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Carcinoma of the Bladder represents the fifth most common malignant tumor of the western world as well as the second most common tumor of the urinary tract after prostate cancer. 70 to 85% of all bladder carcinomas are non-muscle invasive tumors. Transurethral resection of the bladder-tumors (TUR-B) is used both for diagnosis and treatment for this type of cancer. Unfortunately studies have shown that treatment alone with TUR-B is not sufficient due to residual tumor in a second resection (re-TUR) four to six weeks later in up to 75%.
The purpose of this examination was the verification or negation of such high values for residual tumor in re-TUR in modern-day surgery as well as the evaluation of prognostic parameters for residual cancer in re-TUR (staging, grading, number of tumors, EAU risk score, surgeon’s level of education).
In the time between 01/01/2005 and 12/31/2008 a number of 555 transurethral resections have been performed in the university hospital of Marburg. A transitional cell carcinoma (TCC) was found in 332 of the patients and a total of 287 tumors were non-muscle invasive. 179 of those 287 patients received a re-TUR within 4 weeks after the initial TUR-B. These 179 patients represent the population on which this study is based. 145 men (81.0%) with an average age of 71 years and 34 women (19.0%) with an average age of 71,5 years were included (ratio ♂:♀ = 4,3:1).
The rate of residual tumor in our high-volume university hospital after reTUR is 15.6%. Of the examined prognostic factors tumor-multifocality (p=0.012) as well as the tumor being a "high risk tumor" (p<0,01) was statistically significantly related to the rate of residual tumor in re-TUR. Tendencies to higher rates of residual tumor could be shown by using stage and grade. Age, gender and surgeon’s level of education do not impact the rate of residual tumor in re-TUR.
The values of staging and grading as prognostic factors were discussed in different studies with varying results, therefore we cannot draw a definite conclusion concerning their value. With our study as main factor and in agreement with most of the published studies we state the following facts:
Multiple tumors in the initial TUR-B lead to a higher rate of residual cancer in re-TUR and therefore represent an indication for re-TUR independent of staging or grading of the primary tumor. The same is true for high-risk carcinomas which also lead to significantly higher residual tumor in re-TUR and should therefore always be treated with a second transurethral resection of the bladder. Higher staging as well as higher grading shows a non significant tendency to more residual cancer in re-TUR.
Our study finds a rate of residual tumor for re-TUR of roughly 16%. In 1 - 18% this second operation changes treatment strategy significantly because of upstaging.
With a minimum of morbidity and mortality not only can re-TUR insure the patients of the macroscopically complete excision of the tumor at this point of time, it also is the necessary diagnostic tool which enables physicians to treat patients most efficiently and therefore guarantee a maximum amount of quality of life. Concluding we can say that re-TUR still is the first choice for controlling non muscle invasive bladder cancer.