormalities. As a result residual cancer was detected in 14.5% (9 of 62) of such patients. Since transitional cell carcinoma was found to be present in all of the cases who had visible tumor, residual cancer was detected histopathologically in a total of 27 patients (33.8%) of our group. In 12 of these patients the tumor was detected at the primary site, whereas in 11 patients tumor was detected elsewhere. The remaining 4 patients had residual tumors at the site of the first TUR and in another site. Of these 27 patients with residual cancer, in 3 (3.75%) disease was up staged to pT2 and an additional 3 patients had Tis in conjunction with residual pT1 disease. Therefore, second TURB definitely resulted in a major change in the treatment strategy of 3 patients. Intravesical bacillus Calmette-Guerin treatment became almost mandatory in an additional 3 patients in whom Tis was discovered in the second TURB. The distribution of stage as assessed during second TUR is given in table 2. While of 15 patients who had solitary, less than 3 cm tumors, 3 (20%) had residual tumors at the second TUR, 24 (37%) of 65 patients with multifocal and/or more than 3 cm tumors were found to have residual tumors (p ⬎0.05). After initial TUR residual cancers were detected in 5.8%, 38.2% and 62.5% in G1, G2 and G3 tumors, respectively (table 3). The risk of having a residual tumor directly correlated with the grade of the initial tumor (p ⫽ 0.009). Second TURB was performed without a major morbidity on 80 patients with primary T1 transitional cell carcinoma. Minor complications included prolonged bleeding managed conservatively in 3, and epididymitis and transient urinary retention in 1 each. DISCUSSION Although complete TUR of the bladder tumors is the first and the most important aspect in the treatment of almost all
TABLE 2. Stage distribution as assessed during second TUR Histological Results of Second TUR
No. Pts (%)
No residual tumor pTa pT1 pT1 ⫹ pTis pT2
53 (66.25) 7 (8.75) 14 (17.50) 3 (3.75) 3 (3.75)
stages of the disease, relatively little significance is given to improve the surgical skills of the residents. This fact has been extensively studied by Brausi et al, who showed that the quality of TUR had a major impact on recurrence rates.8 The positive effect of an excellent resection is especially evident in superficial disease. Even in this group of patients a type of intracavitary treatment modality deserves more interest than surgical technique. In published reports histopathologically confirmed residual tumors have been reported in 28% to 74% of patients with newly diagnosed or recurrent pT1 bladder cancer at the second TUR.1– 4,6,9 –14 To minimize the effect of inadequate skill, we designed our protocol such that TURB was performed by 4 senior, experienced surgeons. Early recurrence especially high grade and T1 disease has been shown to be one of the most important prognostic factors in regard to recurrence and progression.15,16 To have an evidenced based therapy plan for patients with superficial tumors, it is crucial to differentiate a patient with an early recurrence from those who has residual tumor due to incomplete resection. In our prospective study residual tumors were detected in 27 (33.8%) of 80 patients with newly diagnosed G1-3 pT1 bladder cancers at the second TUR. It must be stressed that 14.5% of the patients with normal cystoscopy ended up having residual cancer after resection of the previously resected area. This fact was also reported by several investigators.17 After the first TUR residual cancers were found in 1 of 17 (5.8%) G1, 21 of 55 (38.2%) G2 and 5 of 8 (62.5%) G3 tumors (p ⫽ 0.009). Klän et al reported a residual tumor rate of 50% in patients with G2-3 pT1 tumors.1 Mersdorf et al detected residual tumors in 58% (26 of 45 patients) of patients with G2-3 pT1 tumors.2 This new information has been reported to alter the proposed therapeutic regimen in 2% (11) of patients. Herr reported a rate of 74% residual tumors in 58 patients with G2-3 pT1 bladder cancer, but information regarding whether tumor resection was complete or incomplete at the first TUR was not available.3 Furthermore, in the aforementioned study 23 of 58 patients with pT1 tumor had no muscle tissue in the specimen at initial TUR to evaluate the invasion.3 The relatively low incidence of residual tumors and residual muscle invasive tumors in our study may be attributed to the strict inclusion criteria. Review of the published reports on this issue is shown in table 4. As can be recognized, second TUR certainly detected a significant percentage of residual tumors and, among them Tis and muscle invasive disease rates were reported with a range of 6% to 24% in different studies.2,4,10,13,14 In our series Tis and muscle invasive disease were detected in 7.5% of patients.
