Second Transurethral Resection of Bladder Tumors: Review of the Literature and Single Center Results
- 1. Division of Urology, Men’s Health Centre, Hospital Brigadeiro, Brazil
Abstract
Purpose: We reviewed the literature related to the importance of the second transurethral resection of bladder tumors (TURBT) and we described the results of second TURBTs in a single center.
Material and methods: We made a retrospective analysis of the patients submitted to second TURBT between April 2013 and September 2016. The criteria were: incomplete initial TURBT; T1 tumors; high-grade tumors; no detrusor muscle in the specimen after initial resection. Our analysis focused on tumor staging, tumor grade, the presence of detrusor muscle in the specimen, and complete resection of visible tumor. An extensive review of literature related to the second TURBT was also performed.
Results: We performed 99 second TURBTs. 80.8% of the patients were male 19.2% were females. The mean age was 69.24 ± 12.21 years. Most of the patients were current (32.5%) or former (48.2%) smokers. The mean time from the beginning of symptoms to surgery was 12.22 ± 9.82 months. The mean time elapsed between the two TURBTs was 7.24 ± 2.51 weeks. The main symptom at diagnosis was macroscopic hematuria (67.4%). On the first TURBT, 61.6% patients presented as Ta staging and 38.4% presented as T1. Upstaging rate after second TUBRT was 14.1%. Regarding tumor grade, the first TURBT presented: 36.4% of low-grade tumors; 63.6% of high-grade tumors. The upgrading rate was 2.0%. In the first TURBT, the presence of detrusor muscle rate was 92.9% and complete resection rate was 70.7%. Upstaging and detrusor muscle absent in the TURBT had no significant association (OR: 2.667, p = 0.257), however, upstaging and incomplete tumor removal had a statistically significant association (OR: 4.063, p = 0.024).
Conclusion: Second TURBT has a primordial role in bladder cancer management and a better outcome of the patient depends largely on its correct use.
CITATION
de Souza Melo PA, Albertini A, Murta CB, de Almeida Claro JF (2017) Second Transurethral Resection of Bladder Tumors: Review of the Literature and SingleCenter Results. J Clin Nephrol Res 4(3): 1066.
INTRODUCTION
Transurethral resection of bladder tumor (TURBT) is paramount in non-muscle invasive bladder (NMIBC) cancer diagnosis in order to make the correct diagnosis and remove all visible lesions.
In selected patients, only one TURBT is not enough to correctly making the diagnosis and remove all viable tumor of the bladder.
The aim of this article is to discuss the importance of the second transurethral resection of bladder tumors and describe the results of second TURBTs in our service.
MATERIALS AND METHODS
Between April 2013 and September 2016, 424 patients were submitted to TURBTs in our service. Following European Association of Urology Guidelines [1], 99 patients had criteria to be submitted to a second TURBT. The criteria were: after incomplete initial TURBT; T1 tumors; high-grade tumors; if there is no muscle in the specimen after initial resection.
We made a retrospective analysis of those patients that performed second TURBT focusing on tumor staging, tumor grade, the presence of detrusor muscle in the specimen, and complete resection of visible tumor. We made a descriptive analysis of our results and we also made a comparative analysis to find out the factors associated with upgrading and upstaging.
An extensive review of literature related to second TURBT was performed searching for articles in English language at PubMed, Scielo, Lilacs and Cochrane databases until January 2017.
STATISTICAL ANALYSIS
Statistical analysis was performed using SPSS version 23 (SPSS, Inc. Chicago, IL). The results were expressed as the mean ± standard deviation and range.
We compared second upgrading during second TURBT versus absence of detrusor muscle and incomplete first TURBT using Chi-square test. Significance was set at p < 0.05.
