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OPTIMISED POSTOPERATIVE ADMINISTRATION OF INTRAVESICAL MITOMYCIN C
669
670
VALUE OF SECOND TURBT IN GRADE 3 STAGE TL TRANSITIONAL CELL CARCINOMA OF THE BLADDER
PROGNOSTIC SIGNIFICANCE OF ABSENCE OF PROPER MUSCLE IN THE RESECTED SPECIMEN OF PRIMARY T1G3 BLADDER CANCER Park J., Song C., Kim J.B., Hong J.H., Kim C.S., Ahn H. Asan Medical Centre, Urology, Seoul, South Korea INTRODUCTION & OBJECTIVES: Absence of proper muscle in the transurethral resection (TUR) specimen often brings difficulty in deciding further treatment plan in patients with high risk bladder cancer. We analysed the recurrence and progression of T1G3 bladder cancer according to the presence or absence of muscle tissue in the specimen. MATERIAL & METHODS: The data from 157 patients with T1G3 bladder cancer on initial TUR specimen were reviewed. Among the 107 patients who underwent TUR (and/or BCG instillation) and were followed up, 36 patients had no proper muscle in their specimen (T1xG3). of the 50 patients who underwent immediate cystectomy, 20 patients had T1xG3 disease. We evaluated the clinical and pathological parameters related to the recurrence, progression during followup, upstaging after radical cystectomy and survival. Median follow-up was 51.2 months (3-177) in the follow-up group and 42.3 months (1-188) in cystectomy group. Between the follow-up and the cystectomy group, there was no difference in clinical factors except for the proportion of non-papillary shaped tumour (38.9% vs. 75.0%). RESULTS: Among the patients followed up after TUR, there was no difference in the recurrence, progression and survival between T1G3 and T1xG3 groups (5-year recurrence-free survival, 49.9% vs. 50.9%; 5-year progression-free survival, 83.2% vs. 82.5%; 5-year cancer-specific survival, 95.9% vs. 91.2%, respectively). Twelve percent of patients with T1G3 disease who underwent immediate cystectomy were upstaged, whereas 56% of T1xG3 patients were upstaged, even in the absence of any radiological evidence suggestive of invasive tumour such as perivesical fat infiltration or hydronephrosis (p=0.002). Compared to patients with T1xG3 disease without progression or upstaging, significantly more T1xG3 patients with disease progression or upstaging had non-papillary tumour (38.5% vs. 80.1%, p=0.006), but there was no difference in tumour size, multiplicity, concomitant carcinomain-situ and BCG instillation. CONCLUSIONS: In primary T1G3 bladder cancer, non-papillary tumour without proper muscle in the TUR specimen is a risk factor of progression during follow-up and upstaging after cystectomy that should raise consideration for repeated TUR or early cystectomy.
Ali-el-Dein B., Badran M., Abu-Eideh R., Nabeeh A., Ibrahiem E.H. Urology and Nephrology Centre, Urology, Mansoura, Egypt INTRODUCTION & OBJECTIVES: Because of the risk of upstaging or detection of a residual tumour in a significant number of patients on second TURBT it is recommended that a second TURBT be carried out in all patients with grade 3 T1 bladder transitional cell carcinoma (TCC). In this prospective study, we report our experience with second TURBT in 30 patients. MATERIAL & METHODS: Between September 2002 and June 2005, 30 patients (24 males and 6 females) with a mean age of 61.5 ± 11 years (range 42 to 86) were included into this study. All the patients underwent urethrocystoscopy, complete TURBT of the visible tumour(s). Urine samples were collected by barbotage for cytology and the upper tract was evaluated by excretory or magnetic resonance urography. A second TURBT was scheduled for all patients within 2 to 4 weeks from the first TURBT. RESULTS: Follow-up ranged from 6to 36 months. On first TURBT, all the patients had a G3pTl bladder TCC. Only 4 patients had an associated CIS and no muscle in the TURBT sample was noted in only 1 patient. On second TURBT 17 patients (56.7%) were free of tumour and received BCG therapy. Out of these only 1 (5.9%) developed recurrence during follow-up. 9 patients (30%) showed residual tumour (G3pT1 in 6 and G3pT1 + CIS in 3). These were randomised either to receive BCG (6) or to undergo early radical cystectomy (3). 3 of the 6 patients treated with BCG (50%) developed recurrence + progression. The other 4 patients (13.3%) showed muscle invasive disease and underwent radical cystectomy. CONCLUSIONS: The significant risk of detecting a muscle invasive disease (13.3%) or residual tumour (30%) strongly recommends the routine performance of second TURBT in grade 3 stage T1 bladder TCC. Recurrence of T1G3 on second TURBT is a poor prognostic sign with a high rate of further recurrence or progression. However, a larger number of patients and longer follow-up are needed to confirm these results.
