AUA 2022: State-of-the-Art Lecture: IBCG Master Class on TURBT

(UroToday.com) The 2022 Annual Meeting of the American Urological Association (AUA) was host to The International Bladder Cancer Group (IBCG) AUA Bladder Cancer Forum which featured a State-of-the-Art Lecture: IBCG Master Class on transurethral resection of bladder tumors (TURBT) presented by Dr. Arnulf Stenzl. Dr. Stenzl began his presentation by noting that bladder cancer has an incidence of 180,000 cases per year in Europe. TURBT remains the gold standard for the initial diagnosis and staging of bladder cancer. The value of a well-performed TURBT remains critical with the percentage of residual cancer at re-staging TURBT being heavily influenced by the performing surgeon’s experience (consultant versus trainee).

Physician training and education remains critical to improving oncologic outcomes. “Flight simulators” with visual and haptic feedback shorten the learning curve, and it is crucial that urologists learn to use the different available tools.

The 5-point VI-RDS score was developed using the individual T2W, DWI, and DCE MRI categories to predict the probability of muscle invasion prior to surgical treatment minimize the risk of understanding bladder cancer lesions at time of TURBT and identify patients who nmay benefit from upfront aggressive surgical or multimodal treatments.

Dr. Stenzl next presented results of his own study in 2010 that demonstrated that hexaminolevulanate guided fluorescence cystoscopy reduces recurrences in patients with nonmuscle invasive bladder cancer. Usage of blue light versus white light TURBT was associated with:

• 16% reduction in the 9-month recurrence rate
• Finding of at least 1 additional CIS tumor in 46% of patients
• 32% of CIS was only detectable with blue light imaging.

Results from the Cysview Registry Group demonstrated that blue light cystoscopy had an overall sensitivity of 91% (versus 76% for white light cystoscopy), specificity of 29%, PPV of 63%, and false positive rate of 30%. In 641 patients, blue light cystoscopy allowed for diagnosis of 12% additional papillary tumors and 43% additional cases of CIS.¹

In addition to reduced recurrence rates, use of blue light cystoscopy with hexaminolevulinate has been shown by Kamat et al. to be associated with a reduced progression rate from 17.6% to 12.2%.²

In an analysis of 1,422 patients, usage of blue versus white light cystoscopy was associated with 23 fewer cystectomies and 180 fewer TURBTs performed. Furthermore, patients undergoing prior white light TURBT prior to radical cystectomy had a significantly better recurrence free survival following cystectomy.

The value of en bloc resection of bladder tumors remains, with analysis from Dr. Stenzl’s group demonstrating that en block resection augmented with photodynamic (PDD) TURBT is associated with superior negative margin rates (53.6%) compared to PDD TURBTs not performed en block (8.5%) and leads to non-significantly superior sampling of detrusor muscle (77.4% versus 66.7%, p=0.28).



Dr. Stenzl concluded his presentation as follows:

• TURBT remains critical to intra-operative tumor/CIS depiction
• TURBT is first and foremost an oncologic operation
• Augmented TURBT with PDD is crucial to minimize recurrence and progression rates
• The quality of resection is critical --> en block resection?
• The importance of mechanical/optical sensor development
• Specimen --> cell cultivation, organoids

Presented by: Arnulf Stenzl, MD, Professor, Department of Urology, University of Tubingen, Tubingen, Germany

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:

1. Daneshmand S, Bazargani T, Bivalacqua TJ ,et al. Blue light cystoscopy for the dianogsis of bladder cancer: Results from the US prospective multicenter registry. Urologic Oncology. 2018;36(8):361.e1-361.e6.
2. Kamat A, Cookson M, Witjes JA, et al. The Impact of Blue Light Cystoscopy with Hexaminolevulinate (HAL) on Progression of Bladder Cancer - A New Analysis. Bladder Cancer. 2016;2(2):273-278.