Should random urothelial biopsies be taken from patients with primary superficial bladder cancer? A decision analysis

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Abstract
To evaluate whether it is worthwhile to implement routine random biopsies from the normal-looking urothelium in the management of patients with primary superficial bladder cancer. Two hypothetical management policies were compared, one of which incorporated random biopsies as an additional prognostic test. In the 'no-biopsy policy', all patients were treated with transurethral resection (TUR) alone, except for patients with a pT1G3 tumour who were treated with adjuvant prophylactic intravesical therapy. In the 'biopsy policy', the choice of treatment was influenced by the presence or absence of dysplastic urothelium in random biopsy specimens, except in patients with a pT1G3 tumour who received adjuvant treatment, irrespective of the result of random biopsies. Decision analysis was used to compare the outcome of these hypothetical policies with respect to the expected 3-year risks of recurrence and progression. Baseline data used in the analysis originated from a large unselected case series, prospectively documented in the Netherlands. The 'biopsy policy' resulted in a 3 year risk of recurrence and a 3 year risk of progression of 52% and 11%, respectively. These 3 year risks were almost identical to the 'no-biopsy policy': 54% and 11%, respectively. In a sensitivity-analysis, the expected 3 year risks of recurrence as well as the expected 3 year risks of progression were found to remain similar with both policies, even with quite extreme assumptions favouring the 'biopsy policy'. In view of the expected small difference in disease outcome between the two management policies, taking random biopsies of normal-looking urothelium at the time of the TUR has no practical value.