Issues‎ > ‎Vol7n2‎ > ‎



Aso Omer Rashid a and Goran Friad Abdulla b 

Department of Surgery, College of Medicine, University of Sulaimani. 
b Department of Urology, Sulaimani Teaching Hospital, Sulaimani, Iraq.

Submitted: 26/2/2017; Accepted: 1/8/2017; Published: 15/8/2017



Bladder cancer is a very common urological malignancy affecting human being, it is the disease related to environment and aging. The biologic behavior or bladder cancer is unpredictable, but the issue of recurrence, progression in relation to morbidity and mortality are well recognized. NMIBC (Non-Muscle Invasive Bladder Cancer); compromise Ta, T1 and Cis with great difference in their management and prognosis. It is found early recurrence and progression of NMIBC as a clinical marker carries a poor prognosis.


To detect the rate of early recurrence, progression, and to evaluate the clinical behavior and final outcome of 44 patients diagnosed with NMIBC.

Materials and Methods

This is a prospective study conducted between June 2013 and December 2014 in Sulaimani Surgical Teaching and Hewa Teaching hospitals. Fourty four patients who had been managed for primary NMIBC were reviewed for their medical records, clinical parameters including patients age ,gender, physical examination, investigations, the operations, tumor morphology and adjuvant therapy were entered into database. Patients were called back for reviewing their course of the disease and to complete their managements.The outcomes of re-resection, recurrence rate , progression and overall survival were recorded in relation to initial management and follow up.


Of 44 patients with primary NMIBC, male: female ratio is 6:1, the mean age is 55 years. Index TURBT revealed 47.7% was Ta, 45.45% was T1 and 6.8% unknown stage with no CIS detection. Grading showed; 18.1% was PUNLMP, 34.1% G1, 13.6% G2, 27.27% G3, and 6.8% was unknown. Tumor size was; 9.09% < 1 cm, 40.9% size was 1-3 cm, and 50% was > 3 cm. The multiplicity; 36.36% was solitary tumor, 31.8% multiple, and 31.8% the multiplicity was not recorded. Initial treatment was 18.2% TURBT alone, 18.2% second TURBT, 4.5% TURBT and immediate intravesical MMC, 61.36% TURBT and 6weeks course of MMC, 6.8% underwent TURBT and 6 weeks’ course of BCG. Mean time to recurrence was 5.6 months and 7 months for progression. Using multivariate analysis, the P value for tumor size and grade of tumor were 0.001 and 0.008 respectively, which are statistically significant for both recurrence and progression.


The biological behavior of NMIBC remained elusive in term of curability, recurrence, progression and mortality. Lack of documentation and irregular follow up schedules were observed obviously. Deviations from the standard guideline management strategy can threaten the life of patients.


Non-muscle invasive urothelial carcinoma, Bladder cancer.


1. Hall Canc, M., Chang, S., Dalbagni, G., Pruthi, R., Seigne, J., Skinner, E., Wolf, J. and Schellhammer, P. Guideline for the Management of Nonmuscle Invasive Bladder er (Stages Ta, T1, and Tis): 2007 Update. The Journal of Urology, (2007). 178(6), pp.2314-2330.

2. Sadetzki, S., Bensal, D., Blumstein, T., Novikov, I. and Modan, B. Selected risk factors for transitional cell bladder cancer. Med Oncol, (2000). 17(3), pp.179-182.

3. Jemal, A., Siegel, R., Ward, E., Hao, Y., Xu, J., Murray, T. and Thun, M. (2008). Cancer Statistics, CA: A Cancer Journal for Clinicians, 2008.58(2), pp.71-96.

4. J. Ferlay, I. Soerjomataram, R. Dikshit, S. Eser, C. Mathers, M. Rebelo, D.M. Parkin, D. Forman, F. Bray . Cancer incidence and mortality worldwide: sources, methods and major patterns in Globocan 2012. International Journal of Cancer. doi:10.1002/ijc.29210 PMID: 25220842 published online 9 October 2014

5. Kiemeney, L., Witjes, J. and Verbeek, AThe clinical epidemiology of superficial bladder cancer. Br. J. Cancer, . (1993). 67(4), pp.806-812.

6. Reynard, J., Brewster, S. and Biers, Oxford Handbook of Urology. Urological Neoplasia: pathology and molecular biology. Oxford Medical Publications, 2nd Edition, (2009). pp.248-267.

7. Arya, M., Shergill, I., Kalsi, J., Muneer, A. and Mundy, A). Viva practice for the FRCS(Urol) Examination. Masterpass, . 2010.pp.78-103.

