Introduction:

According to the AUA Guideline, patients with high grade (HG) pTa bladder tumors categorized as ‘High Risk’ should undergo restaging transurethral resection (reTUR) while the EAU Guideline recommends reTUR only if there is not muscle present in the initial resection.  These statements were generated from a relative paucity of data.  Herein, we investigated the role of reTUR in BCG response to create a risk-adapted approach to the management of HG Ta lesions.

Methods:

An IRB approved review of patients with HG Ta bladder cancer at index transurethral resection (TUR) who received adequate BCG, as defined by the FDA, at our institution from 2000-2019 was performed.  Patients were stratified by (1) presence of residual disease on reTUR and (2) implementation of Guideline-driven reTUR.    

Results:

Of the 209 patients with primary HG Ta bladder cancer who received adequate BCG, 104 underwent reTUR which identified residual disease in 40 patients (38%).  Only one patient (1%) with residual disease was upstaged to T1 and no patients had T2 disease.  Factors associated with residual disease on reTUR included multifocality (62% residual disease group vs. 38% no residual disease, P=0.022), carcinoma in situ (CIS, 44% vs. 12%, P<0.001), index TUR performed outside our institution (10% vs. 37%, P=0.003), and lack of peri-operative chemotherapy (5% vs. 20%, P=0.045, respectively).

In patients meeting AUA criteria for reTUR (N=156), those who were restaged exhibited improved PFS (medians NR, P=0.055) and RFS (median NR vs. 65 mo, P=0.008).  In patients meeting EAU criteria for reTUR (N=70), similar results were identified.  In the 58 patients meeting both Guideline criteria for reTUR, lack of restaging was associated with two-fold increase in recurrence and progression.

Conclusion:

Factors associated with residual disease at reTUR include tumor multifocality, concomitant CIS, and lack of peri-operative chemotherapy.  In all HG Ta patients undergoing adequate BCG, reTUR was associated with improved recurrence and progression rates.  reTUR use concordant with both AUA and EAU Guidelines was associated with improved outcomes compared to lack of restaging, and this was most notable in patients meeting restaging criteria for both Guidelines (AUA High Risk and lack of detrusor muscle in the index specimen).

Funding: The research was supported by the Wayne B. Duddlesten Professorship in Cancer Research, the Raymond and Maria Floyd Bladder Cancer Research Foundation Grant to AMK, and NIH/NCI UTMD Anderson SPORE in Genitourinary Cancer (Bladder) (P50CA091846) to CPND.