Bipolar energy for transurethral resection of non muscle invasive bladder cancer - Histopathological and predicting disease recurrence
Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
BIPOLAR ENERGY FOR TRANSURETHRAL RESECTION OF NON
MUSCLE INVASIVE BLADDER CANCER - HISTOPATHOLOGICAL
AND PREDICTING DISEASE RECURRENCE
Huynh Thai Son1,2, Tran Van Hinh1, Le Anh Tuan1
Pham Quang Vinh1, Nguyen Phu Viet1
SUMMARY
Objectives: To evaluate the histopathology and predict recurrence in bipolar energy for
transurethral resection of bladder tumors (TURBT). Subjects and methods: This was a
prospective and descriptive study that was done between October 2015 and November 2018.
Sixty-two patients of non-muscle invasive bladder cancer underwent bipolar TURBT using saline
irrigation solutions. Results: Male 80.7%, female 19.3%. Average age 61.9 15.1. The history
of bladder tumor surgery: Tumor recurrence 29.0%. Tumor number: single 40.3%; 2 - 7 tumors
48.4%; > 8 tumors 11.3%. Size of tumor: 88.7% ≤ 3 cm, 11.3% > 3 cm. Risk group stratification:
low-risk tumors 20.9%, intermediate-risk tumors 69.3%, high-risk tumors 9.7%. Grading: G1:
80.65%, G2: 17.74%, G3: 1.61%. Staging: Tis 1.61%, Ta 91.94%, T1 6.45%. Conclusion:
Bipolar energy for TURBT with one year follow-up has a recurrence rate of 12.9% and the
complete response was 87.1%. The recurrence rate increases according to risk factors like the
number of tumors, the tumor size, the pre-operation status which is primary or recurrent tumors,
staging and grading of tumors.
* Keywords: Bipolar; Bladder tumor; Saline; Transurethral resection.
INTRODUCTION
there were about 549.400 patients with
new bladder cancer in the world. The
number of deaths due to bladder cancer
was 199.900 people [5].
Bladder cancer, most commonly
epithelium carcinoma, is a common
malignant tumor in the urinary tract. At the
time of diagnosis, approximately 75% are
Therefore, the use of histopathological
non-muscle invasive bladder cancer. After variables such as the number of tumors,
transurethral resection of non- muscle
invasive bladder tumors, the recurrence
disease is 50 - 70%, with 45% progression,
more invasive than before [9].
the tumor size, staging and grading of
tumors. To predict the risk of recurrence
has an important significance. As progression
has a poor prognosis, it is important to
classify patients for further treatment
planning so that the patient can benefit from
early cystectomy or can be best managed
by bladder preservation treatment [7].
The summary of GLOBOCAN-2019
Cancer Journal, bladder cancer has the
8th highest incidence rate in the world and
the 11th highest mortality rate. In 2018,
1Urology Department, Military Hospital 103, Vietnam Medical Military University
2Surgery Department, Military Hospital 17
Corresponding author: Huynh Thai Son ([email protected])
Date received: 20/4/2021
Date accepted: 08/5/2021
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
SUBJECTS AND METHODS
* Research parameters: Age, gender,
history of bladder tumor: primary or
recurrence tumor, tumor number, tumor
size, post-operative pathology: grading,
staging; risk group stratification; recurrence
rate; probability of recurrence categories.
1. Subjects
62 patients were diagnosed with
bladder cancer and its post-operative
pathological results were non-invasive
muscle bladder cancer (pTis, pTa, pT1).
These patients were treated with bipolar
TURBT, from October 2015 to November
2018 at the Urological Department,
Military Hospital 103.
RESULTS
1. Characteristics of patients
- Gender: Male 80.7% (50 cases),
female 19.3% (12 cases).
* Selection criteria:
+ The results of post-operative pathology
were pTis, pTa, pT1.
- Average age: 61.9 15.1 years old,
the youngest 26 years, the oldest 91 years.
+ Patients suffered from primary bladder
cancer or recurrence.
2. Characteristics of tumor
* The status of tumor:
+ Patients were pumped Doxorubicin
into the bladder after surgery according to
the correct regimen.
- Prior recurrence status: Recurrence
tumor 29.0% (18/62).
- The rate of recurrence related to prior
recurrence status:
+ Patients had enough records to conduct
a research analysis.
+ The pre-operation status of tumor
being primary: The rate of post-operation
recurrence 6.8%
2. Methods
* Research design: A prospective and
descriptive study.
+ The pre-operation status of tumor
recurrence: The rate of post-operation
recurrence 27.8%. (OR = 5.25; 95%CI:
1.103 - 25.0501, p = 0,039).
