Jager et al. address the very important issue of a delay in radical cystectomy in carcinoma not invading bladder muscle that results in an inferior outcome. In a previous study, they have shown that such a delay leads to an increased risk of lymph node metastasis and upstaging at the time of radical cystectomy . The authors have been successful in stating the limit to the number of transurethral resection of bladder tumours (TURBTs) that should be performed (i.e. four according to them) and also that the time factor (less than 12 months from first TURBT) is very crucial.
The important point here is ‘when to call it a day?’ for conventional treatment (TURBT ± intravesical therapy) in these high-risk carcinoma not invading bladder muscle. Currently, clear guidelines for this are not available. Tumour characteristics, the presence of carcinoma in situ, multicentricity, a poor response to intravesical therapy and residual tumour at restaging TURBT are perhaps strong indicators for early cystectomy. Biomarkers have not been a great help, although, in the future, they may be able to differentiate between ‘pussy cats and tigers’ in bladder cancer.
Rather than the ‘number’ of TURBTs, the ‘quality’ of the first TURBT may be the deciding factor. In my opinion, the battle of bladder cancer is won or lost on its first assessment. If the first assessment is wrong then the delay for cystectomy is inevitable and the outcome is going to be poor. There is ample of evidence for upstaging in the restaging TURBT in the range 15–53%. Therefore, the quality of the first TURBT has to be very good. There is plenty of evidence that the quality of cystectomy has a direct influence on the overall outcome of the disease . It is imperative that we recognize that the quality of TURBT is also very crucial and comprises the deciding factor with respect to the shape and outcome of further treatment. The issue of quality control in TURBT has been highlighted by Herr and Donat .
There is also an issue of interobserver variability in the histopathological assessment (in the range 30–40%) and, to make the treatment decision, the histopathology report has to be absolutely correct. A dedicated uro-oncopathologist may provide the answer in this case. A high quality TURBT is crucial for providing a good specimen for the histopathologist.
Therefore, it is imperative that we adopt the policy of improving the performance of the first TURBT, which is diagnostic as well as therapeutic in all respects. No doubt the conclusions of Jager et al. are useful, although it is the quality of TURBT rather than number of TURBTs that should remain as the main concern.