Impact of Maximal Transurethral Resection on Pathological Outcomes at Cystectomy in a Large, Multi-institutional Cohort

Abstract

Purpose:While the presence of residual disease at the time of radical cystectomy for bladder cancer is an established prognostic indicator, controversy remains regarding the importance of maximal transurethral resection prior to neoadjuvant chemotherapy. We characterized the influence of maximal transurethral resection on pathological and survival outcomes using a large, multi-institutional cohort.Materials and Methods:We identified 785 patients from a multi-institutional cohort undergoing radical cystectomy for muscle-invasive bladder cancer after neoadjuvant chemotherapy. We employed bivariate comparisons and stratified multivariable models to quantify the effect of maximal transurethral resection on pathological findings at cystectomy and survival.Results:Of 785 patients, 579 (74%) underwent maximal transurethral resection. Incomplete transurethral resection was more frequent in patients with more advanced clinical tumor (cT) and nodal (cN) stage (P < .001 and P < .01, respectively), with more advanced ypT stage at cystectomy and higher rates of positive surgical margins (P < .01 and P < .05, respectively). In multivariable models, maximal transurethral resection was associated with downstaging at cystectomy (adjusted odds ratio 1.6, 95% CI 1.1-2.5). In Cox proportional hazards analysis, maximal transurethral resection was not associated with overall survival (adjusted HR 0.8, 95% CI 0.6-1.1).Conclusions:In patients undergoing transurethral resection for muscle-invasive bladder cancer prior to neoadjuvant chemotherapy, maximal resection may improve pathological response at cystectomy. However, the ultimate effects on long-term survival and oncologic outcomes warrant further investigation.

This Month in Adult Urology

“…Kirk et al (page 882) explore these questions in a large international, multi-institutional cohort of 785 patients. 5 In multivariable models, maximal TUR was associated with downstaging at cystectomy but was not associated with overall survival.…”

A multidisciplinary discussion of BladderPath

“…Previous trials have shown that a small percentage (6-15%) of MIBC cases achieve a complete response with TURBT alone [3][4][5][6]. Studies also suggest that complete TURBT may improve outcomes after trimodal therapy [7,8] and neoadjuvant chemotherapy with cystectomy [9]. This is relatively low quality evidence.…”

En bloc resection of bladder tumour: the rebirth of past through reminiscence

“…In case of muscle-invasive bladder cancer (MIBC), ensuring proper local staging of the disease is most important, and whether you remove the bladder tumour in one piece or multiple pieces has minimal implications in the subsequent management of the disease. In addition, ERBT can possibly achieve maximal transurethral resection, which may be helpful in optimising subsequent treatment such as radical cystectomy and trimodality therapy [ 32 – 34 ]. Therefore, for large bladder tumours, even if we cannot extract the tumour in one piece, it might still be beneficial to optimise the resection quality by resecting the bladder tumour with the usual en bloc resection principles.…”