DISCUSSION
Bladder cancer is an aggressive tumor with high morbidity and mortality
rate. It is really important to choose the best treatment option for BC.
The EAU guidelines recommend re-TUR for possible upstaging of NMIBC to
invasive cancer and for clearance of residual tumor after index
TUR-B9. It was demonstrated that the presence of
residue and tumour upstaging were high in re-TUR series. Therefore
re-TUR is critically important for complete resection and re-staging
after index TUR. Disease management and mortality of the patients may
totally change by the help of re-TUR pathology. Although there are
different recommendations for the timing of re-TUR, the most accepted
time of the procedure is 2 to 6 weeks after the index
TUR-B10.
The upstaging rates of T1 patients were found to be high in the
literature. Fritsche et al analysed the data of 1136 patients treated
with radical cystectomy for clinical T1 high stage group and
demonstrated that nearly half of the pT1 patients (49,7 %) had MIBC
pathology11. These rates supported the inadequacy of
clinical decision-making based on current treatment paradigms and
staging tools for T1_high stage tumors. Herr et al also stated that
re-TUR revealed up to 43 % upstaging and up to 85 % of re-TUR
positivity12. The re-TUR positivity was 51 % and
upstaging rate was 14 % in our study. In recently published reviews,
the residual tumor rates were approximately 51-58 % and T2 upstaging
rates were 8-11 %, which were similar to our study
results13-14. The subgroup analysis in the literature
documented that re-TUR positivity was 17-67 % in Ta patients and
20-71% in T1 patients. Most residual tumours (36-86 %) were found at
the original resection site14. In our study, the
re-TUR positivity was found 27 % for Ta and 55 % for T1 patients that
were similar to literature.
The necessity of re-TUR was not uniformly accepted. Some authors did not
recommend re-TUR due to the low percentage of upstaging, possible
complications and the cost of the surgery15. Gaya et
al claimed that re-TUR is mandatory only if there was no muscle tissue
in the initial resection specimen. They thought that absence of muscle
is the only risk factor for understaging16. However
their patient population was low and the lack of muscle tissue is
actually the reason for complementary TUR-B not for re-TUR. In our
study, the re-TUR positivity of T1_high grade patients was 58 % and
upstaging rate was 15 %. T1 high grade is the highest stage for NMIBC
and these patients are at the edge of the border for MIBC. Therefore it
would be proper to make re-TUR to these patients. On the other hand, the
re-TUR is an invasive operation; the pros and cons of the procedure also
should be considered. There are also question marks about the necessity
of re-TUR especially in the COVID-19 pandemic period. The clinicians
must be more careful to make the surgical indications for their patients
in terms of both patient and public health17. Any
surgical procedure that does not have significant indication must be
questioned. Shared decision making would be a solution for this
situation. By this way, clinicians should discuss the decision of re-TUR
requirement collectively with the patients in the light of
evidence-based literature.
The impact of re-TUR on the long-term outcomes for T1 patients was
discussed in several studies in
literature16-20. Divrik et al revealed in their
prospective randomised clinical trial that re-TUR had significantly
decreased the recurrence and progression rates in patients with newly
diagnosed T1 stage18. In addition to this Sfakianos et
al claimed that the absence of re-TUR before initiating intravesical BCG
therapy for high risk NMIBC significantly increased the risk of
recurrence19. On the other hand, some studies claimed
that the recurrence and progression of T1_high grade patients treated
with BCG without re‐TUR was not as bad as previously
thought20. They reported that the oncological results
and the rate of recurrence / progression will not be affected after
re-TUR for T1_high-grade. Moreover, re-TUR can cause patient distress
and higher re-operation related healthcare costs21. In
our study, we could not find any statically significant relation between
re-TUR and recurrence/progression. It might be due to appropriate
intravesical BCG and other curative treatments plus close follow-up.
The presence of hydronephrosis, CIS, LVI, variant pathology and tumor
size >3cm in index TUR are generally associated with a poor
prognosis of BC. Bishr et al reported that the adverse prognostic
features related with re-TUR were; number of tumours (>3
lesions), tumour size (>3 cm), hydronephrosis, invasion of
the lamina propria (T1), high-grade, concomitant CIS, different tumour
variants and T1 stage 22. We also analysed these
variables in terms of re-TUR positivity. We examined that the re-TUR
positivity rate was significantly higher in patients with these
variables. When these factors present, it would be critically important
to perform re-TUR without a doubt.