What are the guidelines for Re-TURBT (Transurethral Resection of Bladder Tumor) to prevent and treat recurrence in non-muscle-invasive bladder cancer (NMIBC)?

Guidelines for Re-TURBT in Non-Muscle-Invasive Bladder Cancer (NMIBC)

Re-TURBT is strongly recommended for patients with incomplete initial TURBT, absence of muscle tissue in the first resection specimen, high-risk tumors, T1 tumors, or G3/high-grade tumors (except CIS) to prevent recurrence and improve survival outcomes. 1

Indications for Re-TURBT

The 2022 Military Medical Research clinical practice guideline clearly outlines the following indications for repeat TURBT:

• Incomplete initial TURBT
• No muscle tissue in the first resection specimen
• High-risk tumors
• T1 tumor
• G3/high-grade tumor (except CIS)

Evidence Supporting Re-TURBT

A systematic review of 31 studies including 8,409 patients with high-grade Ta or T1 NMIBC found:

• Residual tumor tissues were found in 17-67% of patients with Ta stage tumors and 20-71% of patients with T1 stage tumors upon re-TURBT 1, 2
• For Ta stage tumors, the disease recurrence rate was 16% for patients who received re-TURBT compared to 58% in patients without re-TURBT 1
• For T1 stage tumors, 5 of 6 studies showed that the rate of tumor progression was higher in patients who did not undergo re-TURBT 1
• Re-TURBT could reduce overall mortality (22-30% vs. 26-36% without re-TURBT) 1, 2

Timing of Re-TURBT

The International Bladder Cancer Group (IBCG) recommends performing re-TURBT 2 to 6 weeks after the initial procedure 1. This timing allows for adequate healing while not delaying further treatment if needed.

Exception to Re-TURBT Requirement

For TaG1/low-grade tumors, even if there is no muscle tissue in the first resected specimen, a repeat TURBT is not an obligated choice 1. This is an important exception to note in clinical practice.

Benefits of Re-TURBT

1. Detection of residual disease: Residual tumor is common after initial TURBT, with studies showing 36-86% of residual tumors found at the original resection site 2

2. Accurate staging: Upstaging occurs in 0-8% (Ta to ≥T1) and 0-32% (T1 to ≥T2) of cases 2

3. Reduced recurrence: A recent 2024 study showed that re-TURBT demonstrated efficacy in reducing recurrence among patients with TaHG NMIBC (3-year RFS was 79% vs. 58%, p<0.001) 3

4. Potential reduction in progression: Particularly important for T1 tumors, where progression rates were higher in the non-re-TURBT group in most studies 1, 2

Implementation Considerations

• Quality of the initial TURBT is crucial - a standardized protocol for TURBT can decrease early recurrence rates from 22% to 9.6% 4
• For Ta high-grade tumors, patients with ≥2 risk factors (multifocality, size >3cm, recurrent cancer, CIS, lymphovascular invasion, histological variant, incomplete resection, absence of muscle layer) who did not undergo re-TURBT had lower 3-year progression-free survival (73% vs. 92%) compared to those with 0-1 risk factors 3
• Pathology slides should be reviewed directly with the pathologist when possible to ensure accurate diagnosis and staging 1

Post-TURBT Management

Following complete TURBT (including re-TURBT when indicated), patients should receive immediate postoperative intravesical chemotherapy within 24 hours after TURBT to further reduce recurrence risk, unless contraindicated 1.

Common Pitfalls to Avoid

1. Incomplete initial resection: Ensure complete resection of visible tumors with adequate depth to include detrusor muscle
2. Inadequate sampling: Ensure muscle tissue is included in the specimen for accurate staging
3. Delayed re-TURBT: Perform re-TURBT within the recommended 2-6 week window
4. Missing high-risk features: Pay special attention to T1 tumors and high-grade lesions which have higher rates of residual disease and progression
5. Overlooking the need for re-TURBT in referred patients: Consider re-TURBT in referred patients due to potential discrepancies in initial pathology interpretation 1

By following these guidelines for re-TURBT in NMIBC, clinicians can significantly reduce recurrence rates, improve accurate staging, and potentially improve survival outcomes for patients with bladder cancer.