Immediate second resection during TURBT

The IMMERSE trial was single centre randomised trial that evaluated the role of immediate second deeper resection versus the standard recommendation of restage TURBT.(1) Since the restage procedure entails another anaesthesia and surgery, it is associated with complications and also strains the healthcare infrastructure and subjects the family to mental and financial burden. The authors wanted to assess wether immediate deeper resection after perceived completion of TURBT could improve the detection rates of deep muscles in the final HPE specimen and could avoid restage TURBT. Patients undergoing TURBT who underwent complete resection were included and the procedure was completed with sampling of deep muscle in standard fashion. Once the procedure was deemed complete, using a sealed envelope, it was decided to either end the procedure or take further deeper chips from the base and the margins. The primary end point was inclusion of deep muscle in the final HPE. Adjuvant treatment was provided as per the EAU guidelines. A total of 83 patients were included and 39 had immediate second resection. The deep muscle was present in 66% of the cases in standard resection group as compared to 97% in the immediate second resection group. Also, of the patients who underwent restate TURBT as per the guidelines, 41% had residual tumor in the standard group compared to 15% in the immediate second resection group. 6% and 3% in standard group had upstaging and upgrading at restage TURBT, whereas, none had upstaging or upgrading in second resection group. Detrusor sampling at restage was also better in the immediate second resection group, although this did not reach statistical significance. There were no perforations or complications in either of the groups. Similar results were also found in another study that reported presence of deep muscle in all patients undergoing immediate deep resection compared to 65% in the standard TURBT group.(2) The 2yr RFS was also higher in patient undergoing immediate second resection.(2) The authors of IMMERSE trial concluded that immediate second resection improves detection of deep muscle and has similar rate of deep muscle detection as that at restage TURBT. However, a significant proportion of patients have residual or recurrent tumor at restage TURBT and there is need of improved detection techniques during the primary surgery.