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672
OPTIMISED POSTOPERATIVE ADMINISTRATION OF INTRAVESICAL MITOMYCIN C
EFFICACY OF MANAGING SMALL RECURRENT BLADDER TUMOURS BY DIATHERMY USING THE CYF-4 OLYMPUS FLEXIBLE CYSTOSCOPE UNDER LOCAL ANAESTHESIA IN DAY SURGERY UNIT Chandrasekar P.1, Walkay G.2, Calleary J.2, Samman R.2, Virdi J.2, Potluri B.2 1 Princess Alexandra Hospital, Department of Urology, Harlow, United Kingdom, 2 Princess Alexandra Hospital, Urology, Harlow, United Kingdom INTRODUCTION & OBJECTIVES: Traditionally small bladder tumour recurrences have been treated by cystodiathermy requiring regional or general anesthesia and in many cases an overnight stay in hospital. We conducted a feasibility trial to assess the diathermy destruction and outcome of these recurrent superficial bladder tumours using the CYF- 4 Olympus flexible cystoscope. MATERIAL & METHODS: From June 2002 to June 2005, 65 patients underwent flexible cystoscopy and diathermy destruction of small recurrent bladder tumours using 2% lignocaine gel as topical urethral anaesthesia. The age of the patients ranged from 34 to 94 years (Mean=71.6). Prior to this check cystoscopy, all the patients had undergone transurethral resection of bladder tumour and their tumours were staged and graded. During cystoscopy the urethra and bladder were examined for recurrent tumours (number, location and size). Patients with small recurrent tumours up to 5 in number were treated with diathermy. Patients were asked to grade the pain (mild, moderate, severe) and willingness to undergo the same procedure again. All the patients underwent check flexible cystoscopy 3 months after the diathermy to look for recurrences. RESULTS: 65 patients (49 males and 16 females) had 111 cystodiathermy sessions. A total 176 bladder tumours were diathermised during these sessions. The number of tumours varied from 1 to 5. The size of the tumours ranged between 2mm to 20mm. Among the patients who had cystodiathermy, 2 patients (1.8%) experienced moderate pain and others only mild pain. All patients (99%) except one were willing to undergo the same procedure again. The follow up cystoscopy at 3 months showed no recurrences in 161 sites (91.5%), recurrences at or close to the previous site in 3(1.7%) and recurrence at different site in 12 (6.8%). All these recurrent tumours were managed by repeat cystodiathermy in similar manner, however in 3 patients who had recurrence at different site required general anaesthesia due to larger size. CONCLUSIONS: Cystodiathermy of small recurrent bladder tumours under local anaesthesia using the CYF-4 Olympus flexible cystoscope is safe, effective and well tolerated by the patient in the day surgery unit.
Müller T., Akkad T., Gozzi C., Ramoner R., Mitterberger M., Bartsch G., Steiner H. Medical University Innsbruck, Urology, Innsbruck, Austria INTRODUCTION & OBJECTIVES: Immediate postoperative instillation of chemotherapy decreases the risk of recurrence in patients with superficial bladder cancer. Response rates have been variable, in part because of inadequate drug delivery; therefore an adequate administration time is important to achieve an optimal oncological efficacy. We conducted a prospective randomised study to compare the acceptance of two different intravesical Mitomycin C (MMC) instillation. MATERIAL & METHODS: Between October 2004 and June 2005, 60 patients were randomised after transurethral resection of superficial bladder cancer into two groups. Both groups received intravesical instillation of 40mg MMC diluted in 50 ml Aqua dest. within six hours after surgery. In group A the catheter was clamped, in group B the catheter was not clamped but the urine bag was elevated one meter above the level of the supine patient to enable bladder contractions without rigid resistance – MMC was retained within the bladder by gravity. Discomfort and pain were documented by the patient every 15 minutes on a visual analogue scale (range 1-10). The instillation was terminated after two hours or earlier if pain was not tolerable. RESULTS: In group A the mean instillation time was 83,4 ± 38,1 min (range 15-120) and 11 (36,6%) patients tolerated all 120 minutes of treatment. The mean instillation time in group B was 110,4 ± 20,9 min (range 60-120) and 25 (83,3%) patients completed 120 minutes. The mean overall pain levels measured were significantly lower (p<0.05) in group B (2.7 ± 2.4 in group A and 1.8 ± 1.3 in group B). Histology and number of tumours resected was not significantly different in both groups. CONCLUSIONS: Elevation of the urine bag instead of clamping the catheter was associated with significantly longer instillation times, significantly more patients completing the full two hours and significantly lower pain sensations. The question whether this longer instillation time is associated with lower recurrence rates will be investigated in further studies. Eur Urol Suppl 2006;5(2):190
