Babjuk M. European Urology. 2015 Apr;67(4):815. doi: 10.1016/j.eururo.2014.12.050. IF: 13.938
prof. MUDr. Marek Babjuk, CSc., Department of Urology
Editorial
Expert's summary:
The authors present a retrospective evaluation of data for 1021 patients treated between 1994 and 2006 with bacillus Calmette-Guerin (BCG) for high-risk non-muscle–invasive bladder cancer (NMIBC). They attempt to demonstrate the impact of a restaging/second transurethral resection of the bladder (2nd TURB) performed 2–6 wk after initial resection on treatment outcomes. The 2nd TURB before initiation of BCG therapy was performed in 894 patients, whereas 127 patients received BCG immediately after initial resection. All patients were treated with 6-weekly intravesical administration of Connaught strain BCG without maintenance therapy. After completion of the BCG regimen, patients were assessed regularly using office cystoscopy, cytology, and, if indicated, 2nd TURB.
Pathology examination revealed viable tumour at 2nd TURB in 496 patients (55.5%). After 3 mo, 43.3% of patients who underwent only initial resection had evidence of disease recurrence, compared to 9.6% of those with 2nd TURB. Multivariate analysis revealed that a single TURB was the only significant predictor of any recurrence during the 5-yr follow-up. Significantly shorter progression-free and recurrence-free survival was observed at 5 yr in patients with a single TURB versus restaging TURB.
Expert's comments:
According to European Association of Urology guidelines on NMIBC, 2nd TURB should be performed if the initial resection was incomplete and for all T1 or high-grade tumours. However, the second part of the recommendation has frequently been challenged. It is apparent that we need strong arguments to justify a similar procedure performed within few weeks after the initial one.
Does this article bring new light to the problem? To clearly support the indication for 2nd TURB, it is necessary to demonstrate its impact on improved recurrence-free and progression-free survival. The most recent papers indicate that 2nd TURB can detect residual tumour in 33–52% of patients with high-risk NMIBC, and Sfakianos et al clearly confirmed these observations. However, the question arises as to whether the removal of residual disease is translated into lower recurrence and progression rates when residual tumour can theoretically be ablated by intravesical BCG therapy.
The authors showed that the reduced tumour burden resulting from 2nd TURB improved clinical outcomes. Unfortunately, there are some limitations that reduce the value of the information presented. First, the study was not randomised and the quality of the initial resection was not controlled. Second, the potential of BCG treatment was not fully exhausted, as patients did not receive maintenance therapy.
A randomised controlled trial by Divrik et al demonstrated similar benefits, with reduced recurrence and progression rates for T1 tumours. Interestingly, the 5-yr recurrence-free survival rates of 59% and 32% in patients with and without 2nd TURB were nearly the same as those reported by Sfakianos et al. Unfortunately, although the study by Divrik et al was prospective and randomised, the methodological quality was not without limitations.
Both of these studies support routine 2nd TURB in patients with high-risk NMIBC, but neither of them brings any message regarding selection of individual patients. We all believe that the aim is improvements in initial resection and more precise indication criteria for a repeat procedure. This must be the subject of future prospective trials.
