***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    ***EXAMPLES*** 
    Input: OBJECTIVES To evaluate the influence of lamina propria invasion type at initial transurethral resection ( TUR ) on restaging pathology . MATERIAL S AND METHODS We review ed prospect ively maintained records of all patients with a high- grade pT1 nonmuscle invasive bladder cancer who underwent both initial and restaging TUR within 6 weeks at our center between 2001 and 2016 . The pathology of second TUR specimens was analyzed with regard to the characteristics of lamina propria invasion found at initial resection . RESULTS We included 198 patients , with a median age of 70 years ( interquartile range : 63 - 79 ) .  Muscle was present in the initial TUR specimen in 107 patients ( 54 % ) . Pathology restaging was pT0 in 73 patients ( 37 % ) , pTis in 44 ( 22 % ) , pTa in 27 ( 14 % ) , pT1 in 50 ( 25 % ) , and pT2 in 4 ( 2 % ) . Eighty-seven patients ( 44 % ) had tumors with minimal lamina propria invasion at initial TUR : 53 specimens ( 27 % ) had focal invasion ( few malignant cells in the lamina propria ) ; 15 specimens ( 7.6 % ) had superficial invasion ( invasion of the lamina propria to the level of the muscularis mucosae [ T1a ] ) ; and 19 specimens ( 10 % ) had multifocal superficial invasion ( multiple areas of T1a ) . Of the patients with minimal lamina propria invasion , residual disease was found in 54 patients ( 62 % ) . However , none of those patients had T2 disease . CONCLUSIONS A significant number of patients with T1 tumors have residual disease at restaging TUR as do patients with minimal lamina propria invasion . The extent of T1 invasion does not eliminate the need for repeat TUR OBJECTIVES To determine whether molecular and histopathologic tumor features can predict disease progression in Stage T1 transitional cell carcinoma of the bladder . METHODS Tumor specimens from 43 patients were analyzed with respect to grade , presence of carcinoma in situ , invasion deep or superficial to the lamina propria 's muscularis mucosa , p53 expression using DO-7 and PAb1801 antibodies , age , and sex . Flow cytometry was performed on 30 patients from whom there was adequate paraffin-embedded tissue to assess DNA ploidy . Seven patients underwent immediate cystectomy  as primary treatment and 36 patients retained their bladders and were at risk of recurrence and progression . RESULTS The median follow-up was 79 months . Disease recurred in 17 patients ( 47.2 % ) and progressed in 6 ( 16.7 % ) . Only 3 patients ( 7.0 % ) died of bladder cancer . None of the parameters investigated was statistically significant in predicting recurrence , progression , or survival . Only carcinoma in situ approached statistical significance ( P = 0.0593 ) as a predictor of progression . Early cystectomy did not have a significant effect on cancer-specific survival ( P = 0.3603 ) . The concordance rate between the two p53 antibodies was 88 % ( P < 0.0001 ) . CONCLUSIONS Deep invasion of the lamina propria , p53 positive immunohistochemistry , high grade , and aneuploidy were not significant adverse prognostic factors for either disease progression or survival . Carcinoma in situ associated with Stage T1 transitional cell carcinoma may represent a biologically more aggressive cancer requiring early definitive therapy , but this hypothesis should be evaluated in prospect i ve clinical studies OBJECTIVE To describe our " en bloc " technique for nonmuscle invasive bladder cancer ( NMIBC ) , assess the quality of resection , and report the midterm oncological outcome . MATERIAL S AND METHODS This is an observational prospect i ve longitudinal study , from June 2010 to February 2014 , enrolling patients with clinical ly NMIBC , having tumors of ≤3 cm and ≤4 lesions who underwent electrical en bloc bladder resection .  The primary study end point was recurrence-free survival . Secondary outcomes were feasibility , safety , the presence of detrusor muscle , and the recurrence rate at the first follow-up cystoscopy ( 3 months ) . Statistical analysis was complemented with multivariable analysis . RESULTS Of 87 enrolled patients , 2 showed a nonurothelial carcinoma and 11 showed muscle invasive bladder carcinoma at the definitive pathology . The study cohort consisted of 74 transitional cell carcinoma NMIBC cases , mean age 71 years ± 8 , presenting with a mean tumor diameter of 1.98 ± 0.59 cm and a median number of resected tumors per patients of 1 ( range 1 - 4 ) .  