Systematic Review and Individual Patient Data Meta-analysis of Randomized Trials Comparing a Single Immediate Instillation of Chemotherapy After Transurethral Resection with Transurethral Resection Alone in Patients with Stage pTa–pT1 Urothelial Carcinoma of the Bladder: Which Patients Benefit from the Instillation?

Published on Feb 1, 2016in European Urology17.947
· DOI :10.1016/J.EURURO.2015.05.050
Richard Sylvester96
Estimated H-index: 96
(European Organisation for Research and Treatment of Cancer),
Willem Oosterlinck31
Estimated H-index: 31
(Ghent University Hospital)
+ 13 AuthorsMarek Babjuk25
Estimated H-index: 25
(Charles University in Prague)
Abstract Context The European Association of Urology non–muscle-invasive bladder cancer (NMIBC) guidelines recommend that all low- and intermediate-risk patients receive a single immediate instillation of chemotherapy after transurethral resection of the bladder (TURB), but its use remains controversial. Objective To identify which NMIBC patients benefit from a single immediate instillation. Evidence acquisition A systematic review and individual patient data (IPD) meta-analysis of randomized trials comparing the efficacy of a single instillation after TURB with TURB alone in NMIBC patients was carried out. Evidence synthesis A total of 13 eligible studies were identified. IPD were obtained for 11 studies randomizing 2278 eligible patients, 1161 to TURB and 1117 to a single instillation of epirubicin, mitomycin C, pirarubicin, or thiotepa. A total of 1128 recurrences, 108 progressions, and 460 deaths (59 due to bladder cancer [BCa]) occurred. A single instillation reduced the risk of recurrence by 35% (hazard ratio [HR]: 0.65; 95% confidence interval [CI], 0.58–0.74; p p =0.015; 5-yr death rates 12.0% vs 11.2%), with the difference appearing in patients with an EORTC recurrence score ≥5. Conclusions A single immediate instillation reduced the risk of recurrence, except in patients with a prior recurrence rate of more than one recurrence per year or an EORTC recurrence score ≥5. It does not prolong either time to progression or death from BCa. The instillation may be associated with an increase in the risk of death in patients at high risk of recurrence in whom the instillation is not effective or recommended. Patient summary A single instillation of chemotherapy immediately after resection reduces the risk of recurrence in non–muscle-invasive bladder cancer; however, it should not be given to patients at high risk of recurrence due to its lack of efficacy in this subgroup.
Figures & Tables
📖 Papers frequently viewed together
1,928 Citations
1,490 Citations
602 Citations
#1Marko Babjuk (Charles University in Prague)H-Index: 31
#2Andreas BöhleH-Index: 52
Last. Richard Zigeuner (Medical University of Graz)H-Index: 72
view all 15 authors...
Abstract Context The European Association of Urology (EAU) panel on Non–muscle-invasive Bladder Cancer (NMIBC) released an updated version of the guidelines on Non–muscle-invasive Bladder Cancer. Objective To present the 2016 EAU guidelines on NMIBC. Evidence acquisition A broad and comprehensive scoping exercise covering all areas of the NMIBC guidelines published between April 1, 2014, and May 31, 2015, was performed. Databases covered by the search included Medline, Embase, and the Cochrane L...
1,490 CitationsSource
#1Emad F. Sabir (Sahlgrenska University Hospital)H-Index: 2
#2Sten Holmäng (Sahlgrenska University Hospital)H-Index: 28
AbstractIntroduction: Low grade bladder cancer is common but stage progression is rare. It is possible to treat bladder tumors with the patient under local anesthesia. However, to our knowledge there are no reports of whether only a few or most TaG1 cancers can be treated in the office using local anesthesia.Methods: All 143 patients newly diagnosed with TaG1 bladder cancer between 2008 and 2010 in a large urology unit were retrospectively included in analysis and followed until 2013. In the off...
5 CitationsSource
#1Evi ComplojH-Index: 22
#2Christopher Dechet (UofU: University of Utah)H-Index: 17
Last. Armin PychaH-Index: 38
view all 10 authors...
Objectives Bladder perforation is the second most common complication during transurethral resection of bladder tumours. It is unknown whether perforation affects the natural history of the tumour through cell seeding. The aim of this study was to study the impact of perforation on the oncologic outcomes of bladder carcinoma.
18 CitationsSource
#1Mamoun Elmamoun (The Royal Marsden NHS Foundation Trust)H-Index: 3
#2Tim Christmas (The Royal Marsden NHS Foundation Trust)H-Index: 7
Last. C.R.J. Woodhouse (The Royal Marsden NHS Foundation Trust)H-Index: 17
view all 3 authors...
Objectives To identify a cohort of patients under our care who have had significant and in some cases irreparable damage to their bladders after Mitomycin C (MMC) instillation. To highlight the importance of avoidance and recognition of bladder perforations during transurethral resection of bladder tumour (TURBT) and explore the issue of consent regarding MMC given the serious complications that may occur after its instillation. Patients and Methods Patients referred to our tertiary centre for a...
