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    Bladder Cancer Treatment (PDQ®): Treatment - Health Professional Information [NCI] - Stage 0 Bladder Cancer Treatment

    continued...

    One retrospective series addressed the value of performing a second TUR within 2 to 6 weeks of the first TUR.[9][Level of evidence: 3iiDiv] A second TUR performed on 38 patients with Tis or Ta disease revealed that nine patients (24%) had lamina propria invasion (T1) and three patients (8%) had muscle invasion (T2).[9]

    Such information may change the definitive management options in these individuals. Patients with extensive multifocal recurrent disease and/or other unfavorable prognostic features require more aggressive forms of treatment.

    Evidence (TUR with fulguration followed by immediate postoperative instillation of intravesical chemotherapy):

    1. A 2004 meta-analysis of seven randomized controlled trials (1,476 subjects with stage Ta or stage T1 bladder cancer) compared TUR alone with TUR followed by a single immediate intravesical instillation of chemotherapy.[7]
      • The relapse rate for TUR alone was 48% and 37% for TUR plus intravesical chemotherapy (OR, 0.61; P < .0001). The risk of recurrence declined for patients with single (OR, 0.61) or multiple (OR, 0.44) tumors, but 65% of those with multiple tumors relapsed despite intravesical chemotherapy.
      • Agents studied included epirubicin, mitomycin C (MMC), thiotepa, and pirarubicin.
    2. A subsequent multicenter randomized controlled trial confirmed the reduction in risk of recurrence. A 404-patient study reported a relapse rate of 51% for epirubicin immediately after TUR and a relapse rate of 63% for placebo immediately after TUR (P = .04). However, only small recurrences were prevented in this study, drawing into question the magnitude of benefit.[10]
    3. Similarly, another multicenter randomized controlled trial confirmed the reduction in risk of recurrence. A 305-patient study randomly assigned subjects to an instillation of epirubicin versus no further treatment after TUR and reported relapse rates of 62% with epirubicin and 77% in the control arm (P = .016).[8]
      • The hazard ratio for recurrence was 0.56 (P = .002) with epirubicin. However, the main benefit was seen in patients at lower risk of relapse. Among patients at intermediate or high risk of relapse, the relapse rates were 81% with epirubicin versus 85% with no further treatment (P = .35).
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