Re: Value of Immediate Second Resection of the Tumor Bed to Improve the Effectiveness of Transurethral Resection of Bladder Tumor

Dear Editor:

The authors deserve appreciation for presenting the new concept of immediate second resection in patients with bladder tumor. Certain points need further clarification, however.

The authors' selection criteria for transurethral resection of bladder tumor (TURBT) were large (>2 cm), multiple, recurrent, and broad-based tumors. In the Results section, the authors mentioned the size of tumor as either <3 cm or ≥3 cm but have not given the size range of the tumors. In the group of tumors with sizes ≥3 cm, some tumors could have been really large. In large tumors, complete TURBT is sometimes not possible and also not indicated if radical cystectomy is planned. The intention here is to document muscle invasion and that can be done with deep resection from only one edge of the tumor.

Radical cystectomy is an established treatment modality for muscle-invasive bladder cancer. ¹ In this study, only 8 patients in the immediate resection group and 11 patients in the nonimmediate resection group underwent radical cystectomy (although there were a total of 12 patients with T₂ in each group). The authors have not discussed how they treated the remaining patients with T₂ disease in each group.

The authors mentioned that after radical cystectomy, in the immediate second resection group of 12 patients, 1 (25%) patient showed upstaging and 4 (33.3%) patients showed downstaging while in the nonsecond resection group, of the 13 patients, 2 (100%) and 1 (9.1%) patients had upstaging and downstaging, respectively. The authors did not clarify that these are either pathologic or clinical understaging/upstaging, and in the immediate second resection group, 4 patients of 8 had downstaging, which comes out to be 50% instead of 33.3%.

In various studies, ^{2 –4} clinical understaging (pathologic upstaging) and upstaging (pathologic understaging) of the tumors is reported in 40% to 49% and 22% to 27% of those undergoing radical cystectomy. If the authors' data represent pathologic under/overstaging, it indicates that immediate second resection will lead to more pathologic understaging than conventional TURBT, which might further increase the possibility of overtreatment in superficial bladder cancers. This point should also be discussed in the limitations of the study.

In the Results section, the authors mention that of the 126 patients, 25 underwent cystectomy while 97 patients were followed up. What happened to the remaining four patients?