30 CitationsSource
#1J. Palou-Redorta (Autonomous University of Barcelona)H-Index: 9
#2Morgan RouprêtH-Index: 74
Last. Brent Schwartz (Allergan)H-Index: 2
view all 6 authors...
Purpose The aim of this study was to assess the use of immediate postoperative instillation of intravesical chemotherapy (IPOIC) after transurethral resection of bladder tumour (TURBT) of nonmuscle invasive bladder cancer (NMIBC) in Europe.
28 CitationsSource
#1Marko Babjuk (Charles University in Prague)H-Index: 31
#2Maximilian BurgerH-Index: 53
Last. Morgan Rouprêt (University of Paris)H-Index: 74
view all 11 authors...
Abstract Context The first European Association of Urology (EAU) guidelines on bladder cancer were published in 2002 [1]. Since then, the guidelines have been continuously updated. Objective To present the 2013 EAU guidelines on non–muscle-invasive bladder cancer (NMIBC). Evidence acquisition Literature published between 2010 and 2012 on the diagnosis and treatment of NMIBC was systematically reviewed. Previous guidelines were updated, and the levels of evidence and grades of recommendation were...
881 CitationsSource
#1Nathan Perlis (U of T: University of Toronto)H-Index: 8
#2Alexandre R. Zlotta (U of T: University of Toronto)H-Index: 44
Last. Girish S. Kulkarni (U of T: University of Toronto)H-Index: 34
view all 6 authors...
Abstract Context Non–muscle-invasive bladder cancer (NMIBC) commonly recurs, requiring invasive and costly transurethral resection of bladder tumor (TURBT). A meta-analysis of seven trials published in 2004 demonstrated that intravesical chemotherapy (IVC) following TURBT reduces recurrences. Despite European Association of Urology endorsement, adoption of this practice has been modest. Objective To investigate whether immediate postoperative IVC prolongs the recurrence-free interval (RFI) and e...
100 CitationsSource
#1Michael R. Abern (Duke University)H-Index: 19
#2Richmond Owusu (Duke University)H-Index: 8
Last. Brant A. Inman (Duke University)H-Index: 39
view all 5 authors...
: The role for a single dose of intravesical chemotherapy (IVC) after transurethral resection (TUR) remains unclear in patients with non-muscle-invasive bladder cancer (NMIBC). Several recent randomized clinical trials (RCTs) have evaluated its effect on recurrence, prompting this systematic review of RCTs comparing a single immediate postoperative dose of IVC versus placebo within 24 hours of TUR of NMIBC, and this meta-analysis using a random-effects model to predict the pooled relative risk (...
60 CitationsSource
#1Frank BurksH-Index: 10
#2Alice B. Liu (UM: University of Michigan)H-Index: 1
Last. David C. Miller (UM: University of Michigan)H-Index: 54
view all 11 authors...
Purpose: Despite its established efficacy in reducing recurrence rates for patients with urothelial carcinoma, immediate intravesical chemotherapy is reportedly used infrequently. Accordingly, the Urological Surgery Quality Collaborative implemented a project aimed at understanding and improving the use of immediate intravesical chemotherapy.Materials and Methods: Surgeons in 5 Urological Surgery Quality Collaborative practices prospectively collected clinical and baseline intravesical chemother...
36 CitationsSource
#1Cheryl T. Lee (UM: University of Michigan)H-Index: 42
#2Daniel A. Barocas (Vandy: Vanderbilt University)H-Index: 50
Last. Thomas J. BramleyH-Index: 2
view all 7 authors...
Purpose: Perioperative intravesical chemotherapy following transurethral resection of bladder tumor has been underused despite level 1 evidence supporting its performance. The primary objective of this study was to estimate the economic and humanistic consequences associated with preventable recurrences in patients initially diagnosed with nonmuscle invasive bladder cancer.Materials and Methods: Using population based estimates of nonmuscle invasive bladder cancer incidence, a 2-year model was d...
27 CitationsSource
Cited By177
Background: The incidence of intravesical recurrence (IVR) following radical nephroureterectomy (RNU) is reported in up to 50% of patients with upper tract urothelial carcinoma (UTUC). It was suggested that preoperative diagnostic ureteroscopy (URS) could increase the IVR rate after RNU. However, the available data are often conflicting. Thus, in this systematic review and meta-analysis we sought to synthesize available data for the impact of pre-RNU URS for UTUC on IVR and other oncological out...
#1Marko Babjuk (Charles University in Prague)H-Index: 31
#2Maximilian Burger (University of Regensburg)H-Index: 53
Last. A. Hugh MostafidH-Index: 7
view all 17 authors...
