The significance of secondary electrodesis in the management of non-muscle invasive bladder cancer
Chen Haiguo* Cao Ming Pan Jiahua Sun Jie Chen Qi Chen Yonghui Xue Wei
Department of Urology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China Chen Haigo, Department of Urology, Shanghai Renji Hospital, Shanghai
Abstract: [Objective]: To investigate the rate of positive tumor detection in patients with non-muscle invasive uroepithelial carcinoma of the bladder who underwent secondary electrodesis 4-6 weeks after the first complete electrodesis and its associated factors. [METHODS]: The case data and follow-up of 134 cases of secondary electrosurgery performed from March 2004 to June 2009 in our hospital were retrospectively analyzed. [RESULTS]: Positive tumors were found in 52 of 134 secondary electrosurgery specimens, and 41 of them had a higher tumor stage than the original. The positive secondary electrosurgery was associated with multiple tumors, high-grade tumors and stage T1 tumors in the first electrosurgery. Patients with positive secondary electrosurgery were found to have a higher incidence of tumor recurrence and progression at follow-up. The incidence of surgical complications of secondary electrosurgery was similar to that of conventional electrosurgery. [Conclusion]: Secondary electrosurgery has a higher rate of positive tumor and provides more accurate pathological staging information with good surgical safety. For patients with risk factors such as multiple tumors, high-grade tumors and stage T1 tumors seen in the first transurethral resection, secondary transurethral resection can be routinely performed.
Repeated transurethral resection for nonmuscle invasive bladder cancer
Haige Chen*, Ming Cao, Jiahua Pan, Jie Sun, Qi Chen, Yonghui Chen, Wei Xue
Department of Urology, Shanghai Renji Hospital, Medical School of Shanghai Jiaotong University. 1630, Dongfang Road, Shanghai, China. 200127
Purpose: To investigate the risk factors and positive rate of the repeated transurethral resection of bladder tumor performed 4-6 weeks after an initial TURBT for nonmuscle invasive bladder cancer.
Materials and Methods: From March 2004 to June 2009, 134 patients underwent a repeated TURBT were included in this study. the presence of residual tumor The presence of residual tumor and the correlated risk factors, the complications of the second procedure and the changes of stage and grade between the two different TURBT were In the total 134 patients, the second procedure was performed in the first week of the study.
Results: In the total 134 patients, residual tumor was present in 52 cases, and upgrading occurred for 41 patients. Patients with high grade, T1 stage and Patients with high grade, T1 stage and multifocality tumor at the initial TUR has a higher risk been found residual tumor in the second opinion. The complication of the repeated TURBT was predictable.
Conclusion: A high rate of residual tumor presence would be found in the repeated TURBT. We suggest repeated TURBT should be performed for the patients with high grade, T1 stage or multifocality nonmuscle invasive bladder cancer.
Bladder cancer is the most prevalent genitourinary malignancy in China, and approximately 80% of initially diagnosed bladder cancers are Ta or T1 stage tumors [1]. Currently, transurethral resection of bladder tumor (TURBT) is the treatment of choice for non-muscle invasive bladder cancer, but there is a high recurrence rate after surgery, and how to reduce recurrence is the primary issue in the management of non-muscle invasive bladder cancer. Many authors support re-TURBT (Re-TURBT) 2 to 6 weeks after the initial electrosurgery, including recurrent or residual tumors visible in the bladder, muscle tissue at the original electrosurgical scar and random biopsy if necessary [2]. We have been treating some patients with non-muscle invasive bladder cancer with Re-TURBT since 2004, and we report our observations.
1. Materials and methods.
1.1 Clinical data.
*Author: Hago Chen (1973), Associate Chief Physician. Contact: [email protected]
From March 2004 to June 2009, a total of 134 patients with uroepithelial carcinoma of the bladder were treated with Re-TURBT at our institution, including 111 males and 23 females with a mean age of 64.93±9.65 years (33-88 years), 106 patients with first diagnosis of bladder cancer, 28 with recurrence, 85 with a single tumor, and 49 with multiple (intra-bladder two or more tumors). All patients were diagnosed with non-muscle invasive bladder cancer based on intraoperative TURBT and postoperative pathology, and pathologic staging and grading was verified by a pathologist based on preserved paraffin sections (see Table 1 for specific results), and all intraoperative tumors seen were removed in the first elective resection.
