Tag: re-TUR

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Article of the Week: Impact of Re-TUR on BCG-Treated T1 HG/G3 Bladder Cancer

July 27, 2016/by admin Z.9

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Francesca Pisano and Paolo Gontero, discussing their paper.

If you only have time to read one article this week, it should be this one.

The impact of re-transurethral resection on clinical outcomes in a large multicentre cohort of patients with T1 high-grade/Grade 3 bladder cancer treated with bacille Calmette–Guerin

Paolo Gontero¹, Richard Sylvester², Francesca Pisano¹, Steven Joniau³, Marco Oderda¹, Vincenzo Serretta⁴,Stephane Larre⁵, Savino Di Stasi⁶, Bas Van Rhijn⁷, Alfred J.Witjes⁸, Anne J. Grotenhuis⁸, Renzo Colombo⁹, Alberto Briganti⁹, Marek Babjuk¹⁰, Viktor Soukup¹⁰, Per-Uno Malmstrom¹¹, Jacques Irani¹², Nuria Malats¹³, Jack Baniel¹⁴, RoyMano¹⁴, Tommaso Cai¹⁵, Eugene K. Cha¹⁶, Peter Ardelt¹⁷, John Vakarakis¹⁸, Riccardo Bartoletti¹⁹, Guido Dalbagni²⁰, Shahrokh F. Shariat¹⁶, Evanguelos Xylinas¹⁶, Robert J.Karnes²¹and Joan Palou²²

¹Urology Clinic, Citta della Salute e della Scienza di Torino, University of Studies of Turin, Turin ,⁴Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, ⁶Policlinico Tor Vergata-University of Rome, Rome, ⁹Dipartimento di Urologia, Universita Vita-Salute. Ospedale S. Raffaele, Milan, ¹⁵Department of Urology, SantaChiara Hospital, Trento, ¹⁹Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy, ²Formerly Department of Biostatistics, EORTC Headquarters, Brussels, ³Oncologic and Reconstructive Urology, Department of Urology, University Hospitals Leuven, Leuven, Belgium, ⁵Department of Surgical Science, John Radcliffe Hospital, University of Oxford, Oxford, UK, ⁷Department of Urology, Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Amsterdam, ⁸Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands, ¹⁰Department of Urology, Motol Hospital, University of Praha, Praha, Czech Republic, ¹¹Department of Urology, Academic Hospital, Uppsala University, Uppsala, Sweden, ¹²Department of Urology, Centre Hospitalier Universitaire La Miletrie, University of Poitiers, Poitiers, France, ¹³Genetic and Molecular Epidemiology Group, Spanish National Cancer Research Centre (CNIO), Madrid, ²²Department of Urology, Fundacio Puigvert, University of Barcelona, Barcelona, Spain, ¹⁴Department of Urology, Rabin Medical Centre, Tel Aviv, Israel, ¹⁶Department of Urology, Weill Medical College of Cornell University in New York City, ²⁰Department of Urology, Memorial Sloan Kettering Cancer Center, New York, NY, ²¹Department of Urology, Mayo Clinic, Rochester, MN, USA, ¹⁷Facharzt fur Urologie, Abteilung fur Urologie. Chirurgische Universitats klinik, Freiburg, Germany, and ¹⁸Department of Urology, Sismanoglio Hospital, University of Athens, Athens, Greece

Read the full article

Objectives

To determine if a re-transurethral resection (TUR), in the presence or absence of muscle at the first TUR in patients with T1-high grade (HG)/Grade 3 (G3) bladder cancer, makes a difference in recurrence, progression, cancer specific (CSS) and overall survival (OS).

Patients and methods

In a large retrospective multicentre cohort of 2451 patients with T1-HG/G3 initially treated with bacille Calmette–Guérin, 935 (38%) had a re-TUR. According to the presence or absence of muscle in the specimen of the primary TUR, patients were divided in four groups: group 1 (no muscle, no re-TUR), group 2 (no muscle, re-TUR), group 3 (muscle, no re-TUR) and group 4 (muscle, re-TUR). Clinical outcomes were compared across the four groups.

Results

Re-TUR had a positive impact on recurrence, progression, CSS and OS only if muscle was not present in the primary TUR specimen. Adjusting for the most important prognostic factors, re-TUR in the absence of muscle had a borderline significant effect on time to recurrence [hazard ratio (HR) 0.67, P = 0.08], progression (HR 0.46, P = 0.06), CSS (HR 0.31, P = 0.07) and OS (HR 0.48, P = 0.05). Re-TUR in the presence of muscle in the primary TUR specimen did not improve the outcome for any of the endpoints.

Conclusions

Our retrospective analysis suggests that re-TUR may not be necessary in patients with T1-HG/G3, if muscle is present in the specimen of the primary TUR.

Editorial: Time to re-evaluate and refine re-TUR in bladder cancer?

July 27, 2016/1 Comment/by Hugh Mostafid

In this issue of BJUI, Gontero et al. [1] present data from a large multi-centre study that should allow us to re-evaluate and refine the indications for re-transurethral resection (TUR) in bladder cancer.

Herr [2] first described this procedure in 1999 and for the past 16 years the indications have remained largely unchanged and are summarised in the latest European Association of Urology guidelines on non-muscle-invasive bladder cancer (NMIBC) [3]:

After incomplete initial TUR of bladder tumour (TURBT).
If there is no muscle in the specimen after initial resection.
In all T1 tumours.
In all Grade 3 tumours except primary carcinoma in situ.

