EAU 2017: Perfect transurethral resection

London, England (UroToday.com) In this session, Professor Babjuk discussed his recommendations for state-of-the-art transurethral resection of bladder tumors (TURBT). At the outset, he recommends considering what one might see prior to the operation. The risk of multiple tumors ranges from 25-37% and the risk of concomitant carcinoma in situ (CIS) is 23-30%. Further, the risk of tumor persistence after initial TURBT is 33-55% and tumor understaging occurs in 1.3-25% of all tumors. These factors should be considered prior to bringing the patient to the operating room.

The goal of TURBT remains two-fold: (1) perform a complete resection and (2) make a correct diagnosis. You must detect and remove all papillary lesion in addition to CIS. The depth of invasion must be determined and the specimen must be sent to the pathologist with adequate quality. The European Association of Urology (EAU) guidelines recommend bimanual palpation under anesthesia, urethral inspection, complete resection of the tumor, and precise description of the specimen for pathologic evaluation.

Professor Babjuk touched briefly on enhanced cystoscopic techniques such as narrow band imaging (NBI) and fluorescence cystoscopy. NBI allows for better tumor visualization, and reports indicate reduced recurrence rates at 12 months for low risk tumors.

The technique of TURBT is important and two are acceptable. Resection in fractions during which the exophytic portion of a papillary tumor is excised followed by a deeper muscle wall resection is the most commonly used. Emerging techniques include en bloc resections with either monopolar, bipolar, or laser (Holmium Yag) technologies. The optimal technique and appropriate instruments for individual locations should be selected.

Good pathology is paramount to accurate diagnosis. For the urologist, the EAU recommends referring specimens from different biopsies in separate containers with different labels. For the pathologist, the report should include tumor location, tumor grade, depth of invasion, presence of CIS, and whether detrusor muscle is present. Further, any lymphovascular invasion or unusual histology should be documented. Lastly, additional review for difficult cases by a dedicated genitourinary pathologist should be considered. He encouraged a greater degree of cooperation between urologists and pathologists to ensure the correct diagnosis is rendered.

Criteria of quality are important and the surgeon should be responsible for maintaining low recurrence and low progression rates. A more immediate indicator of quality may be the presence or absence of detrusor muscle. Urologists should keep track of their personal quality metrics and work to improve technique if tallied rates are not consistent with best reported practice.

With regard to re-TURBT, the EAU guidelines recommend performance if there is any doubt about completeness of the initial TURBT or if there is no detrusor muscle in the specimen. Lastly, all T1 tumors should have a re-TURBT within 6 weeks of the initial resection. The rationale for doing this is that residual tumor can be detected in 33-72% and staging errors can be corrected in 2-24% of patients. Re-TRUBT reduces further recurrence in T1 tumors and may provide important prognostic information.

In conclusion, Professor Babjuk stated that TURBT is the critical step in bladder cancer management.

Lead Author: M. Babjuk, Prague, CZ

Written by: Benjamin T. Ristau, MD, SUO Fellow, Fox Chase Cancer Center, Philadelphia, PA.

at the #EAU17 -March 24-28, 2017- London, England