Response to Editorial Comment: “Primary Complete Transurethral Resection of Bladder Tumor Using Photodynamic Diagnosis for High-risk Nonmuscle Invasive Bladder Cancer: Is a Restaging Photodynamic Transurethral Resection Really Necessary?” by Tadrist et al.

We thank Bogdan Geavlete for his comments and really appreciate his perspective on our recent article. ¹ The goal of transurethral bladder tumor resection (TURBT) in TaT1 bladder cancer (BC) is to achieve the optimal diagnosis and completely remove all visible lesions. It is a crucial procedure in the management of BC. B. Geavlete point out that fluorescence-guided biopsy and resection are more sensitive than conventional procedures for the detection of malignant tumors, particularly for carcinoma in situ and papillary tumors. In this perspective, we aimed to evaluate if restaging TURBT (reTUR) is still necessary after initial complete TURBT with photodynamic diagnosis (PDD) in high-risk nonmuscle invasive bladder cancer (NMIBC). We found a 54.2% risk of disease persistence and a 4.5% risk of understaging T1 tumors.

Thus, we support that reTUR is still required despite using PDD at initial TURBT. Our findings are not intended to discredit the added value of PDD during the first TURBT. On the contrary, they underline that high-risk NMIBC is a particularly aggressive disease and, despite the use of alternative diagnostic methods, we need to remain cautious and to question systematically the “complete” character of the first TURBT, especially when the tumors are large or multifocal. ²

Detrusor muscle absence in the first, apparently complete TURBT specimen appears to be a surrogate marker of resection quality by independently predicting early bladder recurrence. ³ In our series, detrusor muscle absence rate was 24.8% and compared favorably with previous series, but it is undeniable that it contributes to the rate of residual tumor observed. Similar to B. Geavlete, we believe that en bloc resection, which was gradually adopted in our center during the study period, can provide high-quality resected samples with the presence of detrusor muscle in 100% of cases as previously reported, ⁴ and may thus help to reduce the rate of residual tumors.

To conclude, many of our current guidelines for NMIBC are based on studies that did not include recent techniques that could improve the quality of our resections and patient prognosis, such as PDD, continuous saline bladder irrigation, ⁵ reTUR using PDD, and the Vesical Imaging-Reporting and Data system score. This reflects the current enthusiasm of our community for this disease, at a time when cystectomy is unfortunately still an option for high-risk NMIBC patients.