The 2-year recurrence-free survival was 85.59 % . All the en bloc resection of bladder tumor sample s showed the presence of detrusor muscle and the recurrence rate at the first follow-up cystoscopy ( 3 months ) was 5.4 % ( 4/74 ) . An extraperitoneal bladder perforation occurred in only one patient . At multivariable analysis , only gender and the presence of carcinoma in situ were independent predictors of recurrence . The midterm follow-up and the absence of a control group are the main limitations . CONCLUSION Our findings confirmed the feasibility and safety of en bloc resection of bladder tumor , with a recurrence-free survival of 85 % after 2 years OBJECTIVE To determine whether thulium : yttrium-aluminum-garnet laser resection of bladder tumor ( TmLRBT ) may offer advantages over classic resection . MATERIAL S AND METHODS From April 2011 to September 2012 , 55 consecutive patients newly diagnosed with clinical stage ≤T2 bladder cancer were enrolled in a prospect i ve study on TmLRBT . Neoplasm was removed en bloc in all cases . When the tumor size was > 3 cm , it was necessary to incise longitudinally and /or across the lesion and the bladder wall at its the base into 2 or more parts . All cases of non-muscle-invasive bladder cancer underwent second look in 30 - 90 days . RESULTS Pathology reported urothelial carcinoma with Ta low grade in 31 patients ( 56.4 % ) , T1 high grade in 18 ( 32.7 % ) , and T2 high grade in 6 ( 10.9 % ) . Histopathologic evaluation showed that the bladder detrusor was provided in all cases . Hemostasis was excellent , and no postoperative hematuria was reported . In a case of T1 G3 , endoscopic re-evaluation showed a focal infiltration of the bladder detrusor , so the patient underwent radical cystectomy . To date , with a mean follow-up of 16 months ( range , 8 - 25 ) , the recurrence rate in patients with superficial disease is 14.5 % . All recurrences were outside the site of first resection , and there was no progression in tumor grade . CONCLUSION TmLRBT is a simple method that seems to overcome the " incise and scatter " problem associated with traditional transurethral resection of bladder tumor . Our initial data on staging accuracy and reduction of the local recurrence rate are encouraging PURPOSE The role of a routine second transurethral resection in evaluating and managing bladder tumors is defined . MATERIAL S AND METHODS From January to October 1998 , 150 patients with new or recurrent bladder tumors underwent repeat transurethral resection  within 2 to 6 weeks after the initial resection , and the results , including the presence of residual tumor and tumor stage , were compared . RESULTS Of the 150 cases 36 ( 24 % ) had no and 114 ( 76 % ) had residual tumor on repeat transurethral resection . Of 96 cases with superficial ( Ta , Tis , T1 ) bladder tumors 72 ( 75 % ) had residual noninvasive tumor and 28 ( 29 % ) were up staged to invasive tumor . Among 54 patients with a muscle invasive tumor 12 ( 22 % ) had no residual tumor on repeat transurethral resection . Results of the second resection changed tumor treatment in 50 patients ( 33 % ) . CONCLUSIONS Many patients with bladder tumors have tumor present after an initial trans-urethral resection . Routine repeat resection is advised to control noninvasive tumors and to detect residual tumor invasion BACKGROUND An European Organisation for Research and Treatment of Cancer analysis of multicentre trials found significant interinstitutional variability in recurrence rates at first follow-up cystoscopy ( RR-FFC ) and attributed this to variable transurethral resection of bladder tumour ( TURBT ) quality . OBJECTIVE To determine whether resection of detrusor muscle ( DM ) in the first , apparently complete TURBT is a surrogate marker of quality and whether the presence of DM is dependent on a surgeon 's experience . DESIGN , SETTING , AND PARTICIPANTS Over a 2-yr period , patients with new bladder tumours that were judged to have been completely resected were recruited from our prospect ively maintained bladder tumour data base . Strict exclusion criteria were applied . MEASUREMENTS Prospect ively recorded tumour size , tumour multiplicity , surgeon category , DM status , grade