Mariappan P, Zachou A, Grigor KM. Detrusor muscle in the first, apparently complete transurethral resection of bladder tumour specimen is a surrogate marker of resection quality, predicts risk of early recurrence, and is dependent on operator experience. Eur Urol 2010: 843-49.
In a nutshell
This is a prospective analysis of transurethral resection bladder tumour (TURBT) quality carried out by the Edinburgh Uro-Oncology group in a single centre on 356 patients over a two-year period.
The aim of the study was to determine if the presence of muscularis propria in the first resection specimen depended on surgeon experience and whether it was a suitable surrogate marker of resection quality. Surgeons were classified as either junior or senior. Data recorded included tumour size, tumour multiplicity, detrusor muscle status, grade and stage of tumour and findings at the three-month follow-up cystoscopy and re-TURBT. The recurrence rate at the three-month follow-up cystoscopy was 44.4% when muscle was absent versus 21.7% when present. Multivariate analyses revealed that large tumours, high grade tumours, and surgery by senior surgeons was independently associated with the presence of detrusor muscle in the resected specimen.
Second opinion
The standard therapy for new non-muscle invasive bladder tumours (NMIBTs) is TURBT followed by intravesical chemotherapy. However, these tumours have a high risk of recurrence. Studies have shown that the quality of TURBT can be assessed by the completeness of resection, recurrence of tumour at the resection site and the presence of detrusor muscle in the resection specimen. Understaging seems to be a common problem. Relatively recent work has shown an overall rate of absence of detrusor muscle in 15.3% of initial resections, resulting in understaging in 49% of T1 tumours without detrusor muscle. Another study identified understaging in 64% of tumours when detrusor muscle was absent and in 30% when muscle was present. The standard of care for high grade or T1 tumours is re-resection after the initial TURBT. Research has shown that a restaging TURBT decreases errors in staging and potentially affects further management of patients with superficial bladder cancer. In conclusion, the study by Mariappan et al showed that the presence of detrusor muscle in the sample and the seniority of the surgeon are important factors in determining a superior outcome. A larger multicentre trial should be considered as the question asked is an important one.
The verdict
- Tumour recurrence at the three-month cystoscopy following TURBT is an important prognostic marker for subsequent
recurrence and varies according to the quality of the resection.
- Incomplete resection with clinical understaging of bladder tumours is common.
- The absence of detrusor muscle in the first TURBT is independently associated with increased risk of early recurrence.
- Surgeon experience is important in the thoroughness of resection.
John P O’Donoghue
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Jeremy P Crew
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