18th Meeting of the EAU Section of Oncological Urology (ESOU21)

ESOU 2021: Re-TUR in Ta High-Grade for Selected Candidates

(UroToday.com) The second Urothelial Cancer session at this year’s European Association of Urology (EAU) Section of Oncological Urology (ESOU) virtual meeting featured a number of presentations, focussing on controversies in the management of urothelial cancers. The third presentation in this session was from Dr. Marco Moschini who discussed the role of repeat transurethral resection of bladder tumor (re-TURBT) in patients with high-grade superficial non-muscle invasive (Ta) bladder cancers.

Dr. Moschini began by highlighting absolute indications, according to EAU non-muscle invasive bladder cancer guidelines, for repeat TURBT including:

1. an incomplete initial resection
2. the absence of muscle in the specimen on initial resection (with the exception of TaLG and primary carcinoma in situ)
3. patients with T1 disease

The rationale for repeat TURBT depends on proven risks of disease persistence and understaging. In a meta-analysis of more than 8000 patients with Ta/T1HG disease have a 50% chance of disease persistence and an 8% risk of understaging T1 tumors. However, the risk of persistence and understaging depends on numerous factors including the quality of the initial TURBT, the experience of the urologist, and the experience of the pathologist.

Dr. Moschini highlighted that repeat TURBT should be performed 2-6 weeks following initial surgery and prior to the initiation of BCG therapy. Notably, this was not routinely done with nearly 40% of patients in the YAU group received Bacillus Calmette-Guerin (BCG) prior to TURBT. However, there was no evidence of survival difference between these groups. However, this approach naturally delays appropriate treatment for the subset with muscle-invasive disease on repeat resection. This group also found that there is a survival difference associated with a time to initiation of BCG which exceeded 100 days, thus emphasizing the importance of timely repeat resection.

Dr. Moschini then discussed the technical approach to repeat TURBT, emphasizing the resection of the primary tumor scar and any visible tumors. This approach is associated with improved recurrence-free survival, improved outcomes after BCG, as well as prognostic information.

Dr. Moschini then presented a clinical case of a patient with an initial diagnosis of a small, solitary papillary tumor which, on TURBT, demonstrated pTa HG urothelial disease without muscle in the specimen. He emphasized the paucity of data regarding repeat TURBT in this cohort of patients with TaHG disease. Dr. Moschini highlighted further data from the YAU group showing that, among patients with pTaHG disease on initial TURBT, repeat resection demonstrated tumor in 38% of cases and the use of a re-resection was associated with improved recurrence rates through similar progression rates.

In conclusion, Dr. Moschini highlighted that, while there are clear indications for re-resection, there is not an entirely clear indication for patients with TaHG disease and, thus, this requires a pragmatic approach.

 

Presented by: Marco Moschini, MD, PhD, Luzerner Kantonsspital, Luzern, Switzerland

Written by: Christopher J.D. Wallis, MD, Ph.D., FRCSC, Instructor in Urology, Vanderbilt University Medical Center, Nashville, Tennessee @WallisCJD on Twitter, during the 18th Meeting of the EAU Section of Oncological Urology (ESOU21), January 29-31, 2021

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