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ORIGINAL ARTICLE
Year : 2016  |  Volume : 29  |  Issue : 3  |  Page : 722-727

Evaluation of second-look transurethral resection in the management of superficial bladder tumors


1 Department of Urology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Urology, Al-Agouza Hospital, Giza, Egypt

Date of Web Publication23-Jan-2017

Correspondence Address:
Mahmoud Mahdy
Al-Agouza Hospital, Giza, 12654
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.198790

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  Abstract 

Objectives
The aim of the present study was to evaluate the role of second-look transurethral resection of bladder tumors (TURBT) in the management of non-muscle-invasive bladder cancer (NMIBC).
Background
Bladder cancer is the ninth most common cancer diagnosis worldwide. Second-look TURBT ensures adequate evaluation of the muscularis propria while detecting and treating residual tumors.
Patients and methods
Thirty-one NMIBC patients underwent a second-look TURBT 2 weeks after the initial TURBT. The procedures carried out included reassessment of the bladder for the detection of residual lesions after initial resection, and the resection of the base of the previous resection site for restaging.
Results
Thirty-one NMIBC patients underwent second-look TURBT 2 weeks after the initial TURBT. Residual tumors were found in 28% of the patients with Ta tumors and 54.2% of the patients with T1 tumors (P = 0.445). The overall percent of residual tumors was 48.4% for all patients. Patients with Ta tumors had no upstaging to a higher stage or grade. On the other hand, in patients with T1 tumors we found that 50% of them were upstaged to T2. Thus, the overall upstaging to T2 was 38.7% of all NMIBC patients (P = 0.413).
Conclusion
Second-look TURBT is highly desirable in patients with high-grade T1 disease and large tumor size (>2-5 cm), especially if deep muscle is not found in the primary resection because of the significant risk for detecting muscle-invasive disease and missed residual tumors.

Keywords: bladder cancer, bladder tumor, cystoscopy, superficial bladder cancer, transurethral resection


How to cite this article:
Badreldin M, Baky TM, Salem SM, Mahdy M. Evaluation of second-look transurethral resection in the management of superficial bladder tumors. Menoufia Med J 2016;29:722-7

How to cite this URL:
Badreldin M, Baky TM, Salem SM, Mahdy M. Evaluation of second-look transurethral resection in the management of superficial bladder tumors. Menoufia Med J [serial online] 2016 [cited 2020 Apr 9];29:722-7. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/722/198790


  Introduction Top


Bladder cancer is the ninth most common cancer diagnosis worldwide, with more than 330 000 new cases each year and more than 130 000 deaths per year, and with an estimated male to female ratio of 3.8: 1.0 [1] .

In Egypt, bladder cancer constitutes 30.3% of all cancer cases [2] , 16.2% of all male cancer cases, and 4% of all women cancer cases. For both sexes together, the frequency of bladder cancer is 10.1% [3] .

Bladder cancer is a heterogeneous condition. Approximately 75% of newly diagnosed transitional cell carcinomas present as non-muscle-invasive bladder cancer (NMIBC), which can be treated with local resection and intravesical therapy [4] .

About 25% of newly diagnosed bladder cancer present as invasive tumor (muscle-invasive bladder cancer) [5] . As many as up to 70% of NMIBC will recur after initial treatment with a 10% of Ta tumors and 35% of T1 tumors progressing to invasive tumor [4] .

A major challenge for screening is to accurately identify tumors that are still superficial, yet at a high risk for progression, to initiate interventions at a more treatable stage. Factors that influence risk for progression include the tumor stage and grade; the number, size, and appearance of lesions; the response to initial treatment; and other factors [6] .

Transurethral resection of bladder tumors (TURBT) is the first step in the initial management of bladder cancer. A TURBT is both diagnostic and therapeutic, and the procedure provides critical staging information. In a TURBT, the configuration (flat, sessile, or papillary), location (trigone, base, dome, or lateral walls), size (cm), and the number of tumors should be recorded. Tumors should be completely resected if they are small, solitary, and available for resection, and also other than superficial appearing low-grade tumors, muscularis propria must be included in the specimen to ensure adequate resection. Management might include directed bladder biopsies of abnormal-appearing urothelium or biopsies of the prostatic urethra. Biopsy or resection of the prostatic urethra should also be considered if the patient has tumor at the bladder neck or if the tumor is within the prostatic urethra [7] .

Since the beginning of the last decade, the value of second-look TURBT for high-risk NMIBC has been revised: the repeated resection ensures adequate evaluation of the muscularis propria while detecting residual tumors and treating residual tumors in ∼75% of patients [8] .

