First, Urologists are more and more aware about the importance of TUR and its standardization. Employment of procedural check list and training programs are widely employed worldwide.
Second, imaging enhancement technologies like fluorescence, narrow band imaging, high definition screens, may help in defining high risk lesions and their margins.
Last but not least, technical improvements like en-bloc resection with bipolar or laser devices, help the pathologist to assess the base of the tumour and to identify micro-foci of infiltration of lamina propria or of detrusor muscle. We made therefore a systematic review of the literature available including series comprising a period of 4 decades.
The most surprising thing is that the rate of under-staging infiltrating tumours is steady across the time, about 10%, irrespective of a macroscopically complete first TUR, of the presence of detrusor muscle in the specimen of the first procedure, and of expertise of the surgeon. Indeed, the rate of residual disease decreased, from 56%, including all series, to 47%, including only series with proven muscle in the specimen of the first TUR, and, finally, to 42%, including only series at low risk of bias (generally the most recent). In conclusion, we cannot rely in our experience or technical improvements to reasonably avoid a second TUR, as far as a 10% risk of under-staging invasive tumours or even a 40% risk of missing a cancer which may change the prognosis are not negligible in the patient and physician perspective.
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Written By: Angelo Naselli