57 Unknown 5.8
16/46 10/40 (25) Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown 18/80 (22.5) No No No Yes (3.9) No No Yes (Unknown) Yes (39) Yes (22) No No No 52.2 (24) Unknown Unknown 39.5 (30) Unknown Unknown 11.9 (5) 52.0 (23) 40.0 (50) Unknown Unknown 47.5 (38)‡ 46 45 58 76 19 30 42 44 123 32 52 80
46 Unknown 87% Recurrent 76 19 30 42 44 123 Unknown 52 80
No. Pts. References
Klän et al1 Mersdorf et al2 Herr3 Schips et al4 Grimm et al6 Vögeli et al9 Brauers et al10 Brake et al11 Brake et al12 Ojea Calvo et al13 Rigaud et al14 Present study
No. Newly Diagnosed
% Multifocal (No.)
With Concomitant Ca in Situ (%)
No. With Visible Residual Tumor at Repeat TUR/Total No. (%)
* In 40 of the 46 patients no tumor was visible to the operating surgeons at the end of initial TUR and complete resection was reported. † Information regarding whether tumor resection was complete or incomplete was usually not available, 23 of 58 patients with pT1 tumor had no muscle in specimen at initial TUR. ‡ Multifocal and solitary but greater than 3 cm: 81.2 (65).
58.8 Unknown Pos Pos 85.7 Unknown Pos 30.0 Unknown 44.0 Unknown 62.5 34.5 Unknown Pos Pos 33.3 Unknown Pos ⫺ Unknown ⫺ ⫺ ⫺ Pos ⫺ Unknown ⫺ ⫺ Unknown
Unknown 38.2
% Residual G3pT1 Tumor % Residual G2pT1 Tumor
50.0* 58.0 74.0 32.9 53.0 43.0 64.0 ⫺ 28.0 53.1 36.5 33.8
Unknown 24 (11) Unknown† 7.9 (6) Unknown Unknown 24 (10) Unknown Unknown 6.0 (2) 7.7 (4) 7.5 (6)
CONCLUSIONS
% Residual G1pT1 Tumor
% Residual G1-3pT1 Tumor
% Alteration in Therapeutic Regimen (No.)
SECOND TRANSURETHRAL RESECTION FOR NEWLY DIAGNOSED pT1 BLADDER CANCER
TABLE 4. Review of published reports (selected only pT1 bladder cancer)
1260
Second TUR is beneficial because in a certain percentage of the patients this additional surgery results in a major change in treatment strategy. Furthermore, true recurrence can be identified by this approach since conventionally residual tumors may be falsely defined as recurrence. This will save the patient from receiving unnecessary treatments. This approach might also have an effect on progression and, thus, bladder preservation. However, these 2 latter arguments will be addressed in a subsequent prospective controlled study with long followup. Our data indicate that it is necessary to perform second TUR in patients with newly diagnosed, high grade (G2-3), stage T1 bladder cancer for true staging and complete resection.
