TURBT的质量对NMIBC治疗的影响.docx

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Introduction
Transurethral resection of bladder tumors (TURBT) is one of the most important diagnostic and therapeutic maneuvers in the management of non-muscle invasive bladder cancer (NMIBC). It is currently the gold standard procedure for the diagnosis, staging, and treatment of bladder cancer. TURBT plays a crucial role in the management of NMIBC by providing tissue specimens for histopathological examination, determining the depth of invasion, and removal of the visible tumors.
The quality of TURBT is a critical factor that determines the successful management of NMIBC. An inadequate or incomplete resection of the tumor during TURBT can result in residual tumor tissue, which can compromise the effectiveness of subsequent treatments and lead to higher recurrence rates. This paper aims to examine the impact of TURBT quality on the management of NMIBC.
Quality of TURBT
The quality of TURBT can be defined by many factors, including the completeness of the resection, the depth of the resection, and the quality of the tissue specimens obtained. A complete resection of the primary tumor is paramount for successful management of NMIBC. Inadequate resection or incomplete resection leads to higher recurrence rates, progression, and shorter time to progression.
The European Association of Urology (EAU) guidelines recommend that the resection should extend through the bladder wall muscle layer (muscle-invasive) to a depth of at least 1mm but aim for more than 3mm [1]. The studies reveal tumor cells in the suburothelial tissue irrespective of the tumor stage, and when the resection extends to the deep suburothelial layer (>3mm), reduces the recurrence rates and reduces the risk of progression.
In addition to the completeness of the resection, the quality of the tissue specimens obtained is also important in diagnosing and determining the aggressiveness of the cancer. The specimens should be representative of the tumor and the grade and stage should be accurately defined. The use of cold-cup biopsy or random biopsies is not recommended as they are limited by sampling errors, and do not provide adequate tissue samples for accurate diagnosis and staging.
Importance of TURBT Quality in the Management of NMIBC
Several studies have demonstrated the impact of TURBT quality on the management of NMIBC. A retrospective study of 1664 patients with NMIBC by Herr and colleagues showed that the completeness of the TURBT resection is one of the most important prognostic factors, with complete resection reducing the risk of recurrence [2]. The same study found that patients with incomplete TURBT had a higher risk of progression to muscle-invasive disease.
A systematic review and meta-analysis of 31 studies by Williams and colleagues showed that a complete TURBT resection is associated with a lower risk of recurrence and progression compared to an incomplete resection [3]. The same study found that repeating TURBT in patients with an incomplete first resection decreased the recurrence rates in 29% of patient. Re-TURBT has become a standard followed by a revaluation of the patient a few weeks later, to exclude the presence of missed areas.
TURBT quality also affects the decision-making in the adjuvant treatment of NMIBC. High-grade tumors or muscle-invasive disease after TURBT require aggressive therapy such as prophylactic intravesical chemotherapy or immunotherapy to decrease the recurrence and progression rates. Conversely, lower grade/Ta tumors are less aggressive, and conservative therapy can be used without adjuvant therapies to prevent over-treatment.
Conclusion
In conclusion, the quality of TURBT has a considerable effect on the management of NMIBC. A complete resection with a deeper suburothelial margin reduces the recurrence and progression rates and provides more accurate pathological staging. TURBT quality affects the severity of the cancer, surgical management plan, and adjuvant therapy as well. It is crucial to attain complete TURBT for optimal treatment; the completeness of the resection fulfills one of the fundamental prerequisites of a successful treatment of NMIBC.