Table 1 Pathologic staging and grading (cases)
Pathological staging
Pathological grading
Ta
T1
Total
Low grade
40
20
60
High Level
35
39
74
Total
75
59
134
1.2 Outcome observation.
Patients in the group underwent secondary electrodesis 4-6 weeks after the first complete cystectomy with general anesthesia under a laryngeal mask, the operator was the same surgeon as the first electrodesis, the scope of electrodesis included recurrent or residual tumors visible in the bladder, muscle tissue at the original electrodesis scar, 26 patients underwent random biopsy at the microscopic visualization of normal bladder mucosa, and pathological specimens were sent separately.
For all patients who did not undergo total cystectomy, we followed them up in the outpatient clinic with examinations every three months until two years, and then every six months, including routine urine examination, cystoscopy and ultrasound of the upper urinary tract. For patients with tumor progression and total cystectomy, they were not included in this study.
1.3 Statistical methods: SPSS11.5 statistical package, chi-square test, and Binary logistic model analysis were used.
2 Results.
In 134 secondary electrodesection specimens, positive tumors were found in 52 cases, with an overall positive rate of 38.81%. Among them, 30.77% (24/78) of the first electrodes were diagnosed as Ta stage secondary electrodes, 50% (28/56) of T1 stage, 23.53% (16/68) of low-grade patients and 54.55% (36/66) of high-grade patients (see Table 2 for details). The positivity rate for multiple tumors was 61.22% (30/49, 12 low-grade and 18 high-grade patients), the positivity rate for the second electrosurgery was 37.74% (40/106, 10 low-grade and 30 high-grade patients), and the positivity rate for recurrent tumors was 42.86% (12/28, 6 low-grade and 6 high-grade patients). According to the logistic regression model analysis, the first electrodes were seen as multiple tumors (P < 0.01), high-grade tumors (P < 0.01) and T1 stage tumors (P = 0.011) were all independent risk factors for positive secondary electrodes.
Table 2 Positive secondary electrosurgery cases (rate) in different pathological stages and grades
Pathological stage
Pathological grade
Ta
T1
Total
Low grade
7 (17.5%)
9 (45%)
16
High level
15 (42.86%)
21 (53.85%)
36
Total
22
30
52
Among the 52 patients with positive secondary electrosurgery, 4 patients were pathologically diagnosed with carcinoma in situ or concomitant carcinoma in situ; 6 patients had a different pathological grade of secondary electrosurgery than the first electrosurgery, including 1 case with higher grade and 5 cases with lower grade; 41 patients were clinically or pathologically diagnosed with muscle invasive bladder cancer after secondary electrosurgery, 37 of which underwent total cystectomy within 6 months after electrosurgery, 4 patients refused to undergo radical surgery, 2 of which Four patients refused radical surgery, two of whom were followed up in the outpatient clinic and two were lost; 11 patients were still diagnosed with non-muscle invasive bladder cancer and were further followed up in the outpatient clinic.
Among the 26 patients who underwent random biopsy, a total of 54 tissue specimens were sent for examination, of which no positive tumor was found.
As of December 2009, excluding 37 patients who underwent total cystectomy and 10 patients who were lost to follow-up, a total of 87 patients received outpatient follow-up with a mean follow-up time of 24.70±15.44 months. Tumor recurrence was found in 31 patients (35.63%) during the follow-up period, including 9 patients with positive secondary electrodes and 22 patients with negative secondary electrodes, and the probability of tumor recurrence was significantly higher in patients with positive secondary electrodes than in those with negative secondary electrodes by χ2 test (χ2=7.52, P=0.01). Eleven cases progressed to total cystectomy for muscle-infiltrating bladder cancer, of which six were positive for secondary electrodes (including two patients with improved pathological stage of secondary electrodes) and five were negative, and the probability of tumor progression was significantly higher in patients with positive secondary electrodes than in those with negative (χ2=15.54, P=0.01). No cases of tumor metastasis or death from bladder tumor were found during the follow-up period in our group of 87 follow-up patients.
In our study, we recorded the following complications after secondary electrosurgery: 9 cases (6.71%) requiring prolonged hospitalization (more than two days) or re-hospitalization within two weeks due to hematuria, 1 case (0.01%) requiring re-surgical treatment for severe hematuria within two weeks after surgery, 11 cases (8.21%) with postoperative fever (temperature higher than 38 degrees and lasting more than two days). There were 21 cases (15.67%) in which the catheter was left in place for more than one week after surgery for various reasons, 10 cases (7.46%) in which urinary retention occurred within two weeks after removal of the catheter, and 6 cases (4.48%) in which urethral stricture required urinary dilation or surgical treatment after surgery.
3. Discussion:
TURBT has been widely used as the standard treatment for non-muscle invasive uroepithelial carcinoma of the bladder, but recent data have shown that a single TURBT is difficult to ensure clearance of the tumor, and according to different reports in the literature, the chance of finding a tumor when a second TURBT is performed within 8 weeks of the first one is as high as 18-77% [3-6], and about 40% of patients staging changes will be detected [7]. Factors affecting the rate of positive secondary electrosurgery include tumor grade and stage, tumor size, interval between electrosurgery, previous history of tumor recurrence, and surgeon’s practice [8-9]. Since reports from various centers have shown a high rate of positive secondary electrosurgery, most scholars now believe that under the operating conditions of TURBT, the characteristics of the tumor itself are the key factors contributing to tumor remnants, and that positive secondary electrosurgery often suggests that patients are at higher risk of tumor recurrence or progression [10].
The results of our study showed that non-muscle invasive uroepithelial carcinoma of the bladder still had a high rate of tumor positivity when secondary electrodes were performed 4-6 weeks after the initial electrodesis. However, according to logisit regression analysis, patients with multiple tumors, high-grade tumors, and stage T1 tumors seen at the first excision had a significantly higher risk of positive tumors at the second excision, which could still indicate that patients with these risk factors are at risk for secondary excision. The pathological grade of the tumor was the most important factor affecting the positive rate of secondary electrosurgery, while in our study whether the tumor was recurrent or not had no significant effect on the positive rate of secondary electrosurgery (P=0.62).
Furthermore, in terms of surgical complications, there were no cases of bladder perforation or rupture due to secondary electrosurgery, and a review of the relevant domestic and international literature also showed that the surgical complications of secondary electrosurgery were basically similar to those of conventional electrosurgery. Therefore, we believe that it is safe to perform secondary electrodesis 4-6 weeks after the first electrodesis.
It is noteworthy that up to 78.85% (41/52) of the patients in this retrospective study with positive secondary electrodesis showed increased pathological staging and 82.69% (43/52) of the patients required total cystectomy treatment during the follow-up period, which is higher than the level reported in the foreign literature. This suggests, on the one hand, that there may have been suspected higher staging in this group of patients at the time of enrollment, and also that our current ability to diagnose staging pathologically is still lacking, in which case secondary electrosurgery is also important in providing an accurate staging diagnosis in patients. In addition, we also observed a higher chance of tumor recurrence and progression in the short term in patients with positive secondary electrosurgery, suggesting that we may need to adopt a more aggressive treatment follow-up strategy for patients with positive secondary electrosurgery, but the number of cases observed in our study is still small and a larger controlled study is needed to support this conclusion. In addition, there was a change in pathological grading in a few
In conclusion, we conclude that secondary electrosurgery for uroepithelial carcinoma of the bladder has a high positive rate and provides more accurate pathologic staging information with good surgical safety. For patients with risk factors such as multiple tumors, high-grade tumors and stage T1 tumors seen at the first excision, we believe that secondary excision should be routinely performed.
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