Two-step TURB improves superficial TCC outcomes

August 1, 2007

A two-step transurethral resection (TURB) procedure in patients with superficial transitional bladder cancer, already part of practice guidelines in Germany, appears to improve patient outcomes by identifying positive tumor beds that may require a second TURB.

Anaheim, CA-A two-step transurethral resection (TURB) procedure in patients with superficial transitional bladder cancer, already part of practice guidelines in Germany, appears to improve patient outcomes by identifying positive tumor beds that may require a second TURB, according to findings from a Swiss study.

"These guidelines were put in place to give sufficient data for accurate staging of the tumor," Osama Shahin, MD, senior physician at the University Hospital Basel Urologic Clinic in Switzerland, told colleagues at the AUA annual meeting. "First, you resect the tumor as you normally would. Then you resect the tumor base and the tumor resection rim, and send this biopsy specimen for separate pathology."

In 2003, University Hospital Basel adopted the two-stage resection originally recommended by the German Association of Urology in 1998. If the tumor bed biopsy is positive, appropriate follow-up treatment is indicated.

As part of the guideline adoption at University Hospital Basel, surgeons began entering relevant clinical and histologic data in a real-time database, including patient follow-up. Dr. Shahin, working with Thomas Forster, MD, and colleagues, abstracted clinical and follow-up data on all 169 initial TURB procedures performed between January 2003 and December 2005. The study population included 138 men and 31 women with a mean age of 72 years. The average follow-up time was 12 months.

High positive biopsy rate

Residual tumor cells were found in the tumor bed biopsy among 33% of the patients.

"This was a high number, as the entire tumor had already been removed," Dr. Shahin said.

Nearly two-thirds (64%) of TURB patients were given a single intravesical dose of epirubicin (Ellence) immediately after the TURB. In addition, a second TURB was performed on 20% of the patients, and 14% were given bacillus Calmette-Guerin (BCG [TheraCys, TICE BCG]) six times weekly for 6 weeks following the initial resection. In the overall population, 33% of patients showed tumor recurrence.

While a positive tumor bed biopsy was a generally negative prognostic indicator, only G3 tumors showed a statistically significant association, with a higher incidence of positive tumor bed histology. Lower-grade tumors showed a clear but insignificant association with positive tumor bed biopsy.

About 45% of T1 tumors had a positive tumor bed, Dr. Shahin said, which is consistent with reports in the literature. Among Ta tumors, 33% of the positive margins were found in the mucosal area surrounding the tumor. The researchers did not analyze the patient population for any possible effect of tumor size, but all of the resected tumors were superficial and none had invaded bladder muscle tissue.

"Even under the guidelines, we try to do a complete initial resection," Dr. Shahin said. "We just do a second pass, a biopsy, to check what we have already done. Based on the patient data we have so far, we believe that second pass is a very good idea. If you find positive margins, a second TURB should be considered."