Data support American Urological Association guideline on bladder tumor re-resection

Key Points

San Francisco-A 4-year retrospective study suggests that re-resection for all T1 bladder tumors, with and without muscle in the original specimen, can provide important prognostic information to guide treatment.

AUA guidelines that recommend re-resection of T1 bladder tumors for which there was no muscle in the original specimen have generated a degree of controversy. Although the guidelines represented the state of expert opinion when they were issued in 2007, there have been little data generated regarding the utility of widespread re-resection of T1 tumors.

"We found that patients with no muscle in the original specimen were more likely to be upstaged to T2 on re-resection," said first author Joshua Langston, MD, urologic surgery resident at the University of North Carolina School of Medicine, Chapel Hill, NC, working with Raj S. Pruthi, MD, and colleagues.

The authors reviewed a case series of 556 transurethral resections of bladder tumor (TURBT) performed at UNC between 2007 and 2010. All of the procedures were performed after the AUA issued its current guidelines recommending re-resection if no muscle was obtained with the primary resection and consideration of re-resection if muscle was obtained.

Case records noted 56 re-resections for patients initially staged with T1 tumors. Of these patients, 15 had no muscle in the initial specimen and 41 had muscle present. Based on re-resection findings, 17 of the 56 patients (30%) had no residual disease, 12 patients (21%) had less than T1 disease, 22 patients (39%) had T1 disease, and five patients (9%) had T2 disease.

Less upstaging than in other studies

There was less upstaging of T1 disease diagnosed from the initial TURBT either with or without muscle in the specimen than has been reported in other studies, Dr. Langston noted. The lower rate is likely due to study methodology, he said. The UNC data are based on pathology from repeat TURBT, while other studies have analyzed cystectomy specimens.

UNC patients whose initial specimens did not include muscle were much more likely to be T2 on re-resection (27% vs. 2%). Patients with no muscle in the original specimen were also less likely to have no residual disease (20% vs. 34%).

Of the patients with initial T1 tumors, 39 (70%) received an initial induction course of intravesical therapy. Just over one-third of patients with T1 disease on re-resection elected radical cystectomy rather than intravesical therapy.

After a mean follow-up of 22 months, 23 of the 39 patients (59%) had no recurrence. Another 15 patients (38%) developed a recurrence and one patient (2%) developed a pulmonary metastasis without a recurrent bladder lesion. Of patients who had a recurrence, five underwent radical cystectomy and 10 opted for a second course of intravesical therapy.

Importantly, response to intravesical therapy varied significantly based on the findings at re-resection, Dr. Langston reported. Of those with no evidence of disease at re-resection, 24% had a recurrence. Of patients with less than T1 disease, 50% had a recurrence and of those with T1 disease, 42% had a recurrence.

"We concluded that re-resection of T1 tumors does provide important staging and prognostic information," Dr. Langston said. "Re-resection not only ensures complete resection of the cancer but also gives you valuable information for determining the most appropriate next steps in therapy for this particular group of patients."