EAU 2018: Complete Transurethral Resection of the Bladder Before Radical Cystectomy Improves Oncological Outcomes

Copenhagen, Denmark (UroToday.com) Pathological downstaging has been associated with improved recurrence-free and cancer-specific survival in patients with invasive bladder cancer. It has been reported that approximately 15-20% of patients can be downstaged to pT0 following a complete transurethral resection of bladder tumor (TURBT). Moreover, a complete resection prior to cystectomy may also decrease the risk of local recurrences as it would prevent tumor potential tumor seeding at the time of cystectomy. The author's abstract aims to assess the oncological outcomes of patients who underwent a complete TURBT prior to radical cystectomy. 

The authors performed a single-center retrospective review of all patients with invasive bladder cancer undergoing a cystectomy from 1995 and 2016. The patient’s medical record was reviewed for completeness of the TURBT prior to radical cystectomy. Patients with an incomplete operative report were excluded from the analysis (n=121). 486 patients were included in the analysis, of those 253 (52%) patients were documented as having a complete TURBT. Patients undergoing a complete TURBT had a pT0 rate of 23% compared to 7.5% of those with an incomplete TURBT.  At a median follow-up of 41 months, those who had a complete TURBT prior to radical cystectomy had a superior RFS (5-year RFS : 57% vs. 37% ; p<0.001) and CSS (5-year CSS: 70.8% vs. 54.5%, p=0.002) compared to those with incomplete resections. On multivariate modeling complete resection of macroscopic tumor (HR: 0.4, p=0.003) remained predictive of RFS after controlling for tumor multifocality, >pStage, CIS, the weight of endoscopic resection, interval time between TURBT and cystectomy and receipt of neoadjuvant chemotherapy (NAC). The authors conclude that complete resection of bladder tumor prior to cystectomy is a modifiable factor that can lead to significant improvements the oncological outcomes of bladder cancer patients. 

While the results are thought-provoking, the study does have some major limitations that were not discussed by the authors during the poster presentation. First, the retrospective nature of the study adds a significant degree of selection bias that the authors fail to control for. In the poster or in the presentation there was no mention of the pathological stage distribution for each of the groups evaluated which are likely a significant confounder in the study. Second, the definition of complete TURBT was based on operative reports which limit the generalizability of the study or any possible standardization of the technique. The main outcome of the study, recurrence-free survival, was not properly defined, so it is unclear if the authors are referring to local recurrences alone or a combination of distant and local recurrences. If RFS is defined as any recurrence, then result obtained does not make much sense since there is no biological reason for why a complete TURBT would prevent distant recurrences. 

In summary, a complete TURBT should be the standard of care in any patients with bladder cancer as it would provide better diagnosis and limit the potential for tumor seeding during radical cystectomy. 

Presented by: V. Graffeille MD, CHU Department of Urology, Rennes, France

Written by: Andres F. Correa, Urologic Oncology Fellow, Fox Chase Cancer Center, Philadelphia, PA at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark.