© 2009 THE AUTHORS 202 JOURNAL COMPILATION © 2 0 0 9 B J U I N T E R N A T I O N A L | 1 0 5 , 2 0 2 – 2 0 7 | doi:10.1111/j.1464-410X.2009.08694.x 2009 THE AUTHORS. JOURNAL COMPILATION 2009 BJU INTERNATIONAL Urological Oncology RISK FACTORS FOR POSITIVE FINDINGS IN HGT1-TCC AND REPEAT TUR ORSOLA et al. Risk factors for positive findings in patients with high-grade T1 bladder cancer treated with transurethral resection of bladder tumour (TUR) and bacille Calmette-Guérin therapy and the decision for a repeat TUR Anna Orsola, Lluís Cecchini, Carles X. Raventós, Enric Trilla, Jacques Planas, Stefania Landolfi, Inés de Torres and Juan Morote Department of Urology, Hospital Vall d’Hebron, Barcelona, Spain Accepted for publication 30 March 2009 was considered positive. The predictive value of 11 clinical and pathological variables was assessed by chi-squared, Mann–Whitney U and multivariate logistic regression. RESULTS Of the 138 patients (14 women, mean age 69 years), 42% had T1a and 58% T1b TCC. Tumour size and carcinoma in situ (CIS) were significantly associated with positive findings and present in 26% (36/138) of the patients. The postBCG-TUR (T1b cases), was positive in 31% (25/80), including seven infiltrating tumours. On multivariate analysis, again a tumour size of >3 cm (odds ratio, OR, 7.02) and associated CIS (OR 5.4) were significantly related to a positive postBCG-TUR. A secondary finding was that at 20.3 months; patients with T1a TCC, who did not undergo a repeat TUR, did not have increased progression; only 3% (two of 58) had progressed compared with 21% (17/80) of those with T1b/c TCC (P < 0.002). CONCLUSIONS In initial HGT1-TCC, tumour size and CIS were predictive factors of positive findings at 3 months after the initial TUR + BCG therapy. Patients with HGT1-TCC invading the LP (T1b TCC) had a seven times higher risk of a positive repeat TUR if the initial tumour was >3 cm and a five-fold increased risk if associated with CIS. The repeat TUR after BCG therapy allowed confirmation of complete resection and pathological evaluation of the BCG response. Although data are still preliminary, the strategy of performing a repeat TUR only in cases with LP involvement, i.e. T1b TCC, did not increase the risk of progression in cases with T1a TCC. KEYWORDS noninvasive bladder cancer, repeat TUR, BCG response, microstaging, high risk Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To determine factors predictive of positive findings at the 3-month follow-up evaluation (after transurethral resection of bladder tumour [TUR] and bacille Calmette- Guérin [BCG] therapy) in patients with initial high-grade (HG)T1 bladder cancer, and to assess the depth of lamina propria (LP) invasion and effectiveness of BCG therapy. PATIENTS AND METHODS In all, 138 patients with initial HGT1- transitional cell carcinoma (TCC) were prospectively assigned, after TUR + BCG and according to depth of LP invasion, to a postBCG-TUR (T1b) or cystoscopy/cytology (T1a) at 3 months. Any finding at 3 months INTRODUCTION As there is a 23–52% risk of progression in high-grade T1 (HGT1) tumours, it has been suggested that the term superficial bladder cancer should be abandoned [1]. Approaches advocated in these cases include early cystectomy [2] or, in an attempt to preserve the bladder, to use a repeat transurethral resection of bladder tumour (TUR) [3]. Guidelines of the European Association of Urology (EAU) [4], Société Internationale d’Urologie [5] and AUA [6] recommend a repeat TUR to confirm complete tumour resection and to exclude understaging. A repeat TUR seems to identify patients with worse prognosis and may improve outcome [7]. However, probably because the follow-ups were too short, prospective studies have failed to show a positive effect on progression-free survival [8,9]. Additionally, up to one third of patients with HGT1 treated with BCG never have a recurrence of their disease [3]. Moreover, because residual tumour is found in around one third of patients with HGT1 having a repeat TUR [3,8,10], most undergo a second anaesthesia and procedure unnecessarily. Prognostic factors able to identify those HGT1 tumours at higher risk of progression, and hence those that will mostly benefit from a repeat TUR, would therefore be very valuable. Recurrence at first cystoscopy (3 months) [11,12] and BCG response [12,13] are strong predictors of progression. In addition, lamina propria (LP) invasion allows patients at high BJUI BJU INTERNATIONAL