and stage of tumour , and findings at first follow-up cystoscopy  ( at 3 mo ) and at early re-TURBT were evaluated . Surgeons were stratified into seniors ( consultants and year 5 or year 6 trainees ) and juniors ( trainees lower than year 5 ) . Early recurrence ( for calculating RR-FFC ) was defined as pathologically confirmed tumour on early re-TURBT or recurrence at the first follow-up cystoscopy . Logistic regression multivariate analyses were carried out to determine associations between variables . RESULTS AND LIMITATIONS In a total of 356 patients , DM was present in 241 patients ( 67.7 % ) . Multivariate analyses revealed that large tumours , high- grade tumours , and surgery by senior surgeons was independently associated with the presence of DM in the resected specimens . The RR-FFCs when DM was absent and present were 44.4 % and 21.7 % , respectively ( odds ratio : 2.9 ; 95 % confidence interval : 1.6 - 5.4 ; p=0.0002 ) . The absence of DM and resection by less experienced surgeons independently predicted a higher RR-FFC . This association was also seen in small and low- grade tumours . The number of patients in this study appears modest , and further validation may be required . CONCLUSIONS DM absence or presence in the first , apparently complete TURBT specimen appears to be a surrogate marker of resection quality by independently predicting the RR-FFC , which is also dependent on surgeon experience PURPOSE We compared the outcomes of repeat transurethral resection plus intravesical mitomycin C with initial transurethral resection of bladder plus intravesical MMC in patients with newly diagnosed pT1 transitional cell carcinoma of the bladder in terms of recurrence , progression and overall survival . MATERIAL S AND METHODS Of 148 newly diagnosed patients with T1 bladder cancer 142 were prospect ively r and omized in 2 groups between January 2001 and January 2005 . A total of 74 patients underwent second TURB  and received adjuvant MMC intravesically ( group 1 ) and 68 patients received adjuvant MMC following the initial TURB ( group 2 ) . All repeat TURB operations were performed 2 to 6 weeks following initial TURB . Patients with incomplete resection , Cis or muscle invasive disease were excluded from study . The first dose of mitomycin C ( 40 mg per week for a total of 8 weeks ) was instilled intravesically in all patients during the first 24 hours after the last surgery . RESULTS Mean followup was 31.5 months ( range 6 to 48 ) with no difference between the 2 groups . The rate of recurrence-free survival was 86.35 % ( SE 0.4 % ) , 77.67 % and 68.72 % in group 1 , and 47.08 % , 42.31 % and 37.01 % in group 2 for the first , second and third year , respectively ( overall 74.32 % vs 36.76 % , log rank 0.0001 ) . Recurrence was observed in 19 of the 74 ( 25.68 % ) patients in group 1 and in 43 of the 68 ( 63.24 % ) patients in group 2 . Ten of the 19 ( 52.63 % ) patients in group 1 and 35 of the 43 ( 81.39 % ) patients in group 2 had recurrence within 12 months . Recurrence was observed in 17.6 % , 25 % and 60 % of patients with G1 , G2 and G3 tumors , respectively , in group 1 . The same rates for group 2 were 25 % , 64 % and 90 % . The RFS rate was significantly worse in the high grade group ( G2 and G3 ) ( p < 0.001 ) . Progression was observed at 4. 
    Output:
    
Second look TURB maximizes staging accuracy , allows to clear residual cancer and yields prognostic advantages allowing key information to identify possible c and i date s for immediate radical cystectomy for very high risk T1HG tumors .
Moreover , it seems to have a therapeutic benefit by improving recurrence- and progression-free survivals .
However , few recent large studies showed that these advantages seem to be limited to patients without detrusor muscle present at first resection .
Similarly , the presence of residual disease and the risk of upstaging are related to the presence of detrusor muscle in specimen .
It could well be that in the future the presence of detrusor muscle would be a quality criteria to avoid an unnecessary second look TURB as shown by recent studies using the en-bloc resection technique .
Finally , it has to be underlined that this is a surgical procedure not free of risks and complications and with a non-negligible impact on patients ' quality of life , waiting lists and healthcare costs .