Second transurethral resection and prognosis of high-grade non-muscle invasive bladder cancer in patients not receiving bacillus Calmette-Guérin.

OBJECTIVE

To define the natural history of T1G3 bladder tumor not receiving intravesical Bacillus Calmette-Guerin (BCG) and assess the diagnostic and therapeutic value of a second transurethral resection (Re-TUR) in these patients.

PATIENTS AND METHODS

Retrospective study on the natural history of 210 patients treated at two institutions for T1G3 bladder carcinoma without associated CIS. In no case was BCG administered; 79 (37.6%) received TUR alone, and 131 (62.4%) Re-TUR 4 to 6 weeks later; 23 (12.4%) underwent cystectomy for tumor progression.

RESULTS

Median follow-up was 55 (78 IQR) months, male/female ratio 8/1, and mean age 70.6+11.8 (range 37-93). 19.5% were free of recurrence at 10 years, and 61.9% free of progression. Independent prognostic factors for progression were solid pattern (HR: 2.71; P=.0004), multiplicity (HR: 2.26; P=.003), and recurrence at 3 months (HR: 3.4; P=.003). Cancer-specific survival was 81.5% at 5 and 69% at 10 years. Independent predictors of survival were: progression during the first year (HR: 17.9; P<.0001), solid pattern (HR: 2.13; P=.02), multiplicity (HR: 2.05; P=.03), and age>65 years (HR: 2.9; P=.03). Re-TUR avoided under-staging (7.4%), detected T1G3 residual disease (10.7%), reduced recurrence rate at 3 months (11.4 to 4.6%; P=.06), and rate of progression on the 1st year (13.9 to 3.8%; P=.0075). However, in these patients the risk remains and no differences were detected in the long term in terms of recurrence (log-rank, P=.14), progression (P=.91), or cancer death (P=.21) in patients treated with Re-TUR.

CONCLUSION

The recurrence in the first 3 months of a T1G3 tumor not receiving BCG is the main risk factor for progression, and progression of this type of tumors within the first year is the main factor of cancer death. The Re-TUR improves both variables but it does not change the long-term prognosis.