Introduction:

We sought to determine whether there was a significant difference in staging accuracy from restaging transurethral resection of bladder tumor (re-TURBT) to pathologic staging in patients receiving a post-neoadjuvant chemotherapy (NAC) re-TURBT prior to radical cystectomy (RC) versus those who underwent a re-TURBT prior to RC but did not receive NAC. We also evaluated pathologic upstaging rates and bladder cancer recurrence. We hoped to elucidate whether restaging TURBT after NAC can have a beneficial effect on the accuracy of diagnosis, either supporting a continued use of a re-TURBT following NAC or call for further investigation into the therapeutic utility of re-staging these patients versus proceeding directly to RC.

Methods:

We derived the cohort from our prospectively maintained IRB approved institutional database (Caisis) and identified 129 patients who underwent RC from 2013 to 2019 with a re-staging TURBT prior to RC. 53 patients received neoadjuvant chemotherapy (NAC) between their initial and re-staging TURBT and 76 patients did not receive NAC. A chi-square test and Fisher’s exact test for categorical variables were used with p<0.05 considered to be significant.

Results:

The overall upstaging rate from re-TURBT to RC was 22.5% and there was no significant difference in the upstaging rate between the NAC and no-NAC groups, with 17.0% upstaged in the NAC group and 26.3% in the no-NAC group (p =0.21). Furthermore, in patients who were cT1 on post-NAC re-TURBT, 62.5% had pT2 or greater. In patients showing absence of residual disease (cT0) on re-TURBT, there was no difference in the rate of absence of tumor on pathological staging (pT0), 38.5% for NAC vs 37.5% for no-NAC group (p=1.0). Additionally, all patients who were cN+ on initial TURBT were pT2 or greater following NAC and re-TURBT. Re-TURBT with staging <rT2 as a predictor for absence of muscle invasive bladder cancer (MIBC) on pathologic staging (<ypT2) did not show a significant difference between the NAC and no NAC group, with a negative predictive value (NPV) of 69.0% and 66.7%, respectively (p=0.83).

Conclusion:

Re-staging TURBT after NAC does not show statistically significant improvement in staging accuracy relative to pathologic stage at RC compared to re-TURBT in patients not receiving NAC. In addition, with all patients who were cN+ on initial TURBT having pT2 or greater, further investigation should be done regarding whether patients that are cN+ prior to NAC proceed to RC without re-TURBT. Secondly, with a high rate of patients who were cT1 on post-NAC re-TURBT having MIBC on pathologic staging, additional investigation should be conducted regarding proceeding with RC in this group versus bladder-sparing options that may traditionally be offered in T1 disease. While we have consistently found that one of the best predictors of positive clinical and survival outcomes is pT0 following RC, endoscopic evaluation, such as re-TURBT, as a predictor of pathologic staging has shown to be inaccurate in our study regardless of whether patients receive NAC or not.

Funding: N/A