The rational and benefits of the second look transurethral resection of the bladder for T1 high grade bladder cancer

Abstract

The second look transurethral resection of the bladder (TURB) represents a fundamental step in the treatment of papillary non-muscle invasive bladder cancer (NMIBC); it is therefore recommended by all guidelines. However, not all the literature agrees on its staging value and its ability to improve oncological outcomes of patients. Therefore, the purpose of this review is to evaluate the strengths and weaknesses of second look TURB, trying to depict its evolving role in the management of high grade NMIBC. Using Medline, a non-systematic review was performed including articles between January 2000 and June 2018. English language original articles, reviews and editorials were selected based on their clinical relevance. To date, TURB seems to be largely inadequate in retrieving a correct diagnosis and in removing all tumor tissue. Second look TURB maximizes staging accuracy, allows to clear residual cancer and yields prognostic advantages allowing key information to identify possible candidates for immediate radical cystectomy for very high risk T1HG tumors. Moreover, it seems to have a therapeutic benefit by improving recurrence- and progression-free survivals. However, few recent large studies showed that these advantages seem to be limited to patients without detrusor muscle present at first resection. Similarly, the presence of residual disease and the risk of upstaging are related to the presence of detrusor muscle in specimen. It could well be that in the future the presence of detrusor muscle would be a quality criteria to avoid an unnecessary second look TURB as shown by recent studies using the en-bloc resection technique. Finally, it has to be underlined that this is a surgical procedure not free of risks and complications and with a non-negligible impact on patients’ quality of life, waiting lists and healthcare costs. Therefore, future studies trying to identify the criteria that may better allow which patients to select for a second look TURB while avoiding an unnecessary intervention with possible risks and associated cost are needed to allow a personalized approach to even this one size fits all strategy.

Application of nomograms in the prediction of overall survival and cancer‑specific survival in patients with T1 high‑grade bladder cancer

“…Transurethral resection with intravesical therapy is the first-line therapy for patients with NMIBC (11). However, recurrence or progression occurs in more than half of all patients, which requires a second resection or cystectomy (38–40). Therefore, the overall situation and the prognosis of the patient must be taken into account when selecting the most appropriate surgical treatment.…”

How well do we manage non-muscle invasive bladder tumors? A UK audit of real-life practices

“…Therefore, the presence of detrusor muscle on initial TUR reduces the benefits of a re-TUR, even more so when patient's quality of life and healthcare costs come into play. 17,18 A retrospective analysis showed that time to recurrence for high-grade TCC after the first resection was significantly shorter compared to those who underwent re-TUR (median = 22 months vs 36 months, p < 0.001). Failure to perform a repeat resection prior to initiation of intravesical BCG therapy for high-risk NMIBC significantly increases the risk of recurrence.…”

“…Therefore, the presence of detrusor muscle on initial TUR reduces the benefits of a re-TUR, even more so when patient’s quality of life and healthcare costs come into play. 17,18…”

Transurethral needle electrode resection and transurethral holmium laser resection of bladder cancer

“…The surgical treatment includes transurethral resection of bladder tumor, transurethral laser surgery, and photodynamic therapy. TURBT is the current "gold standard" for the treatment of NMIBC and also the main treatment [17][18][19]. The objectives of TURBT are as follows: first, complete removal of all tumors within the field of vision to achieve the effect of radical surgical resection; second, resection of tissues for evaluation of pathological grade and stage, determination of the next postoperative treatment plan of the patient, and assessment of prognosis and risk of recurrence.…”