The role of complete TURBT for NMIBC before intravesical therapy and repeat TURBT are confirmed by several studies [1–3, 16, 17]. However, its role before radical cystectomy (RC) is controversial. And the completeness of TURBT was affect by tumor burden, which was also associated with oncological outcome [9, 10, 14]. In several retrospective analyses, complete TURBT was associated with a higher rate of downstaging, which was related to good prognosis [10, 11]. For locally-advanced tumors, complete TURBT was not theoretically possible, and incomplete TURBT was often related to advanced stage (T3-4), which was a predictor of poor prognosis . Thus, whether advanced stage or incomplete TURBT is a more effective predictor of prognosis was assessed. A recent study revealed that advanced stage was a greater predictor than incomplete TURBT, but some biases was inevitable, such as adjuvant therapy, positive surgical margin, and relatively subjective definition of complete TURBT . Thus, we focused on organ-confined bladder cancer (Ta-T2), for which complete TURBT was available, to investigate the role of complete TURBT for RC candidates with organ-confined bladder cancer. For these patients, the primary tumor could be removed completely with RC, the role of complete TURBT would guide clinical practice for RC candidates. If complete TURBT did not improve outcome for these patients, it should be performed with caution to avoid related morbidities. In contrast, complete TURBT should be accomplished as much as possible before RC to improve oncological outcome.
In this study, complete TURBT was related to histological variants, tumor size, downstaging and upstaging. Using logistic analysis, we found that grade, size and histological variants were independent predictors of complete TURBT. These findings demonstrated that the increased tumor size and variant histology were associated with reduced rates of complete TURBT. Second TURBT was not associated with complete TURBT, but was associated with downstaging. Survival analysis results demonstrated that age, complete TURBT and histological variants were independent predictor of disease-free survival (DFS), and downstaging was not associated with lower rates of recurrence. Our study revealed that RC candidates with organ-confined bladder cancer did not benefit from complete TURBT(Fig. 1).
In studies of neoadjuvant chemotherapy for locally-advanced bladder cancer, downstaging and complete response were associated with good outcome. For those patients yielding downstaging, neoadjuvant chemotherapy was related to a better outcome than TURBT alone [5, 9]. These studies revealed that the response to chemotherapy and TURBT before RC toed to better cancer control. But the role of complete TURBT was not significant in some cohorts in which early-stage disease was more effective predictor of prognosis than complete TURBT . In addition to tumor stage, adjuvant therapy and surgical margin status also affected outcome. In this study, these factors were excluded, and we found that complete TURBT was associated with worse DFS, as well as age and T stage, though it was not statistically significant.
Theoretically, complete TURBT might reduce the possibility of field seeding by decreasing tumor exposure during the operation. Additionally, complete TURBT was associated with early-stage disease and less tumor burden, so the role of complete TURBT in oncological outcome was covered. As reported, the circulating cancer cells increased during TURBT, and complete TURBT exhibited potential to increase tumor cell spreading, especially when bladder perforation occurred . Compared to TURBT, RC could remove bladder cancer radically for organ-confined disease and is considerably more reliable than complete TURBT [15, 19]. Based on this study, we had confirmed that complete TURBT did not improve survival for organ-confined bladder cancer patients before RC. And the bias between two groups, such as higher proportion of LVI, concomitant CIS and high-grade tumor, were substantially presented.
In most studies, downstaging had an important impact on survival, even neoadjuvant chemotherapy was not performed [4, 20, 6]. In this study, complete TURBT was related to a higher rate of downstaging, which was from T2/T1 to T1/Ta, and downstaging was not significantly associated with oncological outcome significantly. In Hautmann’s research, a series of RC was performed without neoadjuvant chemotherapy, and patients with maximal tumor stage pT2aN0 had worse survival than patients with preoperative T2aN0 and downstaging by TURBT . However, multivariable analysis was not available in this large population study to confirm the role of downstaging by TURBT, and tumor stage and size were associated with both downstaging and survival. In this study, it was possible that all tumors could be resected completely by RC regardless of downstaging, so the role of complete TURBT and downstaging was not significant to oncologic outcome.
Some advantages of this study included the fact that biases of neoadjuvant/adjuvant therapy, tumor stage and positive surgical margin were excluded, and a relative long-term follow-up was available in this cohort. In addition, the limitations of this retrospective analysis should be mentioned. All cases received care in a single cancer center, and TURBT and RC were performed by different surgeons, who were primarily residents, but the quality was supervised by experienced surgeons. And second TURBT was not performed under consistent criteria. What’s more, these data were prospectively collected from our Bladder Cancer database and follow-up was regularly updated. Finally, all recurrences were collected in this study, and local recurrence alone is rare. However, our study provided reliable information to evaluate the role of complete TURBT for RC candidates with organ-confined disease.