* Research process:
- The patient was diagnosed with
cystoscopy and a biopsy before surgery.
- Indication: tumor size ≤ 5 cm, tumor
number < 25, unlimited tumor position.
* Number of tumors:
Table 1: Number of tumor (n = 62).
- Surgical technique: depending on the
tumor base and tumor location. Small
tumors can be resected en bloc; larger
tumors should be resected separately
infraction. Take the tumor base containing
muscularis propria and its margin to make
the pathology.
Number of
tumors
Number of
patients
%
1 tumor
25
30
7
40.3
48.4
2-7 tumors
≥ 8 tumors
Total
11.3
- Adjuvant intravesical chemotherapy:
Instillation of doxorubicin into the bladder in
the first week post-operative, one dose/week
and treated with 8-week maintenance.
62
100.0
* The rate of recurrence related to the
number of tumors:
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
Table 2: The rate of recurrence related
* The recurrence rate related the
grading level:
to the number of tumors.
- Grade 1: Recurrence rate 8% (4/50),
Grade 2: 27.3% (3/11), Grade 3: 100%
(1/1) (p = 0.0073).
Tumor
Recurrence
(n, %)
p
number
1
1 (4.0)
3 (10.0)
4 (57.1)
* Risk group stratification: According
to the European association of urology
guidelines (EAU)-2019 [4]:
2 - 7
> 8
0,0008
- Low-risk tumors group: 21.0% (13/62);
- Intermediate-risk tumors group: 69.3%
(43/62);
* Size of tumor:
- Tumor ≤ 3 cm: 88.7% (55/62); 3 cm:
11.3% (7/62).
- High-risk tumors group: 9.7% (6/62).
* The recurrence rate related to the
risk group:
Table 3: The rate of recurrence related
to the tumor size .
- Low-risk tumors group: Recurrence
rate 0.0%;
Tumor size
≤ 3 cm
n (%)
p
- Intermediate-risk tumors group:
Recurrence rate 13.9%;
7 (12.7)
1 (14.3)
- High-risk tumors group: Recurrence
rate 33.3% (p = 0.12).
> 3 cm
0.63
The biggest tumors were chosen
*
The probability of recurrence
categories: According to the European
organization for the research and
treatment of cancer scoring system [4]:
* Post-operative pathology:
- Staging: Ta 91.9% (57/62), T1 6.5%
(4/62), Tis 1.6% (1/62);
- Very low-probability of recurrence
group: 19.4% (12/62) ;
- Grading: G1 80.7% (50/62), G2 17.7%
(11/62), G3 1.6% (1/62).
- Low-probability of recurrence group:
41.9% (26/62);
* The recurrence rate related to the
extent of invasive tumor (stage):
- Intermediate-probability of recurrence
group: 32.3% (20/62);
Table 4: The recurrence rate related
the extent of invasive tumor.
- High-probability of recurrence group:
6.4% (4/62).
Stage of
tumor
Status of
p
* Treatment result: Good 96.8%
recurrence (n, %)
(60 cases), moderate 3.2% (2 cases).
Tis
Ta
T1
0 (0.0)
6 (10.5)
2 (50.0)
* Recurrence (one year follow up):12,9%
(8/62).
* Recurrence rate according to the
probability of recurrence categories:
0.06
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
Table 5: Recurrence rate according to probability of recurrence categories.
Probability of recurrence categories
Recurrence
p
Very low
Low
Intermediate
High
diseases
n
%
n
2
%
7.7
n
4
%
n
2
2
4
%
Yes
0
0.0
20.0
80.0
100.0
50.0
50.0
0.042
62
No
12
12
100.0
100.0
24
26
92.3
100.0
16
20
Total
100.0
- Very low-probability of recurrence: 0.0% (0/12);
- Low-probability of recurrence: 7.7% (2/26);
- Intermediate - probability of recurrence: 20.0% (4/20);
- High-probability of recurrence: 50.0% (2/4).
DISCUSSION
respectively (OR: 5.2; 95%CI = 1.103 -
25.0501, p = 0.039). The results showed
that if the pre-operation status has
recurrent tumors, the recurrence rate after
surgery increases up to 5.2 times.
According to research by Ha Manh
Cuong, Do Truong Thanh et al (2019):
The primary tumor had a recurrence rate
of 7.54%, the recurrent tumor had a
recurrence rate of 31.25% (p < 0.05) [1].
