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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 29  |  Issue : 2  |  Page : 95-99

Role of second-look transurethral resection of bladder tumors for newly diagnosed T1 bladder cancer: Experience at a single center


1 Division of Urology, Department of Surgery, Chi Mei Hospital, Chiali, Taiwan
2 Division of Urology, Department of Surgery, Division of Uro-Oncology, Chi Mei Medical Center, Tainan, Taiwan
3 Department of Pathology, Chi Mei Medical Center, Tainan, Taiwan

Date of Web Publication30-Apr-2018

Correspondence Address:
Alex Chien-Hwa Liao
Department of Surgery, Division of Urology, Chi Mei Medical Center, Tainan
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_17_17

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  Abstract 

Objective: The aim of the present study was to evaluate the outcome of second-look transurethral resection of bladder tumors (TURBT) for superficial T1 bladder cancer. Materials and Methods: We enrolled a total of 504 patients who were pathologically diagnosed with urothelial carcinoma and underwent TURBT between January 2012 and December 2016. A total of 240 patients were diagnosed with T1 urothelial carcinoma in the bladder, and 101 (42%) of these patients underwent a second-look TURBT within 4–14 weeks after the initial resection. We assessed the pathological staging of the second-look TURBT. Results: Of the 101 patients who underwent a second-look TURBT, 18 (18%) had residual tumors based on the pathological report: one had pTa disease, seven had pTis disease, nine had pT1 disease, and one had pT2 disease. The residual tumor rate was higher in patients with more than one tumor than in patients with a single tumor; however, there was no significant findings in patients with tumors larger than 3 cm or high histological grade. Conclusion: The results of the present study show that 18% of patients who underwent a second-look TURBT had residual tumors. Early diagnosis of residual tumors or restaging is possible through a second-look TURBT, which could help in deciding the subsequent treatment step if a residual tumor was found.

Keywords: Bladder tumor, Second-look TURBT, Urothelial carcinoma


How to cite this article:
Tseng WH, Liao AC, Shen KH, Chen CH, Liu CL, Hung SH, Su CC, Wang JC, Lee KH, Li CF, Huang SK. Role of second-look transurethral resection of bladder tumors for newly diagnosed T1 bladder cancer: Experience at a single center. Urol Sci 2018;29:95-9

How to cite this URL:
Tseng WH, Liao AC, Shen KH, Chen CH, Liu CL, Hung SH, Su CC, Wang JC, Lee KH, Li CF, Huang SK. Role of second-look transurethral resection of bladder tumors for newly diagnosed T1 bladder cancer: Experience at a single center. Urol Sci [serial online] 2018 [cited 2018 May 24];29:95-9. Available from: http://www.e-urol-sci.com/text.asp?2018/29/2/95/229973


  Introduction Top


The incidence of bladder cancer has been increasing in recent years. In 2014, bladder cancer was the 10th and 11th most common malignancy in Taiwan leading to death in men and women, respectively.[1] The standardized death rate was 2.3/100,000 population, and the male-to-female ratio was about 2:1 in 2014.[1] Approximately, 75% of newly diagnosed cases of bladder cancer are nonmuscle invasive bladder cancer (NMIBC), including stages Ta, Tis, and T1.[2] In these groups of patients, transurethral resection of bladder tumor (TURBT) is the standard procedure for the diagnosis and management of NMIBC.[3] However, bladder cancer is multifocal, with a high recurrence rate. Further, in patients undergoing initial TURBT, the recurrence rate remains high, at 50%–70%, with a progression rate of 15%–30%.[4] Several factors influence the outcome of the initial TURBT, such as multiple tumors, a large tumor or a location with an unidentifiable margin, and effortless bleeding that can obstruct the surgeon's vision, the surgeon's experience and skill, the quality of the specimens, and the pathologist's evaluation. Consequently, the pathological stage of the tumor is underestimated in 9%–49% of patients with NMIBC after the first TURBT,[5] especially in patients with T1 bladder cancer.

Therefore, second-look TURBT has an important role in confirming or restaging to help clinicians make decisions regarding further disease management.

In general, second-look TURBT is performed 2–6 weeks after the initial resection, which includes resection of the primary tumor site.[6] However, in our study, all the patients underwent surgery, other treatments, and follow-up at Chi Mei Medical Center, unlike previous studies, in which the patients were referred from another institution for a secondary opinion.[7] The difference between previous studies and our study is that the majority of our patients also received instillation of a single chemotherapeutic agent after bladder tumor resection,[4] as well as subsequent intravesical chemotherapy or Bacillus Calmette–Guérin (BCG) therapy if the pathological report from the initial resection showed T1 bladder cancer.

Based on our experience with first TURBT and its follow-up, second-look TURBTs in our center are performed 4–14 weeks after the initial resection to ensure that the first resection is complete and accurate and also to assess the effect of the intravesical therapy. In the present study, we analyzed the outcomes of second-look TURBT for superficial T1 bladder cancer in patients treated at Chi Mei Medical Center to evaluate whether this course of treatment is appropriate.