Abbreviations and Acronyms TURB ⫽ transurethral resection of bladder tumors TUR ⫽ transurethral resection
REFERENCES 1. Klän, R., Loy, V. and Huland, H.: Residual tumor discovered in routine second transurethral resection in patients with stage T1 transitional cell carcinoma of the bladder. J Urol, 146: 316, 1991 2. Mersdorf, A., Brauers, A., Wolff, J. M., Schneider, V. and Jakse, G.: 2nd TUR for superficial bladder cancer: a must? J Urol, suppl., 159: 143, abstract 542, 1998 3. Herr, H. W.: The value of a second transurethral resection in evaluating patients with bladder tumors. J Urol, 162: 74, 1999 4. Schips, L., Augustin, H., Zigeuner, R. E., Galle, G., Habermann, H., Trummer, H. et al: Is repeated transurethral resection justified in patients with newly diagnosed superficial bladder cancer? Urology, 59: 220, 2002 5. Dalbagni, G., Herr, H. W. and Reuter, V. E.: Impact of a second transurethral resection on the staging of T1 bladder cancer. Urology, 60: 822, 2002 6. Grimm, M.-O., Steinhoff, C., Simon, X., Spiegelhalder, P., Ackermann, R. and Vögeli, T. A.: Effect of routine repeat transurethral resection for superficial bladder cancer: a long-term observational study. J Urol, 170: 433, 2003 7. Sobin, L. H. and Wittekind, Ch.: Urinary bladder. In: TNM Classification of Malignant Tumours, 5th ed. International Union Against Cancer (UICC). New York: Wiley-Liss, p. 187, 1997 8. Brausi, M., Collette, L., Kurth, K., van der Meijden, A. P., Oosterlinck, W., Witjes, J. A. et al: Variability in the recurrence rate at first follow-up cystoscopy after TUR in stage Ta T1 transitional cell carcinoma of the bladder: a combined analysis of seven EORTC studies. Eur Urol, 41: 523, 2002 9. Vögeli, T. A., Grimm, M.-O. and Ackermann, R.: Prospective study for quality control of TUR of bladder tumors by routine 2nd TUR (ReTUR). J Urol, suppl., 159: 143, abstract 543, 1998 10. Brauers, A., Buettner, R. and Jakse, G.: Second resection and prognosis of primary high risk superficial bladder cancer: is cystectomy often too early? J Urol, 165: 808, 2001
SECOND TRANSURETHRAL RESECTION FOR NEWLY DIAGNOSED pT1 BLADDER CANCER 11. Brake, M., Loertzer, H., Horsch, R. and Keller, H.: Recurrence and progression of stage T1, grade 3 transitional cell carcinoma of the bladder following intravesical immunotherapy with bacillus Calmette-Guerin. J Urol, 163: 1697, 2000 12. Brake, M., Loertzer, H., Horsch, R. and Keller, H.: Long-term results of intravesical bacillus Calmette-Guerin therapy for stage T1 superficial bladder cancer. Urology, 55: 673, 2000 13. Ojea Calvo, A., Nunez Lopez, A., Alonso Rodrigo, A., Rodriguez Iglesias, B., Benavente Delgado, J., Barros Rodriguez, J. M. et al: Value of a second transurethral resection in the assessment and treatment of patients with bladder tumor. Actas Urol Esp, 25: 182, 2001 14. Rigaud, J., Karam, G., Braud, G., Glemain, P., Buzelin, J. M. and Bouchot, O.: T1 bladder tumors: value of a second endoscopic resection. Prog Urol, 12: 27, 2002
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15. Kurth, K. H., Schroeder, F. H., Debruyne, F., Senge, T., PavoneMacaluso, M., de Pauw, M. et al: Long-term follow-up in superficial transitional cell carcinoma of the bladder: prognostic factors for time to first recurrence, recurrence rate, and survival. Final results of a randomized trial comparing doxorubicin hydrochloride, ethoglucid, and transurethral resection alone. EORTC Genitourinary Tract Cancer Cooperative Group. Prog Clin Biol Res, 303: 481, 1989 16. Fitzpatrick, J. M., West, A. B., Butler, M. R., Lane, V. and O’Flynn, J. D.: Superficial bladder tumors (stage pTa, grades 1 and 2): the importance of recurrence pattern following initial resection. J Urol, 135: 920, 1986 17. Jakse, G., Algaba, F., Malmstrom, P. U. and Oosterlinck, W.: A second-look TUR in T1 transitional cell carcinoma: why? Eur Urol, 45: 539, 2004
