Retrospective Study Of Radical Versus Standard Transurethral Resection Of Bladder Tumors In Patients With Non-muscle Invasive Bladder Cancers

Background:Urothelial carcinoma of the bladder is the second most common malignant tumor of the urinary system and one of the most expensive malignant solid tumors.It is a burden to individuals,families and society.According to pathological stages,bladder cancer can be divided into non-muscle invasive bladder cancer（NMIBC）and muscle-invasive bladder cancer（MIBC）,among which NMIBC is the majority.TURBT is the gold standard for treating NMIBC.Foreign studies have shown that up to 17-61%of Ta and 20-71%of T1 patients were found to have residual cancerous tissue when they received repeat resection after 2-8 weeks from the initial resection.Therefore,the European Urological Guidelines recommended Grade Ia treatment with repeat TURBT,and the Chinese Urological Guidelines subsequently recommended it.However,more than half of medical units,including those in China,fail to perform repeat TURBT in accordance with the guidelines,due to reasons including patients’ subjective rejection of short-term secondary surgery and economic factors.According to the experience of our medical unit,the tumor residual rate of NMIBC patients after receiving TURBT is very low.Moreover,our unit adopted radical TURBT to treat NMIBC and achieved ideal clinical effect.Radical transurethral resection of bladder tumor（R-TUR）is based on standard transurethral resection of bladder tumor（S-TUR）and it should be performed to the depth of the fat layer outside the bladder wall at the tumor site.At the same time,the normal bladder mucosa within a radius of about 2cm around the base of the bladder tumor should be removed successively.It has the advantage of a lower recurrence rate than the standard procedure.In this study,we retrospectively analyzed the prognosis of patients with Ta and T1 bladder cancer patients who underwent radical transurethral resection of bladder tumor（RTUR）and standard transurethral resection of bladder tumor（S-TUR）,to determine the difference in the efficacy of the two surgical methods for patients newly diagnosed with Ta and T1 bladder cancer.Objective:The prognosis of Ta and T1 bladder cancer patients receiving R-TUR and S-TUR was retrospectively compared.Methods:From January 1 2010 to December 31 2014,291 patients of one surgeon team,who were newly diagnosed with bladder tumor and received TUR and postoperative intravesical therapy,at Department of Urology,Qilu Hospital of Shandong University was included in the current study.Of note,the patients that received the re-TUR（defined as the second TUR within 8 weeks of the initial TUR）was excluded.The clinicopathological parameters were retrieved from the Hospital Information System（HIS）.And a standard data form was created to collect the data,including patient gender,age,tumor diameter（<3 cm or≥3cm）,tumor focality（solitary or multiple）,tumor location（anterior wall,posterior wall,lateral wall,dome,neck,urethra,ureteric orifice and unknown location）,pathohistological grade（inflamation,papilloma,papillary urothelial neoplasm of low malignant potential,low grade and high grade）and TNM stage（Tis,Ta,T1 and T2,pathological assessments for N stage and M stage are not available for all patients）.All protocols are in accordance to the Declaration of Helsinki,and was approved by the Ethics Boards of Qilu Hospital of Shandong University.The inclusion criteria were:1.newly-diagnosed bladder tumor,2.receiving TUR,but not re-TUR,3.postoperative pathologically confirmed NMIBC.4.Patients who lost clinical data and affected the integrity of the results were removed.Patients were followed-up in the outpatient clinics every 3 months of the first year,every 6 months until 2 to 5 years,and then annually.Follow-up might be modified according to the risk stratification of the Chinese Urological Association guidelines.Follow-up tests routinely include blood routine,urinalysis,ultrasound check for kidney-ureter-bladder,and most important the cystoscopy,followed by biopsies of suspicious lesions if necessary.The primary endpoint was the first-recurrence-free survival（RFS）.And the cancer-specific survival（CSS）was also recorded with an additional follow-up carrying out during the current study.The mean follow-up time was 85.05 months.SPSS software was used for statistical analysis,and t test was used to express the measurement data as mean ± standard deviation（SD）.Counting data is represented as a ratio（%）by the χ2 test.Kaplan-Meier survival curves of the two groups were plotted respectively.P<0.05 indicated that the difference was statistically significant.Results:By analyzing data from 228 NMIBC patients who met the inclusion criteria,patients receiving R-TUR had a longer RFS（P=0.042）than those receiving S-TUR,and there was no significant difference in CSS between the two groups（P=0.413）.Compared with S-TUR,the RFS in the R-TUR group was significantly better than that in the STUR group,and the difference was statistically significant（P=0.114）.There was no significant difference in CSS between the two groups（P=0.676）.For T1 stage patients,R-TUR compared with S-TUR showed a tendency to improve RFS,but it was not statistically significant（P=0.265）,and there was no significant difference in CSS between the two groups（P=0.627）.According to the comparison of different groups of histological grades,the RFS of the R-TUR group was significantly better than that of the S-TUR group for patients with high-grade bladder cancer,with statistical significance（P=0.096）.There was no significant difference in CSS between the two groups（P=0.657）.For patients with low-grade bladder cancer,both RFS and CSS in the R-TUR grouping were better than S-TUR（HR for RFS=0.662,P=0.345,and HR for CSS=0.832,P=0.826,according to Cox regression analysis）.For patients with single tumor,there was no significant difference in CSS between the two groups according to the number of tumors（HR=0.995,P=0.994）,only the RFS of the R-TUR group was better than that of the S-TUR group（Cox regression analysis,HR=0.674;P=0.387）.For patients with multiple tumors,the RFS in the R-TUR group was significantly better than that in the S-TUR group（P=0.018）.When stratified according to the tumor location,there was no significant difference in the RFS between the two groups for patients with dome tumor.For patients without dome tumor,the RPS in the R-TUR group was significantly better than that in the S-TUR group（HR=0.465,P=0.043）.There was no statistically significant difference in CSS（P=0.581）.Conclusion:There was no significant difference between R-TUR and S-TUR in survival rate,but R-TUR significantly reduced the recurrence rate in patients with non-dome tumors.For patients with dome tumor,there was no significant difference in recurrence rate between the two groups,indicating that there was no significant difference in efficacy between R-TUR and S-TUR for patients with dome tumor,but R-TUR is a safe and effective surgical method for patients with non-dome tumor.