Retrospective analysis of transurethral resection, second-look resection, and long-term chemo-metaphylaxis for superficial bladder cancer: indications and efficacy of a differentiated approach.
OBJECTIVE
Because of controversy concerning risk factors for progression, recurrence, and persistence of bladder cancer, we reviewed the data of our patients with superficial bladder tumors. Based on a differentiated approach with second-look transurethral resection (TUR) and/or intravesical metaphylaxis, we wanted to answer the following questions: Was this approach efficient? What risk factors demand a second-look TUR? Is surveillance appropriate for patients at low risk?


METHODS
Retrospectively we analyzed the data of 251 patients with superficial bladder cancer with a mean follow-up time of 69 (range 20 to 107) months. We focused on recurrence rates, tumor-persistence and progression, and types of adjuvant treatment. An early reintervention within 6 to 8 weeks after primary resection was defined as a second-look TUR. To judge the necessity of early reintervention and metaphylaxis, we performed a matched-pair analysis for the low-risk group.


RESULTS
Tumor stages included T(a) (170 patients, 68%); T(1) (72 patients, 29%); carcinoma in situ (CIS) (9 patients, 4%). Grades included grade 1 (58 patients, 23%); grade 2 (117 patients, 47%); and grade 3 (76 patients, 30%). Thirty-eight (15%) tumors were already classified as recurrent. A second-look TUR was performed on 222 (88%) patients, indicating a persistence rate of 25%. Persistence rates for low-risk tumors (T(a) grade 1/2) were 9%; rates for T(a) grade 3 tumors were significantly higher. Risk factors for persistence were multilocularity and higher grade and stage. Matched-pair analysis for the low-risk group did not show any significant advantage for second-look TUR. After complete resection of T(1) grade 3 tumors, the risk of progression is similar to that for tumors of lower grade and stage. The overall recurrence rate was 25%, with a higher risk of upstaging in cases of higher stage or grade and multilocular and persisting tumors.


CONCLUSIONS
The overall tumor recurrence rate of 25% reflects the efficacy of our differentiated approach with selective use of second-look TUR and intravesical metaphylaxis (intravesical chemotherapy). Second-look TUR is indicated for multifocal and recurrent tumors or in patients whose tumors put them at high risk. Patients with grade 2/3 tumors, multifocal grade 1 tumors, and all T(1) tumors received metaphylaxis; intravesical bacillus Calmette-Guerin was instilled in patients with CIS. With this regimen, even in T(1) grade 3 stages, organ preservation can be achieved.
Schulze
Michael
M
Department of Urology, SLK-Kliniken Heilbronn, University of Heidelberg, Germany. michael.schulze@slk-kliniken.de
Stotz
Nicoletta
N
Rassweiler
Jens
J
D000283:Administration, Intravesical; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000008:administration & dosage*; D002295:Carcinoma, Transitional Cell / Q000175:diagnosis / Q000188:drug therapy* / Q000601:surgery*; D017024:Chemotherapy, Adjuvant / Q000379:methods; D015653:Cystectomy / Q000379:methods*; D003558:Cystoscopy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology; D009367:Neoplasm Staging; D012189:Retrospective Studies; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000175:diagnosis / Q000188:drug therapy* / Q000601:surgery*
D000970:Antineoplastic Agents