PURPOSE: A re-transurethral resection of the bladder (re-TURB) is a well-established approach in managing non-muscle invasive bladder cancer (NMIBC) for various reasons: repeat-TURB is recommended for a macroscopically incomplete initial resection, restaging-TURB is required if the first resection was macroscopically complete but contained no detrusor muscle (DM) and second-TURB is advised for all completely resected T1-tumors with DM in the resection specimen. This study assessed the long-term outcomes after repeat-, second-, and restaging-TURB in T1-NMIBC patients. METHODS: Individual patient data with tumor characteristics of 1660 primary T1-patients (muscle-invasion at re-TURB omitted) diagnosed from 1990 to 2018 in 17 hospitals were analyzed. Time to recurrence, progression, death due to bladder cancer (BC), and all causes (OS) were visualized with cumulative incidence functions and analyzed by log-rank tests and multivariable Cox-regression models stratified by institution. RESULTS: Median follow-up was 45.3 (IQR 22.7-81.1) months. There were no differences in time to recurrence, progression, or OS between patients undergoing restaging (135 patients), second (644 patients), or repeat-TURB (84 patients), nor between patients who did or who did not undergo second or restaging-TURB. However, patients who underwent repeat-TURB had a shorter time to BC death compared to those who had second- or restaging-TURB (multivariable HR 3.58, P = 0.004). CONCLUSION: Prognosis did not significantly differ between patients who underwent restaging- or second-TURB. However, a worse prognosis in terms of death due to bladder cancer was found in patients who underwent repeat-TURB compared to second-TURB and restaging-TURB, highlighting the importance of separately evaluating different indications for re-TURB.

Department of Surgical Oncology Netherlands Cancer Institute Antoni Van Leeuwenhoek Hospital Plesmanlaan 121 1066 CX Amsterdam The Netherlands

European Association of Urology Guidelines Office Board Arnhem The Netherlands

European Association of Urology Non Muscle Invasive Bladder Cancer Guidelines Panel Arnhem The Netherlands

Health Evidence and Urology Radboud University Medical Center Nijmegen The Netherlands

Laboratory Medicine Program University Health Network Princess Margaret Cancer Center University of Toronto Toronto Canada

Pathology Città della Salute e della Scienza University of Torino School of Medicine Turin Italy

Pathology Comprehensive Cancer Center Medical University Vienna Vienna General Hospital Vienna Austria

Pathology Fundacio Puigvert Universitat Autònoma de Barcelona Barcelona Spain

Pathology Fundación Instituto Valenciano de Oncología Valencia Spain

Pathology General Teaching Hospital and 1st Faculty of Medicine Charles University Praha Prague Czech Republic

Pathology Hospital Universitario Fundación Alcorcón Madrid Spain

Pathology Medical University of Graz Graz Austria

Pathology Pierre et Marie Curie Medical School Pitié Salpétrière Hospital AP HP Sorbonne University Paris France

Pathology Radboud University Medical Center Nijmegen The Netherlands

Pathology Royal Free London NHS Foundation Trust Royal Free Hospital London UK

Pathology Teaching Hospital Motol and 2nd Faculty of Medicine Charles University Praha Prague Czech Republic

Pathology Tenon Hospital AP HP Sorbonne University Paris France

Pathology University of Regensburg Regensburg Germany

Surgical Oncology University Health Network Princess Margaret Cancer Center University of Toronto Toronto Canada

Urology Amsterdam University Medical Centers Vrije Universiteit Amsterdam The Netherlands

Urology Caritas St Josef Medical Center University of Regensburg Regensburg Germany

Urology Città della Salute e della Scienza University of Torino School of Medicine Turin Italy

Urology Comprehensive Cancer Center Medical University Vienna Vienna General Hospital Vienna Austria

Urology Fundacio Puigvert Universitat Autònoma de Barcelona Barcelona Spain

Urology Fundación Instituto Valenciano de Oncología Valencia Spain

Urology General Teaching Hospital and 1st Faculty of Medicine Charles University Praha Prague Czech Republic

Urology Hospital Universitario Fundación Alcorcón Madrid Spain

Urology Medical University of Graz Graz Austria

Urology Pitié Salpétrière Hospital AP HP GRC no 5 ONCOTYPE URO Sorbonne University 75013 Paris France

Urology Radboud University Medical Center Nijmegen The Netherlands

Urology Royal Free London NHS Foundation Trust Royal Free Hospital London UK

Urology Teaching Hospital Motol and 2nd Faculty of Medicine Charles University Praha Prague Czech Republic

Urology Tenon Hospital AP HP Sorbonne University Paris France

Urology The Stokes Centre for Urology Royal Surrey Hospital Guildford UK

Urology Zuyderland Medical Center Sittard Heerlen The Netherlands

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