In a multi-centre retrospective study of 2 451 patients with high-grade (HG)/Grade 3 (G3) T1 NMIBC treated with BCG, Gontero et al. [1]examined 935 patients who had re-TUR (38% of the total, itself a low figure). Patients were divided into four groups according to the presence or absence of detrusor muscle in the first TURBT specimen:

No muscle, no re-TUR
No muscle, re-TUR
Muscle, no re-TUR
Muscle, re-TUR

The authors found that re-TUR only had a positive impact on recurrence, progression, cancer-specific and overall survival, if detrusor muscle was not present in the original specimen. Importantly, in the presence of detrusor muscle in the original specimen, re-TUR did not improve outcomes. The authors conclude that re-TUR may be unnecessary in HG/G3 T1 patients if detrusor muscle is present at the first TURBT.

These findings are important for two reasons: firstly, Herr’s [2] paper was the first to draw attention to the finding that TURBT, a routine urological procedure, was often carried out inadequately. In recent years, the importance of carrying out a high-quality TURBT has been increasingly recognised [4], whilst the presence of detrusor muscle in the TURBT specimen has been shown to be a good measure of the technical quality of a TURBT [5]. This paper [1] further reinforces the importance of obtaining detrusor muscle in the first TURBT. Indeed, as failure to do so results in the patient having to have a second operation and delays their treatment, perhaps we should start to think of a failure to obtain detrusor muscle at the first TURBT in much the same way as positive margin rates are used as a measure of the quality of radical prostatectomy and by inference, the skill of the surgeon.

Secondly, re-TUR arguably serves one overarching purpose: to identify patients with muscle-invasive bladder cancer (MIBC) who have been under-staged by an inadequate first TURBT and who without a re-TUR would be inadequately treated.

Although a secondary role of re-TUR is to identify patients with residual NMIBC, which has some prognostic value, in practice it rarely changes the patient’s management in this setting, which is intravesical therapy usually with BCG. However, in many healthcare systems the timely organisation of a re-TUR within the recommended 6 weeks is challenging and there is usually a further delay of at least 2 weeks until the pathology is reviewed and a patient with NMIBC can finally commence treatment. In this context, it is not surprising that a recent paper in BJUI showed that the interval to re-TUR was a predictor of recurrence and progression and that a re-TUR after 7 weeks was associated with a much worse outcome [6]. It therefore seems logical to reserve re-TUR only for those patients who truly need it, so that limited resources are focused on ensuring that they receive their operation in a timely manner, ideally within 2–4 weeks. If adopted into day-to-day urological practice, the findings by Gontero et al. [1] will allow many patients with HG/G3 T1 and detrusor muscle in the first TURBT specimen to avoid a re-TUR and start intravesical therapy without further delay. Pragmatically, the same should apply to patients with HG/G3 Ta with detrusor muscle in the specimen. On the other hand, HG/G3 T1 patients without detrusor muscle should be fast-tracked for re-TUR as soon as is practicable and certainly no later than 6 weeks.

The article [1] does have some shortcomings. The study design excludes patients with MIBC, so we do not know by comparison how many patients with MIBC were under-staged at the initial TUR based on subsequent re-TUR but as the authors point out, their conclusions would hold true even in this group, as it is very unlikely that one would miss MIBC if there was adequate detrusor muscle in the pathology specimen.

In conclusion, we should consider refining the indications for re-TUR to improve the utilisation of healthcare resources and ensure that for those that need it, a re-TUR is carried promptly whilst for those that do not, essential intravesical treatment is not delayed.

Read the full article

A. Hugh Mostaﬁd, Consultant Urologist and Honorary

Senior Lecturer The Royal Surrey County Hospital, Guildford, Surrey, UK

References

1 Gontero P, Sylvester R, Pisano F et al. The impact of re-transurethral resection on clinical outcomes in a large multicentre cohort of patients with T1 high-grade/Grade 3 bladder cancer treated with bacille Calmette-Guerin. BJU Int 2016; 118: 44–52

2 Herr HW. The value of a second transurethral resection in evaluating patients with bladder tumors. J Urol 1999; 162: 74–6

3 Babjuk M, Bohle A, Burger M et al. Guidelines on Non-muscle-invasive Bladder Cancer (Ta, T1 and CIS). European Association of Urology, 2015. Available at: https://uroweb.org/wp-content/uploads/EAU-Guidelines-Non- muscle-invasive-Bladder-Cancer-2015-v1.pdf. Accessed 23 November 2015.

4 MostaﬁdH, Brausi M. Measuring and improving the quality of transurethral resection for bladder tumour (TURBT). BJU Int 2012; 109: 1579–82

5 Mariappan P, Zachou A, Grigor KM. Detrusor muscle in the ﬁrst, apparently complete transurethral resection of bladder tumour specimen is a surrogate marker of resection quality, predicts risk of early recurrence, and is dependent on operator experience. Eur Urol 2010; 57:

843–9

6 Baltaci S, Bozlu M, Yildirim A et al. Signiﬁcance of the interval between ﬁrst and second transurethral resection on recurrence and progression rates in patients with high-risk non-muscle-invasive bladder cancer treated with maintenance intravesical Bacillus Calmette-Guerin.

BJU Int 2015; 116: 721–6

Video: Impact of Re-TUR on BCG-Treated T1 HG/G3 Bladder Cancer

July 27, 2016/by admin Z.9