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.