Abstract null null Context null The European Association of Urology (EAU) has released an updated version of the guidelines on non–muscle-invasive bladder cancer (NMIBC). null null null Objective null To present the 2021 EAU guidelines on NMIBC. null null null Evidence acquisition null A broad and comprehensive scoping exercise covering all areas of the NMIBC guidelines since the 2020 version was performed. Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries. Pre...
2 CitationsSource
#1Rajan Veeratterapillay (Freeman Hospital)H-Index: 14
#2Paul Gravestock (Freeman Hospital)
Last. Rakesh Heer (Freeman Hospital)H-Index: 18
view all 8 authors...
Abstract null null Context null White light (WL) cystoscopy and transurethral resection of bladder tumour (TURBT) comprise the current gold standard technique for detecting and grading bladder cancer. However, with WL cystoscopy, recurrence following initial TURBT is high, and identification of smaller tumours and carcinoma in situ is poor. Photodynamic diagnosis (PDD) has been developed to improve the detection of bladder. null null null Objective null To assess the effect of PDD-guided TURBT c...
#1Paul Gravestock (Freeman Hospital)
#2Nicholas Coulthard (Freeman Hospital)
Last. Rakesh Heer (Freeman Hospital)H-Index: 18
view all 4 authors...
To assess the effect of narrow band imaging-guided transurethral resection of bladder tumor compared with white light on recurrence rates in non-muscle-invasive bladder cancer. A systematic review of the literature from inception to November 2020 using Medline, EMBASE and CENTRAL was undertaken. Randomized controlled trials comparing transurethral resection of bladder tumor undertaken with narrow band imaging with those undertaken with white light that reported recurrence rates of at least 12 mo...
1 CitationsSource
Resume null null Les recommandations de l’AFU pour les TVNIM de faible risque preconisent une cystoscopie au 3eme et 12 mois puis annuelle pendant 5 ans. Cependant, les cystoscopies iteratives pendant 5 ans sont-elles indispensables ? Existe-t-il un risque de recidive ou de progression au-dela d'un an ? La cystoscopie est vecue non seulement comme agressive mais aussi provoque parfois un sentiment d'abandon du suivi par certains patients. La cystoscopie provoque : inconfort, douleur, infection, ...
#1Purushottam Parajuli (TU: Tribhuvan University)H-Index: 1
#2BR Luitel (TU: Tribhuvan University)H-Index: 2
Last. Prem Raj Sigdel (TU: Tribhuvan University)H-Index: 1
view all 12 authors...
PURPOSE To define the clinical and pathological patterns of urinary bladder carcinoma from the University Hospital of Nepal. METHODS This is a retrospective analytical study. Patients with bladder mass who underwent surgery over 1 year and who had data record were included in the study. Demographic profile, type of surgery, findings on clinical examination, cystoscopy findings, histopathological report, tumor stage, and post-surgery adjuvant therapy were analyzed. RESULTS Out of 86 patients who ...
#1Jennifer DunsmoreH-Index: 1
#2Eilidh Duncan (Aberd.: University of Aberdeen)H-Index: 17
Last. Steven MacLennan (Aberd.: University of Aberdeen)H-Index: 22
view all 11 authors...
Objective To understand the barriers and facilitators to single instillation of intravesical chemotherapy (SI-IVC) use following resection of non-muscle-invasive bladder cancer (NMIBC) in Scotland and England using a behavioural theory-informed approach. Materials and methods In a cross-sectional descriptive study of practices at seven hospitals, we investigated care pathways, policies, and interviewed 30 urology staff responsible for SI-IVC. We used the Theoretical Domains Framework (TDF) to or...
1 CitationsSource
#2Jay D. Raman (Penn State Milton S. Hershey Medical Center)H-Index: 68
Last. Fabian Yaber (National University of Rosario)
view all 3 authors...
Kidney-sparing procedures for upper tract urothelial carcinoma (UTUC) have evolved from imperative to elective indications for management of low-risk disease. Ureterorenoscopy is the most common procedure for the diagnosis, treatment, and surveillance of UTUC. A notable consideration following ureterorenoscopy is the higher risk of downstream bladder seeding. Here we review the importance of and scientific evidence for chemoprophylaxis after ureterorenoscopy. PATIENT SUMMARY: For patients with l...
1 CitationsSource
#1Michael Wanis (Princess Royal Hospital)
Last. Tim Larner (Princess Royal Hospital)
view all 3 authors...
#1Michael Ahdoot (Cedars-Sinai Medical Center)
#2Dan Theodorescu (Cedars-Sinai Medical Center)H-Index: 5
Introduction null Bladder cancer remains a prevalent and often lethal cancer. Fortunately, recent clinical trials using immunotherapeutics demonstrate promise to improve treatment outcomes. Several of these immunotherapies have already established their value in the metastatic space and likely will soon have indications in the non-metastatic space. null Areas covered null This review will cover immunotherapies ranging for well-studied BCG administration to more novel medications such as PD-L1/PD...