Purpose: We evaluated the potential benefit of a second transurethral resection in patients with newly diagnosed pT1 transitional cell carcinoma of the bladder. Materials and Methods: Between January 2001 and May 2003, 80 patients with stage T1 bladder cancer were included in this protocol in which all patients prospectively received second TUR within 2 to 6 weeks following the initial resection. Patients with incomplete resections were excluded from study. The pathological findings of the second TUR were reviewed. Results: Of the 80 patients who underwent second resection, 18 (22.5%) had macroscopic tumors before resection. However, with the addition of microscopic tumors, overall residual disease was determined in 27 (33.8%) patients. Of the 27 patients 7 had pTa, 14 had pT1, 3 had pT1⫹pTis and 3 had pT2 disease. Residual cancers were detected in 5.8%, 38.2% and 62.5% in G1, G2 and G3 tumors, respectively. The risk of residual tumor directly correlated with the grade of the initial tumor (p ⫽ 0.009). Conclusions: Although second TUR dramatically changed the treatment strategy in a small percentage of cases, we strongly recommend performing second TUR in all cases of primary pT1 disease, especially in high grade cases. Key Words: mycobacterium bovis, bladder neoplasms
ransurethral resection of bladder tumors is the mainstay approach in the diagnosis and the treatment of bladder cancer. The first and the most important rule is the complete resection of the superficial bladder cancer. This procedure is not only mandatory for adequate staging but also serves as the completion of TURB for most of the superficial tumors. Recent studies have suggested that initial TURB may be incomplete in a significant number of cases.1– 6 In this prospective study we evaluated the necessity of a second TUR in patients with newly diagnosed pT1 bladder cancer.
T
MATERIALS AND METHODS From January 2001 to May 2003, a total of 80 patients with newly diagnosed T1 tumors underwent second TUR and prospectively evaluated to document the number of the patients with residual tumors and adequacy of clinical staging in our institution. The mean age was 62.2 years (range 37 to 87, SD 10.4) and 7 of all patients were women. The initial resection of all cases was performed in our institution by 4 experienced surgeons. Patients who were considered to have undergone incomplete resection and specimens of patients not having muscle tissue to evaluate tumor invasion were excluded from this study. During this period we have ex-
Submitted for publication January 17, 2005. Nothing to disclose. * Correspondence: 1394 Sk. No: 11/13, Alsancak-I˙zmir, Turkey (telephone: ⫹90 232 4650888; FAX: ⫹90 232 4646050; e-mail: [email protected], [email protected]).
0022-5347/06/1754-1258/0 THE JOURNAL OF UROLOGY® Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION
cluded 26 patients from this study, 22 because of the lack of muscle tissue in the specimen and an additional 3 patients with incomplete resection and a further patient with perforation. All visible tumors, tumor bed and the margins were resected separately. Cold cup biopsies from normal mucosa were not routinely obtained. All of the tumors were depicted on a bladder map by the surgeon immediately after the operation. Second TUR was routinely performed within 2 to 6 weeks following the initial resection if the histopathological evaluation revealed T1 tumor. Tumors were classified according to the TNM system of the UICC7 and were graded according to the WHO classification. If there were no residual tumor or it was superficial intravesical chemotherapy was planned. However, if muscle invasive residual tumor or Tis were detected subsequent treatment strategy was planned as radical cystoprostatectomy or intravesical bacillus Calmette-Guerin treatment, respectively. Statistical evaluation was performed using the Pearson chi-square test. Informed consent for the treatment strategy was obtained from each patient. RESULTS Of 80 patients with primary T1 tumor, 18.8% were solitary and less than 3 cm and the rest (81.2%) were multiple and/or
Editor’s Note: This article is the first of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 1582 and 1583.
1258
Vol. 175, 1258-1261, April 2006 Printed in U.S.A. DOI:10.1016/S0022-5347(05)00689-0
SECOND TRANSURETHRAL RESECTION FOR NEWLY DIAGNOSED pT1 BLADDER CANCER TABLE 1. Solitary and multifocality after initial TUR, percent residual tumor at second TUR
Macroscopic Appearance
No. After Initial TUR (%)
Solitary, less than 3 cm Solitary, greater than 3 cm Multifocal, less than 3 cm Multifocal, greater than 3 cm
15 (18.8) 27 (33.8) 22 (27.5) 16 (20.0)
No. Residual Tumor After Second TUR (%) 3 (20) 24 (37)
1259
TABLE 3. Grade distribution as assessed during first and second TUR
G1 G2 G3 Overall
No. After First TUR (%)
No. After Second TUR (%)
17 (21.3) 55 (68.7) 8 (10.0) 80 (100)
1 (5.8) 21 (38.2) 5 (62.5) 27 (33.8)
p ⫽ 0.009.