8.Matthew B.K. Shaw, radhakrishna Narahari, Mark I. Johnson, Garratt C. Durkan,Amira El-Sherif, Andrew C Thrope. The influence of high grade and low grade histological Sub classification of G2 Pt1 Transitional cell cancer of bladder on tumour recurrence and progressive rates -5 year reterospective analysis.British Journal of Medical and Surgical Urology(2011)4,152-157.

9. Babjuk, M., Bale, A., Burger, M., Sylvester, R. and Shariat, S. European Association of Urology. Guidelines, 2014 edition, pp.4-48.

10. Guey, L., Garcia-Closas, M., Murta-Nascimento, C., Lloreta, J., Palencia, L., Kogevinas, M., Rothman, N., Vellalta, G., Calle, M., Marenne, G., Tardon, A., Carrato, A., Garcia-Closas, R., Serra, C., Silverman, D., Chanock, S., Real, F. and Malats, N. Genetic Susceptibility to Distinct Bladder Cancer Subphenotypes. European Urology, (2010). 57(2), pp.283-292.

11. Jocham, D., Witjes, F., Wagner, S., Zeyelemarker, B., van Moorsheelar, J., Grimm, M., Muschter, R., Popken, G., Keinig, F. and Kniichel, R. IMPROVED DETECTION AND TREATMENT OF BLADDER CANCER USING HEXAMINOLEVULINATE IMAGING: A PROSPECTIVE, PHASE III MULTICENTER STUDY. The Journal of Urology, (2005). 174(3), pp.862-866.

12. Heney NM, Ahmed S. and Flanagan MJSuperficial bladder cancer: progression and recurrence. J Urol, . (1983). 130(6), pp.1083-1086.

13. Colombo, R., Da Pozzo, L., Lev, A., Freschi, M., Gallus, G. and Rigatti, P. Neoadjuvant Combined Microwave Induced Local Hyperthermia and Topical Chemotherapy Versus Chemotherapy Alone for Superficial Bladder Cancer. The Journal of Urology, (1996). 155(4), pp.1227-1232.

14. Lamm, D., Blumenstein, B., Crawford, E., Montie, J., Scardino, P., Grossman, H., Stanisic, T., Smith, J., Sullivan, J., Sarosdy, M., Crissman, J. and Coltman, CA. Randomized Trial of Intravesical Doxorubicin and Immunotherapy with Bacille Calmette—Guerin for Transitional-Cell Carcinoma of the Bladder. New England Journal of Medicine, . (1991). 325(17), pp.1205-1209.

15. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings. MMWR Recom Rep, (2005). 54(RR-17), pp.1-141.

16. BOhle, A., Jocham, D. and Bock, P. Intravesical Bacillus Calmette-Guerin Versus Mitomycin C For Superficial Bladder Cancer: A Formal Meta-Analysis of Comparative Studies on Recurrence and Toxicity. The Journal of Urology, (2003). 169(1), pp.90-95.

17. Catalona WJ. and Ratliff TL. BCG and superficial bladder cancer: Clinical Experience and mechanism of action. 1990. Surg Annu, 22, p.363.

18. Rischmann, P., Desgrandchamps, F., Malavaud, B. and Chopin, D. BCG Intravesical Instillations: Recommendations for Side-Effects Management. European Urology, (2000). 37(Suppl. 1), pp.33-36.

19. Di Stasi, S., Giannantoni, A., Giurioli, A., Valenti, M., Zampa, G., Storti, L., Attisani, F., De Carolis, A., Capelli, G., Vespasiani, G. and Stephen, RSequential BCG and electromotive mitomycin versus BCG alone for high-risk superficial bladder cancer: a randomised controlled trial. The Lancet Oncology, . (2006). 7(1), pp.43-51.

20. Ojeda, L. and Johnson, D. Partial cystectomy: Can it be incorporated into integrated therapy program?. Urology, (1983). 22(2), pp.115-117.

21. Charlesworth, P., Gray, R., Blick, C., Kilbey, N., Protheroe, A. and Crew, J. Early recurrence of non-muscle invasive bladder cancer as a clinical marker of a poor prognosis and cancer-specific survival. British Journal of Medical and Surgical Urology, (2012). 5(6), pp.284-288.

22. Aldousari, S. and Kassouf, W. Update on the management of non-muscle invasive bladder cancer. Can Urol Assoc (2010).1, 4(1), pp.56-64.

23. Botteman, M., Pashos, C., Redaelli, A., Laskin, B. and Hauser, R. (The Health Economics of Bladder Cancer. PharmacoEconomics, (2003). 22(18), pp.1315-1330.

