UROLOGICAL ONCOLOGY

doi: 10.1590/S1677-55382010000400025

Detrusor muscle in the first, apparently complete transurethral resection of bladder tumour specimen is a surrogate marker of resection quality, predicts risk of early recurrence, and is dependent on operator experience
Mariappan P, Zachou A, Grigor KM; for the Edinburgh Uro-Oncology Group
Department of Urology, Western General Hospital, Edinburgh, United Kingdom
Eur. Urol. 2010; 57: 843-849

Background: An European Organisation for Research and Treatment of Cancer analysis of multicentre trials found significant interinstitutional variability in recurrence rates at first follow-up cystoscopy (RR-FFC) and attributed this to variable transurethral resection of bladder tumour (TURBT) quality.
Objective: To determine whether resection of detrusor muscle (DM) in the first, apparently complete TURBT is a surrogate marker of quality and whether the presence of DM is dependent on a surgeon’s experience.
Design, Setting, and Participants: Over a 2-yr period, patients with new bladder tumours that were judged to have been completely resected were recruited from our prospectively maintained bladder tumour database. Strict exclusion criteria were applied.
Measurements: Prospectively recorded tumour size, tumour multiplicity, surgeon category, DM status, grade and stage of tumour, and findings at first follow-up cystoscopy (at 3 mo) and at early re-TURBT were evaluated. Surgeons were stratified into seniors (consultants and year 5 or year 6 trainees) and juniors (trainees lower than year 5). Early recurrence (for calculating RR-FFC) was defined as pathologically confirmed tumour on early re-TURBT or recurrence at the first follow-up cystoscopy. Logistic regression multivariate analyses were carried out to determine associations between variables.
Results and Limitations: In a total of 356 patients, DM was present in 241 patients (67.7%). Multivariate analyses revealed that large tumours, high-grade tumours, and surgery by senior surgeons was independently associated with the presence of DM in the resected specimens. The RR-FFCs when DM was absent and present were 44.4% and 21.7%, respectively (odds ratio: 2.9; 95% confidence interval: 1.6-5.4; p=0.0002). The absence of DM and resection by less experienced surgeons independently predicted a higher RR-FFC. This association was also seen in small and low-grade tumours. The number of patients in this study appears modest, and further validation may be required.
Conclusions: DM absence or presence in the first, apparently complete TURBT specimen appears to be a surrogate marker of resection quality by independently predicting the RR-FFC, which is also dependent on surgeon experience.

Editorial Comment
The quality of surgery is an important fact. This retrospective analysis of resection quality and analysis of early tumor recurrences now gives some hard arguments in favor of a thorough and radical, deep transurethral resection including detrusor muscle (DM). Through all groups analyzed senior surgeons had better results than junior surgeons in terms of detrusor muscle included in specimen. The important fact is that this directly translated into early tumor recurrence at three months. The absence of DM was associated with a significantly higher risk of both early recurrence at first follow-up cystoscopy and residual disease at early re-TURBT. In patients with TaG1 and TaG2 tumors, the risk of early recurrence was 34.5% in the absence of DM, compared to 14.5% when DM was present (p=.005). In patients with G3 tumors, the overall risk of recurrence was 5-fold higher when DM was absent (< 0.001). In patients with T1 disease the recurrence rates were 81.3% and 34.9% when DM was absent or present, respectively (p=.002).
Therefore, do a good job and mind the presence of detrusor muscle in your TURBT specimen!

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany
E-mail: boehle@urologie-bad-schwartau.de