Complete Transurethral Resection before Radical Cystectomy May Improve Oncological Outcomes

Abstract

Objectives: The objective of this study was to assess the impact of complete transurethral resection of bladder tumors (TURBTs) before radical cystectomy on pathological and oncological outcomes of patients with muscle-invasive bladder cancer (MIBC) and high-risk non-MIBC. Materials and Methods: The charts of all patients who underwent radical cystectomy for bladder cancer in 2 academic departments of urology between 1996 and 2016 were retrospectively reviewed. Patients were divided into 2 groups according to the completeness of the last endoscopic resection before radical cystectomy: macroscopically complete transurethral resection (complete) or macroscopically incomplete transurethral resection (incomplete). The primary end point was the recurrence-free survival (RFS). Secondary end points included cancer-specific survival (CSS) and rates of pT0 and downstaging. Results: Out of 486 patients included for analysis, the TURBT immediately preceding radical cystectomy was considered macroscopically complete in 253 patients (52.1%) and incomplete in 233 patients (47.9%). In multivariate analysis, macroscopically complete TURBT was the strongest predictor of both pT0 disease (OR = 3.1; p = 0.02) and downstaging (OR = 7.1; p < 0.0001). After a median follow-up of 41 months, macroscopically complete TURBT was associated with better RFS (5-year RFS: 57 vs. 37%; p < 0.0001) and CSS (5-year CSS: 70.8 vs. 54.5%; p = 0.002). In multivariate analysis adjusting for multifocality, weight of endoscopic resection specimen, cT4 stage on preoperative imaging, interval between endoscopic resection and radical cystectomy, neoadjuvant chemotherapy, pT stage, and associated carcinoma in situ, macroscopically complete endoscopic resection remained the main predictor of better RFS (HR = 0.4; p = 0.0003) and the only preoperative factor associated with CSS (HR = 0.5; p = 0.01). Conclusion: A macroscopically complete TURBT immediately preceding radical cystectomy may improve pathological and oncological outcomes in patients with MIBC and high-risk MIBC.

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

“…14 Graffeille et al found in a cohort of 486 patients, 18% of whom received NAC, that complete TUR was the strongest factor in multivariable models both associated with pathological outcomes (complete response or downstaging) as well as recurrence-free and cancer-specific survival. 17 Columbia University also recently published their institutional results and found that complete TUR was associated with superior survival outcomes as well as pathological response at cystectomy among patients with clinically localized bladder cancer who received NAC. 16 In combination with this existing literature, our findings suggest that there may be a benefit to maximal TUR prior to NAC and RC in patients with MIBC.…”

“…Squamous and glandular differentiations of urothelial carcinoma were included. We excluded patients who were missing information on the completeness of TUR (n[938), had baseline metastatic disease (n [17) , Photocure, Astra-Zeneca, Merck, Fergene, Abbvie, Cleveland Diagnostics, Nucleix, Ambu, Seattle Genetics, Hitachi, Ferring Research, Verity Pharmaceuticals, Virtuoso Surgical, Stimit, Urogen, Vessi, CAPs Medical, Xcures, BMS, Nonagen, Aura Biosciences, Convergent Genomics; E.Y.V. : Consultant: Abbvie, Advanced Accelerator Applications, Bayer, Clovis, Exelixis, Genzyme, Janssen, Merck, Oncternal; W.K.…”

“…Some authors have reported improved pT0 rates following maximal TUR, as well as reduced recurrence and improved survival. 14-17 Conversely, other studies have found limited to no impact of maximal TUR on these same outcomes. 18,19 Specifically, the additional value of maximal TUR prior to NAC followed by RC is unclear.…”

Complete transurethral resection of bladder tumor before radical cystectomy is not a risk factor for organ-confined bladder cancer: A case-control study

“…[ 4 , 14 , 18 ] In several retrospective analyses, complete TURBT was associated with a higher rate of down-staging, which was related to better prognosis. [ 14 , 19 , 23 ] For locally advanced tumors, complete TURBT was not theoretically possible, and incomplete TURBT was often correlated with advanced stage disease (T3–T4), which was a predictor of poor prognosis. [ 18 ] Thus, further studies are needed to assess whether advanced stage or incomplete TURBT is a more significant predictor of prognosis.…”

“…Lee et al [ 14 ] reported that 34 of 48 patients who underwent complete TURBT had a lower pathologic stage, whereas only 4 of 25 patients achieved down-staging status in the incomplete resection group. Graffeille et al [ 23 ] conducted a multivariate analysis adjusting for multifocality, weight of endoscopic resection specimen, cT4 stage on preoperative imaging, interval between endoscopic resection and RC, neoadjuvant chemotherapy, pT stage, and associated carcinoma in situ, which demonstrated that macroscopically complete endoscopic resection remained the strongest predictor of both pT0 disease (odds ratio, 3.1; p = 0.02) and down-staging (odds ratio, 7.1; p < 0.0001) in RC specimens. Our results were similar to both of these previous studies, which revealed a significant correlation between complete TURBT and down-staging, whereas Zamboni et al [ 18 ] reported that only 8 of 433 patients who underwent complete TURBT had lower pathologic stage, and 6 of 294 patients in the incomplete group had down-staging status ( p = 0.852).…”