The number of tumors is a risk factor
for the prognosis of recurrence, patients
with multiple tumors often have a higher
recurrence rate than single tumors. In this
study, patients with 1 tumor, from 2 - 7
tumors and 8 tumors or more had a
recurrence rate of 4.0%; 10.0% and 57.1%,
respectively (p = 0.0008). According to
the study by Ha Manh Cuong, Do Truong
Thanh et al. (2019): The reccurrence rate
with 1 tumor, from 2 - 7 tumors and
8 tumors or more was 5.55%; 11.11% and
66.66%, respectively (p < 0.01), the
follow-up time was 18 months [1]. The
study by Wang L. et al (2014) had 1 tumor
with the recurrence rate of 24.3%,
multiple tumors with 44.7% recurrence
(p < 0.0001) [10].
When the tumor is larger than 3cm, the
recurrence rate will be higher and the
prognosis will be worse. One year follow-
up results in this study indicate that when
a tumor was ≤ 3 cm and > 3 cm, the
recurrence rate was 12.7% and 14.3%,
respectively (p = 0.63). The study by
Lopez BA et al. indicates that when the
tumor size was 5 cm, the probability of
recurrence was 100% (p < 0.0034),
with an average follow-up time of 63.82
months [8]. The study by Wang L. et al
(2014) shows that if tumor was ≤ 3 cm
and > 3 cm, the recurrence rate was 30.8%
and 44.8%, respectively (p = 0.006), the
If the pre-operation status is recurrent
tumors, the rate of post-operation
recurrence is often higher. In this study,
as for the pre-operation status related to
the primary tumor and recurrent tumor,
the recurrence rate was 6.8% and 27.8%, average follow-up time of 27 months [10].
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
This study showed that the higher the gradually according to the level of risk.
grading level, the higher the recurrence
rate; at grade 1, grade 2 and grade 3, the
recurrence rate was 8.0%, 27.3% and
100%, respectively (p = 0.0073). Wang
L.'s study also showed that the higher the
pathology of the tumor, the higher the
recurrence rate (p < 0.0001) [10].
In the group of low-risk patients, the
intermediate-risk group and the high-risk
group, the recurrence rate was 5.26%;
9.75% and 44.44%, respectively [1].
Based on the classification by Nguyen
Ky [2], we had the following treatment
results: Good 96.8% (60 cases), moderate
3.2% (2 cases).
The extent of invasive tumors has a
very important prognostic value. The
higher the staging level, the higher the
recurrence rate. In the stage Ta tumors,
the recurrence rate of tumors was 10.5%,
and in the stage T1 tumors, the recurrence
rate increased up to 50%, with p = 0.06.
This result was also consistent with the
study by Wang L et al. (2014): In stage Ta
tumor, the rate of recurrence was 31.1%;
in stage T1 tumor, the rate of recurrence
increased to 66.7% (p < 0. 0001) [10].
After 12 months of follow-up, there
were 8 cases of recurrence (12.9%); but
there were no cases of tumor pathology
raising staging and grading level. In one
year follow-up result evaluation: 87.1%
responded well, 12.9% partially responded,
none of the patients did not respond to
treatment. This study also showed that
the recurrence rate increased gradually
according to the probability of recurrence
groups (p = 0.042); the group with a very
low probability of recurrence, the low
group, the intermediate group and the
high group had a recurrence rate of 0%;
7.7%; 20% and 50%, respectively. One
year after surgery, the recurrence rate in
this study is also consistent with the study
results by Abotaleb A. A. (2017) 15.2% [3],
Gupta N. P. (2011) 12.24% [6].
Stratification of patients with bladder
tumors in risk groups is needed for the
purpose of follow-up, prognosis and
adjuvant treatment after surgery. In this
study, stratification is based on EAU-2019
guidelines [4]: The low-risk tumors group
accounted for 21.0%; the intermediate-
risk tumors group was 69.3% and the
high-risk group was 9.7%. We found that
the recurrence rate in this study increased
gradually according to the level of risk.
The higher the risk, the higher the rate of
recurrence. The recurrence rate of low-
risk group, the intermediate-risk group
and the high-risk group was 0.0%; 13.9%
and 33.3%, respectively (p = 0.12).
A recent study by Ha Manh Cuong,
Do Truong Thanh et al. (2019) also
CONCLUSION
Bipolar energy for TURBT with a year
follow-up has a recurrence rate of 12.9%
and the complete response is 87.1%. The
recurrence rate increases according to
risk factors like the number of tumors, the
tumor size, the preoperation status, which
is primary or recurrent tumors, staging
showed that the recurrence rate increased and grading of tumors.
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
GLOBOCAN sources and methods. International
journal of cancer 2019; 144(8):1941-1953.
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