more than 3 cm in diameter (table 1). Regarding the grading of the tumors resected by the first TURB, 21.3%, 68.7% and 10% had G1, G2 and G3 transitional cell carcinoma, respectively. Cystoscopy performed 2 to 6 weeks after initial resection showed that 18 (22.5%) patients had visible tumors. Our protocol dictated TUR of the previously resected areas even if there were no macroscopic abnormalities. As a result residual cancer was detected in 14.5% (9 of 62) of such patients. Since transitional cell carcinoma was found to be present in all of the cases who had visible tumor, residual cancer was detected histopathologically in a total of 27 patients (33.8%) of our group. In 12 of these patients the tumor was detected at the primary site, whereas in 11 patients tumor was detected elsewhere. The remaining 4 patients had residual tumors at the site of the first TUR and in another site. Of these 27 patients with residual cancer, in 3 (3.75%) disease was up staged to pT2 and an additional 3 patients had Tis in conjunction with residual pT1 disease. Therefore, second TURB definitely resulted in a major change in the treatment strategy of 3 patients. Intravesical bacillus Calmette-Guerin treatment became almost mandatory in an additional 3 patients in whom Tis was discovered in the second TURB. The distribution of stage as assessed during second TUR is given in table 2. While of 15 patients who had solitary, less than 3 cm tumors, 3 (20%) had residual tumors at the second TUR, 24 (37%) of 65 patients with multifocal and/or more than 3 cm tumors were found to have residual tumors (p ⬎0.05). After initial TUR residual cancers were detected in 5.8%, 38.2% and 62.5% in G1, G2 and G3 tumors, respectively (table 3). The risk of having a residual tumor directly correlated with the grade of the initial tumor (p ⫽ 0.009). Second TURB was performed without a major morbidity on 80 patients with primary T1 transitional cell carcinoma. Minor complications included prolonged bleeding managed conservatively in 3, and epididymitis and transient urinary retention in 1 each. DISCUSSION Although complete TUR of the bladder tumors is the first and the most important aspect in the treatment of almost all
TABLE 2. Stage distribution as assessed during second TUR Histological Results of Second TUR
No. Pts (%)
No residual tumor pTa pT1 pT1 ⫹ pTis pT2
53 (66.25) 7 (8.75) 14 (17.50) 3 (3.75) 3 (3.75)
stages of the disease, relatively little significance is given to improve the surgical skills of the residents. This fact has been extensively studied by Brausi et al, who showed that the quality of TUR had a major impact on recurrence rates.8 The positive effect of an excellent resection is especially evident in superficial disease. Even in this group of patients a type of intracavitary treatment modality deserves more interest than surgical technique. In published reports histopathologically confirmed residual tumors have been reported in 28% to 74% of patients with newly diagnosed or recurrent pT1 bladder cancer at the second TUR.1– 4,6,9 –14 To minimize the effect of inadequate skill, we designed our protocol such that TURB was performed by 4 senior, experienced surgeons. Early recurrence especially high grade and T1 disease has been shown to be one of the most important prognostic factors in regard to recurrence and progression.15,16 To have an evidenced based therapy plan for patients with superficial tumors, it is crucial to differentiate a patient with an early recurrence from those who has residual tumor due to incomplete resection. In our prospective study residual tumors were detected in 27 (33.8%) of 80 patients with newly diagnosed G1-3 pT1 bladder cancers at the second TUR. It must be stressed that 14.5% of the patients with normal cystoscopy ended up having residual cancer after resection of the previously resected area. This fact was also reported by several investigators.17 After the first TUR residual cancers were found in 1 of 17 (5.8%) G1, 21 of 55 (38.2%) G2 and 5 of 8 (62.5%) G3 tumors (p ⫽ 0.009). Klän et al reported a residual tumor rate of 50% in patients with G2-3 pT1 tumors.1 Mersdorf et al detected residual tumors in 58% (26 of 45 patients) of patients with G2-3 pT1 tumors.2 This new information has been reported to alter the proposed therapeutic regimen in 2% (11) of patients. Herr reported a rate of 74% residual tumors in 58 patients with G2-3 pT1 bladder cancer, but information regarding whether tumor resection was complete or incomplete at the first TUR was not available.3 Furthermore, in the aforementioned study 23 of 58 patients with pT1 tumor had no muscle tissue in the specimen at initial TUR to evaluate the invasion.3 The relatively low incidence of residual tumors and residual muscle invasive tumors in our study may be attributed to the strict inclusion criteria. Review of the published reports on this issue is shown in table 4. As can be recognized, second TUR certainly detected a significant percentage of residual tumors and, among them Tis and muscle invasive disease rates were reported with a range of 6% to 24% in different studies.2,4,10,13,14 In our series Tis and muscle invasive disease were detected in 7.5% of patients.