  Materials and Methods Top


We enrolled a total of 504 patients who were diagnosed with bladder cancer by undergoing TURBT between January 2012 and December 2016 in this retrospective study, and complete preoperative clinical evaluation, including medication, physical examination, and laboratory tests, was performed [Figure 1]. We recorded 240 patients who were diagnosed with T1 urothelial carcinoma in the bladder, and excluded patients who had been previously diagnosed bladder cancer, had cancer in the upper urinary tract or prostatic urethra, were not identified muscularis propria in the initial TURBT, did not accept second-look TURBT within 4–14 weeks, or were lost to follow-up. All our initial TURBT resected visible tumor with base, and we had not done extended TURBT.[8] Hence, we did not know whether the margin is free, but all of tumors base are free. Moreover, we defined the adequate stage for the initial TURBT need to include the muscularis propria, or it was not the adequate stage and we excluded from this study.
Figure 1: Flowchart of patients who underwent second-look transurethral resection of bladder tumor

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Whether the patient does the second-look TURBT or not and the interval between the initial and second-look TURBT was determined according to the attending physician's decision without a certain indication and protocol. All patients underwent intravesical therapy once a week for 6–12 weeks after the initial TURBT, and during the intravesical therapy, cystoscopy and urine cytology were not received. Most patients then underwent second-look TURBT after complete whole intravesical therapy. Finally, only 101 patients underwent a second-look TURBT within 4–14 weeks after the initial resection. All second-look TURBT procedures were performed by experienced urologists and senior residents and included deep and wide resections around the site of the first TURBT. Deep muscle specimens were collected during the second-look TURBT and sent for the histopathological assessment; the tumors were staged according to the tumor–node–metastasis classification of the American Joint Committee on Cancer as low- or high-grade tumors in line with the classification system of the the World Health Organization/International Society of Urological Pathology.[9] In the present study, we analyzed the residual tumor rate based on the pathology of the second-look TURBT of the 101 patients diagnosed with T1 bladder cancer at Chi Mei Medical Center between January 2012 and December 2016.

We assessed the data from the 101 patients using descriptive statistics. Further, we used the Chi-square test to analyze the data on the risk factors of residual and the rate of upstaging. P < 0.05 was considered to be statistically significant.


  Results Top


[Table 1] shows the clinical and pathological characteristics of the 101 patients who underwent second-look TURBT after the initial TUR. The mean age of the patients was 65.8 years (range: 26–89 years). There were 76 men (75%) and 25 women (25%). The clinical reasons for undergoing the initial resection were hematuria in 80 patients (79%); incidentally observed tumors in an ultrasound or computed tomography on regular health examination in five patients (5%); lower urinary tract symptoms in seven patients (7%); and dysuria, urinary tract infection, or a combination of two of the above problems in the remaining nine patients (9%).
Table 1: Clinical characteristics and first transurethral resection of bladder tumor results

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In the first TURBT, we also recorded the presence of macroscopic lesions, and the tumors were larger than 3 cm in 36 patients (36%) and smaller than 3 cm in the remaining 65 patients (64%). A total of 64 patients (63%) had a single tumor in their bladder, whereas 37 patients (37%) had multiple tumors in their bladder. According to the histopathological analysis of the specimens, 86 patients (85%) had high-grade tumors and only 15 patients (15%) had low-grade tumors.

After the initial transurethral resection, we administered intravesical therapy to the patients on the next day, and the patients then underwent intravesical therapy once a week for 6–12 weeks. A total of 88 (87%), 6 (6%), and 7 patients (7%) were administered epirubicin, mitomycin C, and BCG therapy, respectively.

The mean interval between the initial and second-look TURBT was 7.4 weeks (range: 4–14 weeks), and the results of the pathological examination of the specimens are shown in [Table 2].
Table 2: Pathological report of second-look TURBT

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Of the 101 patients who underwent a second-look TURBT, 18 (18%) had residual tumors based on the pathological report: one patient (1%) had pTa disease, seven patients (7%) had pTis disease (carcinoma in situ), nine patients (9%) had pT1 disease, and one patient (1%) had pT2 disease. Overall, only one patient diagnosed with pathological T2-stage disease experienced tumor upstaging after the second-look TURBT and needed a change in treatment strategy. Besides that patient, the other 11 patients who still had residual tumors required extension of the course of intravesical therapy; however, no change was observed in the disease staging of the bladder cancer.

