The prognostic value of routine second transurethral resection in patients with newly diagnosed stage pT1 non-muscle-invasive bladder cancer: results from randomized 10-year extension trial

  • Askin ErogluEmail author
  • Rahmi Gokhan Ekin
  • Gokhan Koc
  • Rauf Taner Divrik
Original Article



To evaluate the impact of routine second TUR on the long-term outcome of patients with newly diagnosed stage pT1 non-muscle-invasive bladder cancer (NMIBC)

Material and methods

A total of 210 patients (mean age 62.1 years, 89.5% were males) with stage pT1 NMIBC who underwent first TUR were prospectively randomized into two groups including second TUR (n = 105) and no second TUR (n = 105) groups. Data on recurrence, disease progression, 7-year and 10-year recurrence-free survival (RFS), progression-free survival (PFS) and overall survival (OS) were recorded.


The median follow-up time was 119 months (IQR 65-168). Per-protocol (PP) analysis revealed that compared to patients without second TUR, patients with second TUR had significantly higher 5-year, 7-year and 10-year rates for RFS (59.4%, 57.9% and 54.8% vs. 36.3%, 31.7% and 26.8%, respectively, p < 0.001) and PFS (93.3%, 91.9% and 90.4% vs. 74.0%, 71.4% and 68.5%, respectively, p < 0.001). According to PP and intention-to-treat (ITT) analyses, the 10-year OS rate was significantly higher in patients with second TUR (59.1 vs. 40.8%, p = 0.004). Multivariate analysis revealed that undergoing second TUR (OR 1.661, 95% CI 1.156–2.385, p = 0.006) was an independent determinant of prolonged OS.


In conclusion, these findings indicate the prognostic value of second TUR in stage pT1 NMIBC patients, not only for RFS and PFS advantages but also for the long-term OS advantage. Therefore, second TUR should be routinely performed in all stage pT1 NMIBC patients with life expectancy of at least 10 years, given the positive contribution to all oncological outcomes.


