SIU 2017: Is It Always Necessary to Perform Restaging TUR for cT1 Urothelial Carcinoma of the Bladder?

Lisbon, Portugal ( In this State-of-the-Art lecture, Dr. Palou addresses the question of repeat TURBT for staging in patients with initial diagnosis of pT1 Urothelial Bladder Cancer. 

The rate of incomplete resection, and therefore understaging, has always been cited as the primary reason to pursue a re-resection. Meta-analyses have identified residual disease on re-resection at rates up to 61%, though even at its best, at least 25%. The understaging resulting in missed pT2 disease is the most worrisome component, and meta-analyses have demonstrated understaging rates of approximately 15%. 

Re-TUR indications: 

  • After suspicion of incomplete TURBT – completeness of TURBT has been associated with outcomes – for any therapy, a more complete resection results in better response!
  • If there is no muscle in the specimen – with exception of LG pTa and primary CIS
  • In any pT1 tumor, regardless of muscle in the specimen
But there is no consensus on the timing of the procedure – typically 2-6 weeks. 

Does the experience of the surgeon matter? Yes!
  • Wide variation in early recurrence rates across centers in Europe
  • Surgeons with less than 5-10 years experience have higher recurrence rates
  • Muscle in the TUR specimen varies between 54% and 94% depending on surgeon experience
Does technique matter? Yes!
  • Zolosky et al – Once he resected a tumor on initial turbt, he sent off the specimen, then performed a wider and deeper resection and sent it as a second specimen. 35% residual tumor though not visualized! Higher in the pT1-3 disease.
  • Dogantekin et al – prospective randomized study of immediate re-resection (same sitting) by a separate urologist. Once first urologist completed, second urologist came in and resected more. On re-turbt at 6 weeks, patients who had an immediate re-turbt had much lower rates of residual disease. 
Divrik et al (Eur Urol 2010) – patients who underwent repeat TURBT had much better long-term recurrence-free outcomes than patients who did not, and also had better response to BCG therapy. Likely due to contamination with pT2 patients in the patients not re-resected. 

Re-staging TURBT, besides ensuring maximal resection and completeness of resection, predicts progression. Herr et al (BJU 2006) – patients with persistent HG pT1 disease had much higher rates of progression than those with pT0 or pTa residual disease (76% vs. 14%). Progression was better stratified by the residual tumor pathology than the pathology on the first resection!

However, in a study by Gontero et al (BJU), looking at the impact of re-resection on a large retrospective cohort of 2451 patients with HG pT1 disease treated with BCG found that re-resection did not affect risk of recurrence or progression. The only predictor of higher recurrence or progression was the absence of muscle in the specimen. Based on this, Dr. Palou suggested that some T1 patients may be spared re-resection if muscle present in the specimen. 

In a study his group completed, they assessed predictors of having residual disease on repeat TURBT in patients with initial pTa or pT1 disease. On multivariable analysis, either having multiple tumors or large tumors were associated with residual disease; the presence of musce was no longer significant. 

Based on these studies, he concludes the following:

  1. In pT1 tumors, if there is muscle in the specimen, do we need to repeat TURBT? Probably not. (But not definite)
  2. Factors predictive of residual disease are: multifocal disease and tumors > 3 cm.
  3. The 25.3% progression rate of patients with pT1 disease after repeat TUR is far lower than previously reported
  4. Perform a complete TUR on initial TURBT! 

SUBMITTED BY: Thenappan Chandrasekar, MD (Clinical Fellow, University of Toronto) (twitter: @tchandra_uromd)