670
VALUE OF SECOND TURBT IN GRADE 3 STAGE TL TRANSITIONAL CELL CARCINOMA OF THE BLADDER
PROGNOSTIC SIGNIFICANCE OF ABSENCE OF PROPER MUSCLE IN THE RESECTED SPECIMEN OF PRIMARY T1G3 BLADDER CANCER Park J., Song C., Kim J.B., Hong J.H., Kim C.S., Ahn H. Asan Medical Centre, Urology, Seoul, South Korea INTRODUCTION & OBJECTIVES: Absence of proper muscle in the transurethral resection (TUR) specimen often brings difficulty in deciding further treatment plan in patients with high risk bladder cancer. We analysed the recurrence and progression of T1G3 bladder cancer according to the presence or absence of muscle tissue in the specimen. MATERIAL & METHODS: The data from 157 patients with T1G3 bladder cancer on initial TUR specimen were reviewed. Among the 107 patients who underwent TUR (and/or BCG instillation) and were followed up, 36 patients had no proper muscle in their specimen (T1xG3). of the 50 patients who underwent immediate cystectomy, 20 patients had T1xG3 disease. We evaluated the clinical and pathological parameters related to the recurrence, progression during followup, upstaging after radical cystectomy and survival. Median follow-up was 51.2 months (3-177) in the follow-up group and 42.3 months (1-188) in cystectomy group. Between the follow-up and the cystectomy group, there was no difference in clinical factors except for the proportion of non-papillary shaped tumour (38.9% vs. 75.0%). RESULTS: Among the patients followed up after TUR, there was no difference in the recurrence, progression and survival between T1G3 and T1xG3 groups (5-year recurrence-free survival, 49.9% vs. 50.9%; 5-year progression-free survival, 83.2% vs. 82.5%; 5-year cancer-specific survival, 95.9% vs. 91.2%, respectively). Twelve percent of patients with T1G3 disease who underwent immediate cystectomy were upstaged, whereas 56% of T1xG3 patients were upstaged, even in the absence of any radiological evidence suggestive of invasive tumour such as perivesical fat infiltration or hydronephrosis (p=0.002). Compared to patients with T1xG3 disease without progression or upstaging, significantly more T1xG3 patients with disease progression or upstaging had non-papillary tumour (38.5% vs. 80.1%, p=0.006), but there was no difference in tumour size, multiplicity, concomitant carcinomain-situ and BCG instillation. CONCLUSIONS: In primary T1G3 bladder cancer, non-papillary tumour without proper muscle in the TUR specimen is a risk factor of progression during follow-up and upstaging after cystectomy that should raise consideration for repeated TUR or early cystectomy.
Ali-el-Dein B., Badran M., Abu-Eideh R., Nabeeh A., Ibrahiem E.H. Urology and Nephrology Centre, Urology, Mansoura, Egypt INTRODUCTION & OBJECTIVES: Because of the risk of upstaging or detection of a residual tumour in a significant number of patients on second TURBT it is recommended that a second TURBT be carried out in all patients with grade 3 T1 bladder transitional cell carcinoma (TCC). In this prospective study, we report our experience with second TURBT in 30 patients. MATERIAL & METHODS: Between September 2002 and June 2005, 30 patients (24 males and 6 females) with a mean age of 61.5 ± 11 years (range 42 to 86) were included into this study. All the patients underwent urethrocystoscopy, complete TURBT of the visible tumour(s). Urine samples were collected by barbotage for cytology and the upper tract was evaluated by excretory or magnetic resonance urography. A second TURBT was scheduled for all patients within 2 to 4 weeks from the first TURBT. RESULTS: Follow-up ranged from 6to 36 months. On first TURBT, all the patients had a G3pTl bladder TCC. Only 4 patients had an associated CIS and no muscle in the TURBT sample was noted in only 1 patient. On second TURBT 17 patients (56.7%) were free of tumour and received BCG therapy. Out of these only 1 (5.9%) developed recurrence during follow-up. 9 patients (30%) showed residual tumour (G3pT1 in 6 and G3pT1 + CIS in 3). These were randomised either to receive BCG (6) or to undergo early radical cystectomy (3). 3 of the 6 patients treated with BCG (50%) developed recurrence + progression. The other 4 patients (13.3%) showed muscle invasive disease and underwent radical cystectomy. CONCLUSIONS: The significant risk of detecting a muscle invasive disease (13.3%) or residual tumour (30%) strongly recommends the routine performance of second TURBT in grade 3 stage T1 bladder TCC. Recurrence of T1G3 on second TURBT is a poor prognostic sign with a high rate of further recurrence or progression. However, a larger number of patients and longer follow-up are needed to confirm these results.