RESULTS
On the period studied, we performed 99 second TURBTs. Table 1
Table 1: Baseline characteristics of patients submitted to second TURBT
| Characteristic | Value |
| n (patients) | 99 |
| Age (years), mean ± SD | 69.24 ± 12.21 |
| Gender Male, % Female, % |
80.8% 19.2% |
| Smoking Current smoker, % Former smoker, % Non-smoker, % |
32.5% 48.2% 19.3% |
| ASA score ASA 1, % ASA 2, % ASA 3, % |
4.3% 73.1% 22.6% |
| Time from beginning of symptoms to surgery in months, mean ± SD | 12.22± 9.82 |
| Symptoms at diagnosis Macroscopichematúria, % Microscopichematúria, % LUTS, % Others, % Asymptomatic, % |
67.4% 14.0% 7.0% 3.5% 8.1% |
| Time from first TURBT to second TURBT in weeks, mean ± SD | 7.24 ± 2.51 |
describes the pre-operative characteristics of our patients. 80 patients were male (80.8%) and 19 were female (19.2%). The mean age was 69.24 ± 12.21 years, ranging from 28 to 89 years. Most of the patients were current (32.5%) or former (48.2%) smokers. The mean time from the beginning of symptoms to surgery was 12.22± 9.82 months. The main symptoms at diagnosis were: macroscopic hematuria (67.4%), microscopic hematuria (14.0%), and lower urinary tract symptoms (LUTS) (7.0%).
The mean time elapsed between the first and the second TURBT was 7.24 ± 2.51 weeks.
The results of the first TURBT showed that 61.6% patients presented as Ta staging and 38.4% presented as T1. On the second TURBT, the results were: T0 = 46.5%, Ta = 27.3%, T1 = 21.2%, Tis = 1.0%, and T2 = 4.0%. The upstaging rate after second TURB was 14.1%.
In regard to tumor grade, the first TURBT had 36.4% of lowgrade tumors, and 63.6% of high-grade tumors. On the second TURBT, 20.2% of the patients had low-grade tumors, 33.3% had high-grade tumors, and 46.5% had no malignancy in the specimen. The upgrading rate was only 2.0%.
During the first TURBT, most of the cases had detrusor muscle included in the specimen (92.9%). We performed a complete resection of the tumor in 70.7% of the cases, but in 29.3% of the TURBTs, a complete resection was not achieved during the first procedure.
Table 2 summarizes TURBTs results.
Table 2: First and second TURBTs results.
| First TURBT | Second TURBT | |
| Staging T0, % Ta, % T1, % Tis, % T2, % |
- 61.6% 38.4% - - |
46.5% 27.3% 21.2% 1.0% 4.0% |
| Upstaging rate, % | - | 14.1% |
| Grade Low grade, % High grade, % T0, % |
36.4% 63.6% - |
20.2% 33.3% 46.5% |
| Upgrading rate, % | - | 2.0% |
| Complete tumor resection | 70.7% | 85.9% |
| Detrusor muscle present in specimen | 92.9% | 54.5% |
When we compared upstaging during second TURBT with detrusor muscle absent in the specimen of the first TURBT, we could not find a statistically significant association (OR: 2.667, CI 95%: 0.464 – 15.322, p = 0.257) (Table 3).
Table 3: Upstaging in second TURBT vs absence of detrusor muscle in first TURBT.
| Detrusor absent | ||||
| Yes | No | Total | ||
| Upstaging? | Yes |
2 |
12 13.0% |
14 14.1% |
| No | 5 71.4% |
80 87.0% |
85 85.9% |
|
| Total | 7 100.0% |
92 100.0% |
99 100.0% |
|
| Odds-ratio: 2.667; Confidence interval 95%:0.464 – 15.322; p =0.257 | ||||
However, when we compared upstaging with a complete initial TURBT, incomplete tumor removal had a statistically significant association with tumor upstaging (OR: 4.063, CI 95%: 1.264 – 13.062, p = 0.024) (Table 4).
