Soria Francesco, Marra Giancarlo, D'Andrea David, Gontero Paolo, Shariat Shahrokh F
Department of Urology and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.
Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, Turin, Italy.
Transl Androl Urol. 2019 Feb;8(1):46-53. doi: 10.21037/tau.2018.10.19.
The second look transurethral resection of the bladder (TURB) represents a fundamental step in the treatment of papillary non-muscle invasive bladder cancer (NMIBC); it is therefore recommended by all guidelines. However, not all the literature agrees on its staging value and its ability to improve oncological outcomes of patients. Therefore, the purpose of this review is to evaluate the strengths and weaknesses of second look TURB, trying to depict its evolving role in the management of high grade NMIBC. Using Medline, a non-systematic review was performed including articles between January 2000 and June 2018. English language original articles, reviews and editorials were selected based on their clinical relevance. To date, TURB seems to be largely inadequate in retrieving a correct diagnosis and in removing all tumor tissue. Second look TURB maximizes staging accuracy, allows to clear residual cancer and yields prognostic advantages allowing key information to identify possible candidates for immediate radical cystectomy for very high risk T1HG tumors. Moreover, it seems to have a therapeutic benefit by improving recurrence- and progression-free survivals. However, few recent large studies showed that these advantages seem to be limited to patients without detrusor muscle present at first resection. Similarly, the presence of residual disease and the risk of upstaging are related to the presence of detrusor muscle in specimen. It could well be that in the future the presence of detrusor muscle would be a quality criteria to avoid an unnecessary second look TURB as shown by recent studies using the resection technique. Finally, it has to be underlined that this is a surgical procedure not free of risks and complications and with a non-negligible impact on patients' quality of life, waiting lists and healthcare costs. Therefore, future studies trying to identify the criteria that may better allow which patients to select for a second look TURB while avoiding an unnecessary intervention with possible risks and associated cost are needed to allow a personalized approach to even this one size fits all strategy.
二次经尿道膀胱肿瘤切除术（TURB）是乳头状非肌层浸润性膀胱癌（NMIBC）治疗中的关键步骤，因此所有指南均推荐采用。然而，并非所有文献都认同其分期价值及改善患者肿瘤学结局的能力。因此，本综述旨在评估二次TURB的优缺点，试图阐述其在高级别NMIBC管理中不断演变的作用。通过检索Medline进行非系统性综述，纳入2000年1月至2018年6月期间的文章。根据临床相关性选择英文原创文章、综述和社论。目前来看，TURB在获取准确诊断及切除所有肿瘤组织方面似乎存在很大不足。二次TURB可最大限度提高分期准确性，有助于清除残留癌灶，并具有预后优势，可为识别极高风险T1HG肿瘤的即刻根治性膀胱切除术候选者提供关键信息。此外，它似乎还具有治疗益处，可改善无复发生存率和无进展生存率。然而，近期少数大型研究表明，这些优势似乎仅限于首次切除时无逼尿肌的患者。同样，残留疾病的存在及分期上调风险与标本中逼尿肌的存在有关。很可能未来逼尿肌的存在将成为避免不必要二次TURB的质量标准，如近期使用切除技术的研究所显示。最后必须强调的是，这是一种并非毫无风险和并发症的手术，对患者生活质量、等待名单及医疗成本有不可忽视的影响。因此，未来需要开展研究以确定哪些标准能更好地筛选适合二次TURB的患者，同时避免不必要的、可能存在风险及相关成本的干预，从而实现针对这一“一刀切”策略的个性化方法。
