The Value of Immediate Postoperative Intravesical Epirubicin Instillation as an Adjunct to Standard Adjuvant Treatment in Intermediate and High-risk NMIBC - Beyond the Abstract

Non-muscle invasive bladder cancer (NMIBC) comprises a major sector of bladder cancer in the United States and Europe. Complete transurethral resection of the bladder tumors (TURBT) is the first and the most important step in the treatment of NMIBC. Although many NMIBCs are amenable to treatment with TURBT alone, the recurrence rate of bladder cancer can be as high as 75%. 

It is hypothesized that one of the mechanisms for early recurrence of NMIBC following TURBT is implantation of floating cancer cells into the bladder urothelium following resection, what is called seeding phenomenon. 

Many investigators have studied the value of immediate postoperative instillation of chemotherapy for the prevention of recurrence of NMIBC following resection. According to the European Association of Urology (EAU) guidelines, to decrease the risk of recurrence, ‘‘one postoperative instillation of chemotherapy should be given in all patients after TUR of presumably non–muscle invasive bladder cancer’’. 

This evidence was strengthened by three large meta-analyses comprising 1476 to 3103 patients that have consistently shown that one immediate installation of chemotherapy after TURBT significantly reduced the recurrence rate by 11.7% to 13.0% compared to TURBT alone. 

However, the evidence for the efficacy of this treatment originates from studies that have focused on patients with low risk for recurrence (Figure 1). 


Figure1; Limitations of the studies recommending immediate installation.

There are insufficient data supporting the general recommendation of the EAU that all patients with NMIBC should be treated with early installation. In the present study, we investigated the role of immediate post-TURBT instillation of epirubicin on the behavior of intermediate and high risk NMIBC regarding recurrence, progression as well as possible untoward adverse events of immediate installation.

Our results demonstrated that single immediate post-TURBT instillation of chemotherapy had no impact on the reduction of recurrence rate in intermediate and high-risk patients. It neither prolongs time to recurrence, time to progression nor reduces the number of recurrences. Patients with recurrence rate more than one per year, single papillary tumor more than three cm or multiple papillary tumors are most likely to be intermediate or high-risk patients. So, they should be abandoned from immediate post-TURBT instillation of epirubicin. 

The general recommendation of EAU for the utilization of immediate post-TURBT instillation of chemotherapy in “all” patients with NMIBC should be re-evaluated, and we advocate strict specification of patient and tumor criteria in which immediate installation is indicated.

Written by: Amr Elsawy, MD, Urology and Nephrology Center, Al Manşūrah, Egypt

Read the Abstract