Bladder cancer Stage pT1 Second TUR Overall survival Long-term prognosis 



Carcinoma in situ






Non-muscle-invasive bladder cancer


Overall survival


Progression-free survival


Per protocol


Recurrence-free survival


Transurethral resection


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Babjuk M, Böhle A, Burger M et al (2017) EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder: update 2016. Eur Urol 71:447CrossRefGoogle Scholar
  2. 2.
    Torre LA, Bray F, Siegel RL et al (2015) Global cancer statistics, 2012. CA Cancer J Clin 65:87PubMedPubMedCentralGoogle Scholar
  3. 3.
    Cambier S, Sylvester RJ, Collette L et al (2016) EORTC nomograms and risk groups for predicting recurrence, progression, and disease-specific and overall survival in non-muscle-invasive stage Ta-T1 urothelial bladder cancer patients treated with 1–3 years of maintenance Bacillus Calmette-Guérin. Eur Urol 69:60CrossRefGoogle Scholar
  4. 4.
    Sylvester RJ, van der Meijden AP, Oosterlinck W et al (2006) Predicting recurrence and progression in individual patients with stage Ta T1 bladder cancer using EORTC risk tables: a combined analysis of 2596 patients from seven EORTC trials. Eur Urol 49:465CrossRefGoogle Scholar
  5. 5.
    Soukup V, Duskova J, Pesl M et al (2014) The prognostic value of T1 bladder cancer substaging: a single institution retrospective study. Urol Int 92:150CrossRefGoogle Scholar
  6. 6.
    Shen Z, Xie L, Chen T et al (2016) Risk Factors predictive of recurrence and progression for patients who suffered initial recurrence after transurethral resection of stage pT1 bladder tumor in Chinese population: a retrospective study. Med (Baltim) 95:e2625CrossRefGoogle Scholar
  7. 7.
    Divrik RT, Sahin AF, Yildirim U et al (2010) Impact of routine second transurethral resection on the long-term outcome of patients with newly diagnosed pT1 urothelial carcinoma with respect to recurrence, progression rate, and disease-specific survival: a prospective randomised clinical trial. Eur Urol 58:185CrossRefGoogle Scholar
  8. 8.
    Divrik RT, Yildirim U, Zorlu F et al (2006) The effect of repeat transurethral resection on recurrence and progression rates in patients with T1 tumors of the bladder who received intravesical mitomycin: a prospective, randomized clinical trial. J Urol 175:1641CrossRefGoogle Scholar
  9. 9.
    Eble JN, Sauter G, Epstein JI et al (2004) World Health Organization classification of tumours. Pathology and genetics of tumours of the urinary system and male genital organs. IARC Press, LyonGoogle Scholar
  10. 10.
    Herr HW (2015) Role of repeat resection in non-muscle-invasive bladder cancer. J Natl Compr Canc Netw 13:1041CrossRefGoogle Scholar
  11. 11.
    Divrik T, Yildirim U, Eroglu A et al (2006) Is a second transurethral resection necessary for newly diagnosed pT1 bladder cancer? J Urol 175:1258CrossRefGoogle Scholar
  12. 12.
    Rigaud J, Karam G, Braud G et al (2002) Value of second endoscopic resection in stage T1 bladder tumors. Prog Urol 12:27PubMedGoogle Scholar
  13. 13.
    Zurkirchen MA, Sulser T, Gaspert A et al (2004) Second transurethral resection of superficial transitional cell carcinoma of the bladder: a must even for experienced urologist. Urol Int 72:99CrossRefGoogle Scholar
  14. 14.
    Vogeli TA, Grimm M-O, Simon X et al (2002) Prospective study to assess repeat transurethral resection in superficial bladder cancer. Urologe A 41:470Google Scholar
  15. 15.
    Schips L, Augustin H, Zigeuner RE et al (2002) Is repeated transurethral resection justified in patients with newly diagnosed superficial bladder cancer? Urology 59:220CrossRefGoogle Scholar
  16. 16.
    Jakse G, Algaba F, Malmstrom PU et al (2004) A second-look TUR in T1 transitional cell carcinoma: why? Eur Urol 45:539Google Scholar
  17. 17.
    Cumberbatch MGK, Foerster B, Catto JWF et al (2018) Repeat transurethral resection in non–muscle-invasive bladder cancer: a systematic review. Eur Urol 73:925CrossRefGoogle Scholar
  18. 18.
    Naselli A, Hurle R, Paparella S et al (2018) Role of restaging transurethral resection for T1 non-muscle invasive bladder cancer: a systematic review and meta-analysis. Eur Urol Focus 4:558CrossRefGoogle Scholar
  19. 19.
    Gontero P, Sylvester R, Pisano F et al (2016) The impact of re-transurethral resection on clinical outcomes in a large multicentre cohort of patients with T1 high-grade/Grade 3 bladder cancer treated with bacille Calmette-Guérin. BJU Int 118:44CrossRefGoogle Scholar
  20. 20.
    Audenet F, Retinger C, Chien C et al (2017) Is restaging transurethral resection necessary in patients with non-muscle invasive bladder cancer and limited lamina propria invasion? Urol Oncol Semin Orig Investig 35:603Google Scholar
  21. 21.
    Gendy R, Delprado W, Brenner P et al (2016) Repeat transurethral resection for non-muscle-invasive bladder cancer: a contemporary series. BJU Int 117:54CrossRefGoogle Scholar
  22. 22.
    Sfakianos JP, Kim PH, Hakimi AA et al (2014) The effect of restaging transurethral resection on recurrence and progression rates in patients with nonmuscle invasive bladder cancer treated with intravesical bacillus Calmette-Guérin. J Urol 191:341CrossRefGoogle Scholar
  23. 23.
    Kim W, Song C, Park S et al (2012) Value of immediate second resection of the tumor bed to improve the effectiveness of transurethral resection of bladder tumor. J Endourol 26:1059CrossRefGoogle Scholar
  24. 24.
    Mack D, Höltl W, Bassi P et al (2001) The ablative effect of quarter dose bacillus Calmette-Guerin on a papillary marker lesion of the bladder. J Urol 165:401CrossRefGoogle Scholar
  25. 25.
    Hashine K, Ide T, Nakashima T et al (2016) Results of second transurethral resection for high-grade T1 bladder cancer. Urol Ann 8:10CrossRefGoogle Scholar
  26. 26.
    Iida K, Naiki T, Kawai N et al (2016) Bacillus Calmette-Guerin therapy after the second transurethral resection significantly decreases recurrence in patients with new onset high-grade T1 bladder cancer. BMC Urol 16:1CrossRefGoogle Scholar
  27. 27.
    Herr HW (2005) Restaging transurethral resection of high risk superficial bladder cancer improves the initial response to bacillus Calmette-Guerin therapy. J Urol 174:2134CrossRefGoogle Scholar
  28. 28.
    Angulo JC, Palou J, García-Tello A et al (2014) Second transurethral resection and prognosis of high-grade non-muscle invasive bladder cancer in patients not receiving bacillus Calmette-Guérin. Actas Urol Esp 38:164CrossRefGoogle Scholar
  29. 29.
    Mowatt G, N’Dow J, Vale L et al (2011) Photodynamic diagnosis of bladder cancer compared with white light cystoscopy: systematic review and meta-analysis. Int J Technol Assess Health Care 27:3CrossRefGoogle Scholar
  30. 30.
    Burger M, Grossman HB, Droller M et al (2013) Photodynamic diagnosis of non-muscle-invasive bladder cancer with hexaminolevulinate cystoscopy: a meta-analysis of detection and recurrence based on raw data. Eur Urol 64:846CrossRefGoogle Scholar

Copyright information

© Japan Society of Clinical Oncology 2019

Authors and Affiliations

  1. 1.Baskent University Zubeyde Hanim HospitalIzmirTurkey
  2. 2.Urla State HospitalIzmirTurkey
  3. 3.Tepecik Training and Research HospitalIzmirTurkey
  4. 4.Ege Sehir HospitalIzmirTurkey

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