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JU INSIGHT Repeat Transurethral Resection of Muscle-invasive Bladder Cancer Prior to Radical Cystectomy is Prognostic but Not Therapeutic
By: Kelly K. Bree, MD; Andrea Kokorovic, MD; Mary E. Westerman, MD; Patrick J. Hensley, MD; Nathan A. Brooks, MD; Wei Qiao, PhD; Yu Shen, PhD; Ashish M. Kamat, MD; Colin P. Dinney, MD; Neema Navai, MD | Posted on: 17 Jan 2023
Bree KK, Kokorovic A, Westerman ME, et al. Repeat transurethral resection of muscle-invasive bladder cancer prior to radical cystectomy is prognostic but not therapeutic. J Urol. 2023;209(1):140-149.
Study Need and Importance
The gold standard for diagnosis of bladder cancer is transurethral resection of bladder tumor (TURBT), which provides information regarding tumor type, grade, and stage. While TURBT can be therapeutic in nonmuscle-invasive bladder cancer, the role of tumor debulking with repeat TURBT (reTURBT) in patients with muscle-invasive bladder cancer (MIBC) undergoing radical cystectomy (RC) remains unclear. Given the paucity of data addressing the role of reTURBT in patients with MIBC, we sought to evaluate the impact of reTURBT prior to RC on oncologic outcomes in a contemporary cohort at a tertiary care center.
What We Found
An Institutional Review Board approved (IRB No. RCR03-0631) review of patients with cT2N0 MIBC who underwent RC at our institution between 2005 and 2017 was performed. Patients with and without reTURBT were matched 1-to-1 by propensity score. Matching was done by age, gender, receipt of neoadjuvant chemotherapy, preoperative hydronephrosis, variant histology, lymphovascular invasion, or carcinoma in situ on index TURBT. A total of 548 patients were included after matching. Despite the routine performance of exam under anesthesia and staging imaging, 37.5% of patients with presumed cT2 disease were found to have extravesical disease on RC pathology. Recurrence-free survival and overall survival demonstrated no significant difference based upon performance of reTURBT (P = 1.0 and P = .3, respectively). However, when outcomes were stratified by pathology on reTURBT, those with pT0 had superior outcomes compared to those with residual muscle-invasive disease, irrespective of receipt of neoadjuvant chemotherapy. Although pT0 pathology on reTURBT was associated with improved outcomes, it is notable that >60% of patients with pT0 pathology had residual viable disease at the time of RC (see Table).
Limitations
This study was a retrospective review from a single institution. Additionally, there was inherent selection bias in patient selection for reTURBT based upon the discretion of the operating surgeon.
Table. Concordance Between Clinical Stage Following Repeat Transurethral Resection of Bladder Tumor With Pathological Stage at Radical Cystectomy
| Clinical staging following reTURBT | Pathological stage at radical cystectomy No. (%) |
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|---|---|---|---|---|---|
| pT0 | ≤pT1a | pT2 | pT3 | pT4 | |
| cT0 (n = 94) | 37 (39) | 28 (30) | 12 (13) | 14 (15) | 3 (3.2) |
| ≤cT1 (n = 113) | 24 (21) | 43 (38) | 16 (14) | 21 (19) | 9 (8.0) |
| cT2 (n = 170) | 24 (14) | 19 (11) | 35 (21) | 81 (48) | 11 (6.5) |
| Abbreviation: reTURBT, repeat transurethral resection of bladder tumor. a≤T1 = Ta, Tis, T1. |
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Interpretation for Patient Care
In this large analysis of patients with cT2N0 MIBC from a tertiary referral center, there is no evidence that tumor restaging with reTURBT prior to RC improved outcomes. Pathology of reTURBT was prognostic, and absence of residual disease at reTURBT is a surrogate for less extensive disease burden, which portends improved survival outcomes. Additionally, this study highlights that current clinical staging for bladder cancer is an unreliable indicator of the extent of true residual disease with more than one-third of cT2 patients having extravesical disease at RC.
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