We also analyzed the residual tumors rate in high-risk patients [Table 3], and the residual tumors rate was higher in patients with more than one tumor than in patients with a single tumor (P = 0.006). However, there were no significant findings in the residual tumors rate in patients with tumors larger than 3 cm and a high histological grade. The mean follow-up time was 22.5 months, and 25 patients had recurrent tumors [Table 4]. Patients were classified into two groups: the group that had “no residual tumors” (14/83, recurrence rate = 16.9%; the mean time for recurrence: 15.8 months) and the group that had “residual tumors” (11/18, recurrence rate = 61.1%; the mean time for recurrence: 13.6 months).
Table 3: Analysis of the residual rate of high-risk patients

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Table 4: Long-time tumor recurrence rate after second-look TURBT

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  Discussion Top


TURBT is performed to confirm the diagnosis and determine the extent of disease within the bladder. The standard treatment for Ta, T1, and Tis disease is TURBT, and NCCN guidelines strongly suggest second-look TURBT for T1 tumor during the initial TURBT.[9]

Studies on T1 bladder tumors with a second-look TURBT in the past decade [7],[10],[11],[12],[13],[14],[15] have shown rates of occurrence of residual tumors of 32.9%–77.6%; these rates include incompletely resected tumors in the initial TUR and early recurrent tumors. The rate of upstaging to muscle invasive cancer is 1.7%–27.6%, which indicates that second-look TURBT is necessary for accurate staging and appropriate therapy [Table 5].
Table 5: Results of Second-look TURBT in patients with T1 tumor

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In our experience at Chi Mei Medical Center, the rate of occurrence of residual tumors on second-look TURBT is 18%, and the upstaging rate is 1%. Several reasons could have affected the outcome of the second-look TURBT, and one of these is the referral system. In most countries, patients are transferred to a referral center or an academic center for a second[7],[10],[11],[12],[13],[14],[15] opinion for their cancer management and are frequently self-referred;[15] however, because of the convenient transportation and inexpensive medical costs in Taiwan, most patients go directly to their medical center for diagnosis and treatment when they have any clinical problems. Therefore, both the initial and second-look TURBT, in our study, were performed at Chi Mei Medical Center, and the specimens were sent to the Department of Pathology in our institution for analysis. Therefore, we believe that the relatively low residual tumor rate and progression rates, in our study, are the result of the effective first resection and subsequent treatment.

Another reason for the differences in the residual tumor rate between our study and previous studies may be that all initial resections and second-look resections were performed by experienced surgeons using standard and meticulous methods. The treatment strategy and duration of all the patients who underwent 6–12 weeks of intravesical therapy, and the epirubicin, mitomycin C, and BCG therapy regimens were decided by their respective urologists. The mean and median intervals between the initial and second-look resections were 7.4 and 8 weeks, respectively; therefore, compared with other studies, which had intervals of only about 2–6 weeks,[7],[10],[11],[12],[13],[14],[15] most of our patients received whole intravesical therapy. Thus, we observed better outcomes following intravesical therapy than those reported in previous studies [Table 5]. However, we found the residual tumor is not correlated with different chemotherapeutic agent of intravesical instillation, and the data were not showed. In our study, 64 patients (63%) had a single tumor at the initial TURBT, and this is a higher rate than that found in other studies (34.5%–63%).[10],[13],[16],[18] This high rate suggests that our cases were diagnosed earlier than the cases in the other studies, and this could be related to our country's health insurance system, which is convenient and cheap.[1] In our country, patients with symptoms such as hematuria tend to seek medical treatment at medical center immediately, and urine analysis, cystoscopy, and imaging studies are typically arranged within 1 month.

Although TURBT is not considered to be an aggressive treatment and is also a diagnostic method, it has an estimated chance of complications of 8.1%. The most common complications in the present study were pain or spasm (3.0%), retention (2.8%), and infection (2.1%), and 0.5% of the TURBT resulted in perforation.[17] Therefore, the suitability of second-look TURBT is still unclear. The European Association of Urology and National Comprehensive Cancer Network guidelines strongly suggest second-look TURBT for T1 bladder cancer, as well as for other risk factors, including high-grade tumor histology, more than one tumor, or tumor sizes of ≥3 cm.[6],[9] Based on our study, the multiple tumor group in the initial TURBT have higher residual tumor rate and we suggest to receive second-look TURBT.

In the present study, 18 of the 101 patients (18%) were found to have residual bladder cancer and needed to undergo further treatment, such as increasing the duration of intravesical therapy to the bladder, changing the dose, or other types of medicine. Moreover, the upstaging rate of bladder tumors in our study was 1%. Therefore, second-look TURBT can be performed on patients with T1 bladder cancer, and although there is a chance of complications, our results show that it still has an indispensable role. In our study, it showed a higher recurrence rate than that of the group that had “residual tumors” [Table 4].

There were some limitations in our study. First, the fact that this was a retrospective study with a small sample population is the most important limitation that could have introduced bias. Second, in our study, the indication for second-look TURBT depended on the surgeons' intraoperative finding and experience. Therefore, the association between the interval from initial to second-look TURBT and tumor outcomes, such as recurrence, progression, or survival, should be investigated in the future. Third, the percentage of patients that accepted second-look TURBT in the group of patients diagnosed with T1 urothelial carcinoma increased year by year; however, this percentage was still only 42% over the 5 years of this study, and the sample size is too small to be able to reflect the real situation.


  Conclusion Top


Based on our experience at Chi Mei Medical Center, the rate of occurrence of residual tumor of T1 bladder cancer from second-look TURBT was 18%. Although this residual tumor rate is relatively low, we still cannot negate the important role of second-look TURBT, especially the high-risk patients, because it is useful in the early diagnosis of residual tumors and restaging, which could help us in deciding the subsequent treatment step if tumor was found.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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