671
672
OPTIMISED POSTOPERATIVE ADMINISTRATION OF INTRAVESICAL MITOMYCIN C
EFFICACY OF MANAGING SMALL RECURRENT BLADDER TUMOURS BY DIATHERMY USING THE CYF-4 OLYMPUS FLEXIBLE CYSTOSCOPE UNDER LOCAL ANAESTHESIA IN DAY SURGERY UNIT Chandrasekar P.1, Walkay G.2, Calleary J.2, Samman R.2, Virdi J.2, Potluri B.2 1 Princess Alexandra Hospital, Department of Urology, Harlow, United Kingdom, 2 Princess Alexandra Hospital, Urology, Harlow, United Kingdom INTRODUCTION & OBJECTIVES: Traditionally small bladder tumour recurrences have been treated by cystodiathermy requiring regional or general anesthesia and in many cases an overnight stay in hospital. We conducted a feasibility trial to assess the diathermy destruction and outcome of these recurrent superficial bladder tumours using the CYF- 4 Olympus flexible cystoscope. MATERIAL & METHODS: From June 2002 to June 2005, 65 patients underwent flexible cystoscopy and diathermy destruction of small recurrent bladder tumours using 2% lignocaine gel as topical urethral anaesthesia. The age of the patients ranged from 34 to 94 years (Mean=71.6). Prior to this check cystoscopy, all the patients had undergone transurethral resection of bladder tumour and their tumours were staged and graded. During cystoscopy the urethra and bladder were examined for recurrent tumours (number, location and size). Patients with small recurrent tumours up to 5 in number were treated with diathermy. Patients were asked to grade the pain (mild, moderate, severe) and willingness to undergo the same procedure again. All the patients underwent check flexible cystoscopy 3 months after the diathermy to look for recurrences. RESULTS: 65 patients (49 males and 16 females) had 111 cystodiathermy sessions. A total 176 bladder tumours were diathermised during these sessions. The number of tumours varied from 1 to 5. The size of the tumours ranged between 2mm to 20mm. Among the patients who had cystodiathermy, 2 patients (1.8%) experienced moderate pain and others only mild pain. All patients (99%) except one were willing to undergo the same procedure again. The follow up cystoscopy at 3 months showed no recurrences in 161 sites (91.5%), recurrences at or close to the previous site in 3(1.7%) and recurrence at different site in 12 (6.8%). All these recurrent tumours were managed by repeat cystodiathermy in similar manner, however in 3 patients who had recurrence at different site required general anaesthesia due to larger size. CONCLUSIONS: Cystodiathermy of small recurrent bladder tumours under local anaesthesia using the CYF-4 Olympus flexible cystoscope is safe, effective and well tolerated by the patient in the day surgery unit.
Müller T., Akkad T., Gozzi C., Ramoner R., Mitterberger M., Bartsch G., Steiner H. Medical University Innsbruck, Urology, Innsbruck, Austria INTRODUCTION & OBJECTIVES: Immediate postoperative instillation of chemotherapy decreases the risk of recurrence in patients with superficial bladder cancer. Response rates have been variable, in part because of inadequate drug delivery; therefore an adequate administration time is important to achieve an optimal oncological efficacy. We conducted a prospective randomised study to compare the acceptance of two different intravesical Mitomycin C (MMC) instillation. MATERIAL & METHODS: Between October 2004 and June 2005, 60 patients were randomised after transurethral resection of superficial bladder cancer into two groups. Both groups received intravesical instillation of 40mg MMC diluted in 50 ml Aqua dest. within six hours after surgery. In group A the catheter was clamped, in group B the catheter was not clamped but the urine bag was elevated one meter above the level of the supine patient to enable bladder contractions without rigid resistance – MMC was retained within the bladder by gravity. Discomfort and pain were documented by the patient every 15 minutes on a visual analogue scale (range 1-10). The instillation was terminated after two hours or earlier if pain was not tolerable. RESULTS: In group A the mean instillation time was 83,4 ± 38,1 min (range 15-120) and 11 (36,6%) patients tolerated all 120 minutes of treatment. The mean instillation time in group B was 110,4 ± 20,9 min (range 60-120) and 25 (83,3%) patients completed 120 minutes. The mean overall pain levels measured were significantly lower (p<0.05) in group B (2.7 ± 2.4 in group A and 1.8 ± 1.3 in group B). Histology and number of tumours resected was not significantly different in both groups. CONCLUSIONS: Elevation of the urine bag instead of clamping the catheter was associated with significantly longer instillation times, significantly more patients completing the full two hours and significantly lower pain sensations. The question whether this longer instillation time is associated with lower recurrence rates will be investigated in further studies. Eur Urol Suppl 2006;5(2):190