What percentage of high-grade T1 bladder cancer is upstaged on repeat Transurethral Resection of Bladder Tumor (TURBT)?

From the Guidelines

Approximately 20-71% of high-grade T1 bladder cancer is upstaged on repeat transurethral resection of bladder tumor (TURBT), as reported in a systematic review published in 2018 1. This significant rate of upstaging underscores the importance of performing a repeat TURBT within 2-6 weeks after the initial resection for all patients with high-grade T1 bladder cancer. The repeat procedure serves multiple critical purposes:

• it can detect residual tumor that was missed during the initial resection,
• identify deeper invasion that wasn't previously recognized,
• and ensure complete removal of the tumor. Upstaging typically means that what was initially thought to be T1 disease (invasion into the lamina propria but not muscle) is found to actually be T2 disease or higher (muscle-invasive bladder cancer), which significantly changes treatment approach from bladder-sparing options to more aggressive interventions such as radical cystectomy. The high rate of upstaging occurs because the initial TURBT may not adequately sample the depth of invasion, particularly if muscle was not included in the specimen, or because tumor cells can be dispersed during the procedure and reimplant in the resection site, creating the appearance of deeper invasion on repeat evaluation. A strong recommendation for repeat TURBT in patients with T1 disease is supported by guidelines from various organizations, including the AUA 1 and NCCN 1. Additionally, a systematic review and meta-analysis of 31 studies found that repeat TURBT was associated with a reduced risk of recurrence and progression in patients with high-grade T1 bladder cancer 1. Therefore, repeat TURBT is a crucial step in the management of high-grade T1 bladder cancer, and it should be performed within 2-6 weeks after the initial resection to ensure accurate staging and optimal treatment outcomes. Key points to consider when deciding on repeat TURBT include:
• The presence of residual tumor or incomplete resection after the initial TURBT
• The absence of muscle in the initial resection specimen
• The presence of high-grade or high-risk tumor features
• The patient's overall health and ability to undergo repeat surgery. By prioritizing repeat TURBT in the management of high-grade T1 bladder cancer, clinicians can improve patient outcomes and reduce the risk of recurrence and progression.

From the Research

Upstaging of High-Grade T1 Bladder Cancer

• The percentage of high-grade T1 bladder cancer that is upstaged on repeat Transurethral Resection of Bladder Tumor (TURBT) varies across studies.
• A study published in 2015 found that 10.3% of patients with T1 high-grade bladder cancer were upstaged to ≥T2 after a second TURBT 2.
• Another study published in 2020 reported that upstaging at re-TURBT is not a negligible event in T1 tumors, occurring in 8-15% of cases 3.
• A Canadian study published in 2018 found an upstaging rate of 9.2% in patients with T1 high-grade urothelial carcinoma of the bladder on repeat resection 4.

Factors Associated with Upstaging

• Tumor size and carcinoma in situ (CIS) have been identified as predictive factors of positive findings at 3 months after the initial TUR + BCG therapy 5.
• The depth of lamina propria (LP) invasion has also been associated with an increased risk of upstaging 5.
• A study published in 2018 found that timely repeat resection, within 12 weeks, appears to be associated with preventing disease progression 4.

Implications for Clinical Practice

• The current evidence suggests that a routine second TURBT procedure should be recommended in patients with T1 high-grade bladder cancer to accomplish adequate tumor resection and to identify patients who may need to undergo prompt cystectomy 2.
• The use of multiparametric MRI (mpMRI) and en bloc resection technique may also play a role in improving the selection of patients for re-TURBT and reducing the risk of upstaging and residual disease 3.