Could we safely omit a Repeat Transurethral Resection of the Bladder (re-TURB) after Hexaminolevulinate Photodynamic Diagnostics (PDD)-TURB?

Abstract

Objective: Bladder cancer (BC) is considered one of the malignancies with moderate-high incidence, high rate of recurrence and costly management. Diagnosis and staging are thus important for therapeutic purposes. Considering the risk of residual tumour and understaging, in specific cases, international guidelines recommend performing a second transurethral resection of the bladder (reTURB). Our study aimed to evaluate the impact of hexaminolevulinate Photodynamic Diagnostics (PDD) at first TURB on the rate of residual tumour. Materials and Methods: We retrospectively analysed patients undergoing TURB in our centre between 2012 and 2020. Eightytwo patients had a re-TURB after a first complete TURB with a delay < 3 months. Patients who had an incomplete first resection were excluded. We compared patients who underwent standard white light cystoscopy/TURB and then hexaminolevulinate PDDguided reTURB (group A, n = 49) and patients with PDD-cystoscopy/ TURB at the first procedure then white light cystoscopy/reTURB (group B, n = 33). The residual tumour rate at reTURB as well as median recurrence-free survival (RFS) were compared between the two groups. Results: Residual tumour at reTURB was detected in 48.8% of cases in our cohort, with a significant difference between the two groups (71.4% in group A versus 12.5% in group B, p < 0.001). After a median follow-up of 22 months, the median RFS was 15 months in Group A and 32 months in Group B, but this difference was not significant (p = 0.7). Conclusions: Using PDD at the time of the initial TURB had a statistically significant impact on the rate of residual tumour at the reTURB. Nevertheless, the percentage of residual tumour even with the use of PDD does not allow for safely omitting second resection. Performing a reTURB with PDD for patients who did not have it initially, provides the same benefit in terms of recurrence-free survival.

Differences in oncological benefits from second transurethral resection between white‐light initial surgery and photodynamic diagnosis‐guided initial surgery for primary high‐risk non‐muscle invasive bladder cancer

“…Two other retrospective studies investigated the rate of residual tumor rate and/or tumor upstaging to MIBC of second TUR in patients with high‐risk NMIBC treated with the initial PDD‐TURBT using intravesical instillation of hexaminolevulinate 13,14 . That study excluded patients who had an incomplete first resection.…”

“…Another retrospective study by Lorusso et al. compared residual tumor rate at second TUR specimens and BRFS between 49 patients who underwent an initial WL‐TURBT followed by second TUR with PDD guidance, and 33 patients receiving the initial PDD‐TURBT followed by second TUR without PDD guidance 14 . That study showed that residual tumor rate was significantly different between the two groups ( p = 0.001; 71% vs. 13%), but the BRFS was not significantly different ( p = 0.7) after a median follow‐up of 22 months.…”

“…Two other retrospective studies investigated the rate of residual tumor rate and/or tumor upstaging to MIBC of second TUR in patients with high-risk NMIBC treated with the initial PDD-TURBT using intravesical instillation of hexaminolevulinate. 13,14 That study excluded patients who had an incomplete first resection. Tadrist et al demonstrated that residual tumor was pathologically detected in second TUR specimens in 59% of patients (n = 64) and upstaging to T2 tumor was observed in 4.5% of patients (n = 5) after the initial PDD-TURBT.…”

“…A cumulative analysis of prospective studies showed that the odds for residual tumor rate was significantly low after PDD‐TURBT (odds ratio = 0.28) 12 . Two retrospective studies that assessed the residual tumor rate and recurrence‐free survival after PDD‐TURBT showed that a second TUR is required even after an initial complete resection 13,14 . However, these studies had small sample sizes (109 and 33 patients, respectively), and did not assess the effect of postoperative treatments such as intravesical Bacillus Calmette–Guérin (BCG) therapy.…”