In addition, many reports suggest that a second-look TURBT improves the initial response rate to intravesical bacille Calmette-Guιrin therapy [9] , reduces the frequency of subsequent tumor recurrence, and appears to delay early tumor progression [10] .

Reresection results in clinical upstaging to muscle-invasive tumor in 9-28% of patients [8] . Second-look TURBT is typically carried out 2 weeks after the initial TURBT [10] .

Second-look TURBT is a valuable procedure for the accurate staging of NMIBC. Its acceptance has changed the treatment strategy of a significant proportion of patients. Second-look TURBT is indicated in T1, high-grade, large sized (>3 cm), and nodular tumors because of the significant risk for detecting muscle-invasive disease [11] . Moreover, it is indicated when initial resection has been incomplete or the specimen contains no muscle tissue [12],[13] . Therefore, the aim of the present study was to evaluate the role of second-look TURBT in management of NMIBC.


  Patients and methods Top


This prospective study included 31 patients who underwent second-look TURBT during the period between January 2013 and January 2014. Out of 80 patients who underwent cystoscopy in Menoufia University Hospital for the suspicion of bladder cancer, 12 patients proved to be free of malignancy, eight patients had polypoid cystitis, three patients had benign prostatic hyperplasia, and one patient proved to be free. Out of 68 patients diagnosed in the initial TURBT as bladder cancer cases, 34 patients had muscle-invasive bladder cancer and 34 patients had NMIBC. Thirty-one NMIBC patients underwent a second-look TURBT 2 weeks after the initial TURBT and the remaining three patients refused to undergo the procedure.

Patients who refused the second-look TURBT or had a muscle-invasive tumor or proved to be free of malignancy were excluded from the study.

Transurethral  resection of all residual tumors, including the muscle in the resected specimen and deep resection of the edges and base of the site of previous resection, was carried out and then sent for pathological evaluation.

The changes of the stage or grade from the initial pathology reports, interval between the initial TURBT and the second-look TURBT, and the presence of residual tumor were analyzed. If there were residual tumors, the stage and grade of residual tumor, and the percent of upstaging or upgrading were also analyzed.

For statistical analyses we used the χ2 test and the confidence interval was 95%.


  Results Top


The mean age of bladder cancer cases (68 patients) was 61.54 ± 12.8 years (37-80). There were 58 (85%) men and ten (15%) women with a male to female  ratio of 5.8: 1 ([Figure 1] and [Table 1]).
Figure 1: Outcome of first-look cystoscopy. BPH, benign prostatic hyperplasia; MIBC, muscle-invasive bladder cancer; NMIBC, non-muscle-invasive bladder cancer.

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Table 1 Outcome of first-look cystoscopy


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Following were the findings of the initial TURBT in the cases of NMIBC: as regards the size of the tumor, ten (32.3%) patients had a tumor size of less than 2 cm and the remaining 21 (67.7%) patients had a tumor size of more than 2-5 cm; as regards tumor appearance, 25 (80.6%) patients had papillary lesions and the remaining six (19.4%) patients had nodular lesions; and as regards the multiplicity of tumor masses, 23 (74.2%) patients had single masses and eight (25.8%) patients had multiple masses. Following were the histopathological results of the first-look TURBT: as regards tumor stage, seven (22.6%) patients had Ta tumors and the remaining 24 (77.4%) patients had T1 tumors; and as regards tumor grade, 16 (51.6%) patients had low-grade tumors (G1), two (6.5%) patients had intermediate-grade tumors (G2), and 13 (41.9%) patients had high-grade tumors (G3) ([Table 2]).{Table 2}

Findings of the second-look TURBT revealed residual tumors in 28% of the cases with Ta tumors and 54.2% of the cases with T1 (P = 0.445). The overall percent of residual tumors in our study was 48.4% for all cases. The rate of residual tumors in the second-look TURBT was found to have a significant statistical relation to the high-grade tumors in the first-look TURBT (P = 0.020); otherwise the relation to other parameters was statistically insignificant ([Table 3] and [Figure 2]).
Figure 2: Correlation between residual tumors in the second-look transurethral resection of bladder tumors (TURBT) and histopathological and morphological results of the first TURBT.

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Table 2 Findings of first-look transurethral resection of bladder tumors in NMIBC


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In the present study, patients with Ta tumors underwent a second-look TURBT, which resulted in no upstaging to a higher stage or grade, whereas in patients with T1 tumors who underwent the second-look TURBT, 50% of them were upstaged to T2; these findings include 53.3% of patients who had residual tumors in the second-look TURBT ([Figure 3]) and 25% of the patients who had no residual tumors in the second-look TURBT.   Moreover, biopsies were taken from the old resection site ([Figure 4]). Thus, the overall upstaging to T2 was 38.7% of all NMIBC cases in our study (P = 0.413) ([Table 4]).
Figure 3: Correlation between patients with residual tumors that upstaged to T2 and their histopathological and morphological findings at the initial transurethral resection of bladder tumors.