Table 4: Upstaging in second TURBT vs incomplete resection in first TURBT.
| Complete resection | ||||
| No | Yes | Total | ||
| Upstaging? | Yes | 8 27.6% |
6 8.6% |
14 14.1% |
| No | 21 72.4% |
64 91.4% |
85 85.9% |
|
| Total | 29 100.0% |
70 100.0% |
99 100.0% |
|
| Odds-ratio: 4.063; Confidence interval 95%: 1.264 – 13.062; p =0.024 | ||||
Upgrading rate is too low in our sample, hampering an adequate analysis.
DISCUSSION
A complete TURBT with detrusor muscle included in the specimen is essential to accurately assess if there is detrusor invasion, grade tumor and can be curative in NMIBC. The absence of detrusor muscle in the specimen is associated with higher risk of residual disease, early recurrence and tumor understaging [2,3]. Dutta et al. reported a 64% risk of understaging T1 tumors after resection with absence of detrusor muscle, compared with 30% when muscle was present [4]. However, complete tumor removal is not always possible. Several factors are correlated to incomplete resection, such as large tumors, anatomic inaccessibility, massive bleeding, clinical instability demanding the surgeon to abbreviate the surgery. In those patients in which there is residual tumor, a repeat TURBT is necessary. American Urological Association (AUA) guidelines states that in a patient with NMIBC who underwent an incomplete initial resection (not all visible tumor treated), a clinician should perform a second TURBT or endoscopic treatment of all remaining tumor if technically feasible (Strong Recommendation; Evidence Strength: Grade B) [5].
Moreover, there are selected cases where a repeat TURBT is advised even if a complete resection was performed previously. Papillary tumors invading subepithelial connective tissue (T1) and high-grade tumors have a significant risk of residual tumor after the first TURBT even when the urologist thought he had done a complete resection (T1 = 33-55%; high-grade = 41.4%) [6- 10]. When a second TURBT is performed after some weeks of the first resection, residual tumor is found at least 40% of the time [11-13]. Besides that, the tumor is often understaged by initial resection. Amling et al. found that the potential for understaging high-risk disease ranged from 18% to 37% [14]. The likelihood that muscle-invasive bladder cancer (MIBC) is detected by the second resection of initially T1 tumor ranges from 4-25%. If detrusor muscle is absent after first resection the likelihood of finding MIBC increases to 45% [15]
Ta, T1 or T2 tumors have a completely different treatment and prognosis. Repeat TURBT is able to change treatment in about one-third of patients [16]. A second TURBT also appears to increase disease-free survival. Grimm et al showed in a cohort study that after 5 years, 64% of the patients undergoing repeat TURBT were disease-free compared to 40% in those patients who were not submitted to repeat TURBT [6]. Moreover, immunotherapy with bacillus Calmette-Guérin (BCG) is probably more effective when associated with a second TURBT. Herr HW published a study where 347 patients with high-risk NMIBC underwent single TURBT vs TURBT plus repeat TURBT before receiving 6 weekly intravesical BCG treatment. Of the patients who underwent a single TURBT, 75% had a residual or recurrent tumor at the first cystoscopy and 34% had progression, compared with 29% who had residual or recurrent tumors and 7% who had progression after undergoing repeat TURBT [17].
AUA states that in a patient with high-grade Ta or T1 disease, a second TURBT should be performed within six weeks of the initial TURBT [5]. European Association of Urology (EAU) recommends in its guidelines to performed a second TURBT in the following situations: after incomplete initial TURBT; if there is no muscle in the specimen after initial resection, with exception of TaG1 tumors and primary CIS; in all T1 tumors; in all highgrade tumors, except primary CIS (Grade of recommendation: A). EAU also advises that, if indicated, a second TURBT should be performed within 2-6 weeks after initial resection and should include the resection of primary tumor site [1].
CONCLUSION
Second TURBT has a primordial role in bladder cancer management that cannot be neglected in high-risk NMIBC, incomplete first TURBT resection or when detrusor muscle is absent in first TURBT specimen. A better outcome of the patient depends largely on its correct use.
