Dr. Witjes began his discussion by noting that although he will argue against TURBT, current EAU guidelines do recommend performing a repeat TURBT in high-risk HG Ta and T1 tumors.
Although Dr. Witjes does not dispute the importance of a re-resection in the T1 cohort, he does note that stratifying T1 disease patients is crucial. De Jong et al. evaluated 263 patients with documented high risk T1 NMIBC with 73% classified as having extensive lamina propria invasion and 27% as microinvasion (median follow up of 68 months). BCG failure was significantly higher in those with extensive disease (41% versus 21%, p=0.002) and the 3-year high grade recurrence free survival was significantly worse in the extensive T1 cohort (64% versus 83%, p=0.004). On multivariable analysis, T1 substaging was an independent predictor of high-grade recurrence (HR 3.2, p-0.005) and progression (HR 3.0, p=0.009). Thus, one can conclude that T1 substaging is important and has the potential to guide treatment decisions on BCG versus alternative strategies at diagnosis.1
The significance of a good TURBT thus becomes crucial to obtain an adequate, deep resection with minimal cautery artifact.. In Dr. Witjes's opinion, the secret to a good TURBT is presence of detrusor muscle. Mariappan et al. demonstrated in 473 NMIBC specimens (69.6% of which had detrusor muscle) that presence of detrusor muscle was associated with significantly improved recurrence. Senior surgeons performing the procedure were more likely to sample detrusor at time of TURBT (OR 4.9) and had lower recurrence (OR 5.3) at first follow up cystoscopy.
There are various ways to optimize TURBT performance in 2022:
- TURBT training/experience
- Air cystoscopy
- Use of photodynamic diagnosis/narrow band imaging during resection
- Second look TURBT (Dr. Witjes wonders why it was not adequate the first time)
While Dr. Witjes does not argue against the value of repeat TURBT in select cases, he questions why a large proportion of recurrences/progression occur at the site of initial resection? Shouldn’t the resection have been complete/extensive enough if properly performed?
Does the presence of detrusor muscle in the initial TURBT specimen influence outcomes in T1 patients undergoing repeat TURBT? Gontero et al. reported the results of 2,451 HGT1 patients with BCG, 38% of who underwent a repeat TURBT. The authors grouped the patients into 4 groups:
- Re-TURBT yes, Detrusor Yes
- Re-TURBT yes, Detrusor No
- Re-TURBT no, Detrusor Yes
- Re-TURBT no, Detrusor no
A recent systematic review of 24 studies evaluating upstaging from T1 to muscle invasive disease after repeat TURBT was performed. 4,678 patients were included of whom 50% underwent a repeat TURBT. Upstaging rates ranged between 0 and 32%.
Dr. Witjes went on to present data from his own series of 295 patients in 3 centers with T1 disease, visually complete resection, detrusor present without tumor, and at least one year follow up. Of these 295 patients, 24% had a repeat TURBT at the discretion of the surgeon. Significant predictors of outcome in multivariable analysis included the choice of BCG schedule and tumor multiplicity, but not repeat TURBT. A recent comparative effectiveness study of re-resection for 7,666 T1 bladder cancer by the Toronto group demonstrated that re-TURBT was associated with lower overall mortality (HR 0.88, 95% CI 0.81-0.95), but not cancer-specific mortality (HR 0.87, 95% CI 0.75-1.02).
Dr. Witjes went on to present the downsides of performing a repeat TURBT:
- An extra operation with increased risk in an unhealthy, older population
- It causes a delay in effective intravesical BCG therapy for 1-2 months
- It is unnecessary in case of a negative re-TURBT (>50%)
- Perhaps a radical TURBT with enhanced visualization and reduced residual tumor could make re-TURBT redundant
- Certainly, re-TURBT should be done in case of any doubt about the initial resection
- By the urologist
- Incomplete resection
- Inadequate deep biopsy
- By the pathologist
- No detrusor
- High grade cytology and low-grade tumor
- By the urologist
- But in case both are sure about a good resection and negative muscle involvement, upfront intravesical BCG in these high-risk patients seems defendable
Dr. J.A. (Fred) Witjes, MD, Professor, Department of Urology, Radboud University, Nijmegen, Netherlands
Written by: Rashid Sayyid, MD, MSc – Urology Chief Resident, Augusta University/Medical College of Georgia, @rksayyid on Twitter during the 2022 American Urological Association (AUA) Annual Meeting, New Orleans, LA, Fri, May 13 – Mon, May 16, 2022.
References:
- De Jong FC, Hoedemaeker RF, Kvikstad v, et al. T T1 Substaging of Nonmuscle Invasive Bladder Cancer is Associated with bacillus Calmette-Guérin Failure and Improves Patient Stratification at Diagnosis. J Urol. 2021;205(3):701-708l