57 Unknown 5.8
16/46 10/40 (25) Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown 18/80 (22.5) No No No Yes (3.9) No No Yes (Unknown) Yes (39) Yes (22) No No No 52.2 (24) Unknown Unknown 39.5 (30) Unknown Unknown 11.9 (5) 52.0 (23) 40.0 (50) Unknown Unknown 47.5 (38)‡ 46 45 58 76 19 30 42 44 123 32 52 80
46 Unknown 87% Recurrent 76 19 30 42 44 123 Unknown 52 80
No. Pts. References
Klän et al1 Mersdorf et al2 Herr3 Schips et al4 Grimm et al6 Vögeli et al9 Brauers et al10 Brake et al11 Brake et al12 Ojea Calvo et al13 Rigaud et al14 Present study
No. Newly Diagnosed
% Multifocal (No.)
With Concomitant Ca in Situ (%)
No. With Visible Residual Tumor at Repeat TUR/Total No. (%)
* In 40 of the 46 patients no tumor was visible to the operating surgeons at the end of initial TUR and complete resection was reported. † Information regarding whether tumor resection was complete or incomplete was usually not available, 23 of 58 patients with pT1 tumor had no muscle in specimen at initial TUR. ‡ Multifocal and solitary but greater than 3 cm: 81.2 (65).
58.8 Unknown Pos Pos 85.7 Unknown Pos 30.0 Unknown 44.0 Unknown 62.5 34.5 Unknown Pos Pos 33.3 Unknown Pos ⫺ Unknown ⫺ ⫺ ⫺ Pos ⫺ Unknown ⫺ ⫺ Unknown
Unknown 38.2
% Residual G3pT1 Tumor % Residual G2pT1 Tumor
50.0* 58.0 74.0 32.9 53.0 43.0 64.0 ⫺ 28.0 53.1 36.5 33.8
Unknown 24 (11) Unknown† 7.9 (6) Unknown Unknown 24 (10) Unknown Unknown 6.0 (2) 7.7 (4) 7.5 (6)
CONCLUSIONS
% Residual G1pT1 Tumor
% Residual G1-3pT1 Tumor
% Alteration in Therapeutic Regimen (No.)
SECOND TRANSURETHRAL RESECTION FOR NEWLY DIAGNOSED pT1 BLADDER CANCER
TABLE 4. Review of published reports (selected only pT1 bladder cancer)
1260
Second TUR is beneficial because in a certain percentage of the patients this additional surgery results in a major change in treatment strategy. Furthermore, true recurrence can be identified by this approach since conventionally residual tumors may be falsely defined as recurrence. This will save the patient from receiving unnecessary treatments. This approach might also have an effect on progression and, thus, bladder preservation. However, these 2 latter arguments will be addressed in a subsequent prospective controlled study with long followup. Our data indicate that it is necessary to perform second TUR in patients with newly diagnosed, high grade (G2-3), stage T1 bladder cancer for true staging and complete resection.
Abbreviations and Acronyms TURB ⫽ transurethral resection of bladder tumors TUR ⫽ transurethral resection
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