Initially, most patients present with nonmuscle invasive bladder cancer (NMIBC) with disease confined to mucosa (stage Ta, carcinoma in situ) or submucosa (T1), characterized by a far lower mortality rate compared with muscle invasive bladder cancer (MIBC), but also by a recurrence rate higher than any other organ confined tumors.
Why do we accept recurrence rates for superficial bladder cancer, which are astronomically high, at up to 64% at 5 years?
For non-muscle invasive bladder carcinoma (NMIBC), transurethral resection of bladder tumor (TURBT) is the cornerstone of treatment and successful management of these tumors relies on adequate initial resection and accurate histological diagnosis.
Since the exact pathologic staging of UBC is essential for determining treatment strategies, complete and correct resection is essential to achieve good prognosis.
Even if the ‘golden standard bladder resection is not convertible to all, in our center our target is to use all the available methods to obtain the best results with this procedure.
The aim of initial TURB is to remove all visible tumor and obtain tissue for histological diagnosis. As recently proved by Choi and coll, anesthesia is crucial in performing endoscopic bladder resection. We always perform TURBt under regional anaesthesia plus obturator nerve block, to allow paralysis (if required by tumor location) and thereby minimizing the risk of stimulating the obturator nerve and subsequent adduction of the thigh muscles, which can result in bladder perforation.
We always use NBI for cystoscopy before resection, to detect all the visible lesions and to be more precise on the margins of resection.
The tumor is resected using precise movements of the loop to ensure sufficient depth to obtain muscle for diagnosis, but not slow enough to lead to charring of the specimen or deep enough to cause perforation of the bladder. Actually, in our center, since about two years, we are treating all patients affected by bladder tumors with en bloc resection, using Knife Collins Bipolar electrode whether the size and position of the lesions. We experienced, as others before us, that this kind of ‘resection philosophy’, whether the energy use, follows oncological principles of removing tumor in other parts of the body and is able to improve specimen orientation, making histological reporting more straightforward. The technique appears to allow accurate reporting of depth of invasion, open the way to pT1 bladder cancer substaging which could be the new frontier for pathologists.
Once the tumor is resected, base and margins, are either resected and sent for pathology in a separate, appropriately, labelled pot.
In this standardized way of performing the bladder resection we have reduced the risk of inadequate operation.
If the patient has high-risk bladder tumour, T1 tumour, multiple high grade Ta tumours, or carcinoma in situ, we always perform early reresection at 4–6 wk, to minimise the risk of staging error and to ensure complete resection and distinguish recurrence from residual tumor.
In pT1 HG disease, the re-cTURBt can be useful as a risk indicator of recurrence and progression, as we experienced in our center. In the high risk persistent bladder neoplasms group we observed recurrent and progression rate higher than in T0 bladder tumours group (Δ = + 17.3% and = Δ + 62.5%, p < 0.05).
In view of the still high rate of recurrence, we are sure that TURBT should be modified to provide en-bloc resection of the specimen, based on the established oncological principle of dissecting through normal tissue and increase the quality of the specimen and the presence of lamina muscularis propria (LMP, detrusor muscle) reducing, in the future, the need of second resection even in high-risk tumor.
Il Professor Roberto Giulianelli, CUrA, Nuova Villa Claudia Clinic, Rome, Italy
Dr. ssa Gabriella Mirabile, CUrA, Nuova Villa Claudia Clinic, Rome, Italy
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