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Figure 4: Correlation between patients in whom no residual tumors [underwent second-look transurethral resection of bladder tumors (TURBT) from the old resection site] were upstaged to T2 and their histopathological and morphological findings at the initial TURBT.

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Table 4 Correlation between patients which upstaged to T2 in the second - look transurethral resection of bladder tumor and their histopathological and morphological findings at the initial transurethral resection of bladder tumor


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  Discussion Top


In the present study, histopathological examination of the resected tumors in the initial TURBT revealed that 22.6% of the patients had Ta tumors and the remaining 77.4% had T1 tumors. As regards tumor grade, 51.6% of the patients had low-grade tumors (G1), 6.5% had intermediate-grade tumors (G2), and the remaining 41.9% had high-grade tumors (G3).

In the present study, 31 of the 34 NMIBC patients underwent a second-look TURBT and the remaining three patients refused to undergo the procedure. Residual tumors were found in 28% of the cases with Ta tumors and 54.2% of the cases with T1. The overall percent of residual tumors in the present study was 48.4%. This is in agreement with the findings of other studies that reported that the rate of residual tumor detected by a second-look TURBT varies between 27 and 78% [14] .

Most of the researchers have reported that the rate of residual tumors increases with the extent of infiltration noted in the first resection. It ranges from 33 to 78% after resection of T1 tumor [8] , whereas it is only 6% after resection of Ta tumor [15] . Overall, 37% of the 215 patients with Ta and 43% with T1 tumors had residual malignant tumor in the second-look TURBT [16] .

In the present study, residual tumors in the second-look TURBT were found in 76.9% of patients with high-grade, 50% of patients with intermediate-grade, and 25% of patients with low-grade tumors. This is in agreement with the results obtained by Divrik et al. [17] who reported 5.8, 38.2, and 62.5% recurrence for G1, G2, and G3 tumors, respectively.

Regarding tumor upstaging in the second-look TURBT in our study, for patients with Ta tumors (22.6% of all cases), a second-look TURBT resulted in no upstaging to a higher stage or grade. On the other hand, in patients with T1 tumors who underwent a second-look TURBT, we found that 50% of them were upstaged to T2; these findings include 53.3% of the patients who had residual tumors in the second-look TURBT. Moreover, 25% of the patients had no residual tumors in the second-look TURBT.   Biopsies were taken from the old resection site, and thus the overall upstaging to T2 was 38.7% of all superficial bladder cancer cases in our study. These findings are comparable to those of other studies. In their study, Miladi et al. [8] reported that the tumor stage was underestimated at the initial TURBT in 9-49% of the tumors. Han et al. [18] reported that 31.3% of cases were upstaged in the second-look TURBT. Herr et al. [10] found that 9% patients with low-grade T1 and 28% patients with high-grade T1 were upstaged to T2 in the second-look TURBT. Brauers et al. [19] found that upstaging to T2 was present in 24% of patients.

Zurkirchen et al. [20] reported that 20.2% of the cases of Ta and T1 tumors were upstaged to a higher stage in the second-look TURBT. According to a study by Mersdorf et al. [15] , 14% of Ta tumors versus 24% of T1 tumors were upstaged after the second resection. Herr [21] found that 19.8% of the 96 tumors initially staged as superficial (Tis, Ta, and T1) in fact proved to be muscle invasive.

In the present study, the increased percent of upstaged cases to T2 (38.7%) in the second-look TURBT compared with the percent in other studies can be attributed to the poor quality of the resected tissue such as the absence of muscle in some resected specimens or incomplete resection of the whole tumor in the initial TURBT or the use of cold cup biopsy. The absence of muscle in some resections is explained by the different levels of experience among surgeons performing the TURBT. Zurkirchen et al. [20] demonstrated the impact of a learning curve in the quality of resection, with rates of residual tumor at second resection of 37% for beginners and 26% in the hands of experienced surgeons. Herr [21] reported that the absence of muscle in the resected specimen was found to be an important source of error. In the absence of muscle the percent of error was 49%, whereas in its presence it was only 14%. These findings underline the importance of assessment of muscle in the first resection as optimal resection provides better staging.


  Conclusion Top


Second-look TURBT is an important procedure in patients with NMIBC. It seems to be highly desirable in any patient with high-grade T1 cancer and those having a large tumor size (>2-5 cm), especially if deep muscle is not found in the primary resection specimen because of the significant risk for detecting muscle-invasive disease and missed residual tumors on primary resection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 3], [Table 3], [Table 4]



 

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