24. Vikram, R., Sandler, C. and Ng, C. Imaging and Staging of Transitional Cell Carcinoma: Part 1, Lower Urinary Tract. American Journal of Roentgenology, (2009). 192(6), pp.1481-1487.

25. Abbaszadeh, S., Taheri, S. and Nourbala, M. Bladder Tumor in Women with Microscopic Hematuria: An Iranian Experience and a Review of the Literature. Advances in Urology, 2009, pp.1-5.

26. Calabria, F. and Sternberg, C. Localized and locally advanced bladder cancer. Current Treatment Options in Oncology, (2002). 3(5), pp.413-428.

27. Parkin, D., Pisani, P. and Ferlay, J. Global cancer statistics. CA: A Cancer Journal for Clinicians, (1999). 49(1), pp.33-64.

38. Badrinath RK, Peter RC. McAninch, J. and Lue, T. Smith and Tanagho's General Urology. Urolothelial Carcinoma: Cancer of the Bladder, Ureter, and Renal Pelvis. International Edition, (2013). 18th edition, pp.310-325.

29. Holmang, S., Hedelin, H., Anderstrom, C. and Johansson, S. (1995). The Relationship Among Multiple Recurrences, Progression and Prognosis of Patients with Stages TA and T1 Transitional Cell Cancer of the Bladder Followed for at least 20 years. The Journal of Urology, pp.1823-1826.

30. LA, K. and JA, W. Predictability of recurrent and progressive disease in individual patients with primary superficial bladder cancer. J Urol, (1993). 150(1), pp.60-64.

31. Parmar, M. and Freedman, L. Prognostic factors for recurrence and followup policies in the treatment of superficial bladder cancer: report from the British Medical Research Council Subgroup on Superficial Bladder Cancer (Urological Cancer Working Party). J Urol, (1989). 142(2), pp.284-288.

32. Ali-El-Dein, B., Sarhan, 0., Hinev, A., Ibrahiem, E., Nabeeh, A. and Ghoneim, M. Superficial bladder tumours: analysis of prognostic factors and construction of a predictive index. BJU International, (2003). 92(4), pp.393-399.

33. Brausi, M., Collette, L., Kurth, K., van der Meijden, A., Oosterlinck, W., Witjes, J., Newling, D., Bouffioux, C. and Sylvester, R. Variability in the Recurrence Rate at First Follow-up Cystoscopy after TUR in Stage Ta T1 Transitional Cell Carcinoma of the Bladder: A Combined Analysis of Seven EORTC Studies. European Urology, (2002). 41(5), pp.523-531.

34. Lutzeryer, w. and Rubben, H. Prognostic parameters in superficial bladder cancer: an analysis of 315 cases. J Urol, (1982). 127(1), pp.250-252.

35. Kaasinen, E., Rintala, E., HeIlstrem, P., Viitanen, J., Juusela, H., Rajala, P., Korhonen, H. and Liukkonen, T.Factors Explaining Recurrence in Patients Undergoing Chemoimmunotherapy Regimens for Frequently Recurring Superficial Bladder Carcinoma. European Urology . (2002). 42(2), pp.167-174.

36. Mostafid, A., Rajkumar, R., Stewart, A. and Singh, R. Immediate administration of intravesical mitomycin C after tumour resection for superficial bladder cancer. BJU International, (2006). 97(3), pp.509-512.

37. Bouffioux, C., Kurth, K., Bono, A., Oosterlinck, W., Kruger, C., Depauw, M. and Sylvester, R. Original Articles: Bladder Cancer: Intravesical Adjuvant Chemotherapy for Superficial Transitional Cell Bladder Carcinoma: Results of 2 European Organization for Research and Treatment of Cancer Randomized Trials With Mitomycin C and Doxorubicin Comparing Early Versus Delayed Instillations and Short-Term Versus Long-Term Treatment. The Journal of Urology, (1995). 153(3), pp.934-941.

38. Huncharek, M., Geschwind, J., Witherspoon, B., McGarry, R. and Adcock, D. Intravesical chemotherapy prophylaxis in primary superficial bladder cancer. Journal of Clinical Epidemiology, (2000). 53(7), pp.676-680.

39. Sylvester, R., van der Meijden, A., Oosterlinck, W., Witjes, J., Bouffioux, C., Denis, L., Newling, D. and Kurth, K. Predicting Recurrence and Progression in Individual Patients with Stage Ta T1 Bladder Cancer Using EORTC Risk Tables: A Combined Analysis of 2596 Patients from Seven EORTC Trials. European Urology, (2006). 49(3), pp.466-477.