Transurethral Resection of Bladder Tumors: Improving Quality Through New Techniques and Technologies

The Current Progress and Future Options of Multiple Therapy and Potential Biomarkers for Muscle-Invasive Bladder Cancer

Bladder cancer is a common disease in men and the elderly. Current treatment paradigms include radical resection of the bladder and lymph nodes or transurethral resection, both supported by chemotherapy and/or radiation. New modalities, such as illumination-based therapies are also being translationally pursued. However, while survival rates have increased due to combined therapies (particularly chemotherapy, radiation, immune checkpoint inhibitors, and surgery), a lack of diagnostic markers leads clinical professionals to rely on frequently invasive and expensive means of monitoring, such as magnetic resonance imaging or bladder cystoscopy. To improve real-time diagnostic capabilities, biomarkers that reflect both the metabolic and metastatic potential of tumor cells are needed. Furthermore, indicators of therapy resistance would allow for rapid changes in treatment to optimize survival outcomes. Fortunately, the presence of nanoscale extracellular vesicles in the blood, urine, and other peripheral fluids allow for proteomic, genomic, and transcriptomic analyses while limiting the invasiveness of frequent sampling. This review provides an overview of the pathogenesis and progression of bladder cancer, standard treatments and outcomes, some novel treatment studies, and the current status of biomarker and therapy development featuring exosome-based analysis and engineering.

Effectiveness and Safety of a Modified Technique of Transvesical Obturator Nerve Block to Avoid Adductor Contractions during Transurethral Resection of Bladder Tumors

<b><i>Introduction:</i></b> The aim of the study was to evaluate the effectiveness of a modified transvesical obturator nerve block (ONB) in the prevention of obturator nerve reflex and consecutive bladder perforations (BPs) during transurethral resection of bladder tumors (TURBTs). <b><i>Materials and Methods:</i></b> A retrospective analysis of all patients resected in 2014–2015 due to a bladder tumor of the lateral walls, including a follow-up period until December 2018, was performed. Two groups were defined: in the first group, all patients underwent TURBT with a modified transvesical ONB. The second group underwent conventional TURBT with intermittent resection. Primary endpoints were the rates of adductor contractions and BPs. <b><i>Results:</i></b> Ninety-four out of 1,145 resected patients presented with tumors on the lateral wall of the bladder and a complete dataset including a long-term follow-up. Thirty-six patients were treated in the ONB group, and 58 patients comprised the control group. The median age in the 2 groups was 70.8 and 71.8 years in the first and second groups, respectively. Adductor spasms were reported in 8.33 versus 25.86% (<i>p</i> = 0.057) and perforation in 2.78 versus 17.24% (<i>p</i> = 0.047) in groups 1 and 2, respectively. After a median follow-up of 32.5 months, there was no significant difference in recurrence rates (52.78 vs. 51.72%, <i>p</i> = 0.672). In a subgroup analysis, lower perforation rates were recorded for the ONB group in patients with tumors &#x3c;3 cm (0/30 vs. 8/46, <i>p</i> = 0.076) and in patients with unifocal tumors (0/12 vs. 5/23, <i>p</i> = 0.141). <b><i>Discussion/Conclusion:</i></b> The simplified approach of transvesical ONB demonstrated in this study appears to be an inexpensive, safe, effective, and simple-to-use technique.

Transurethral Resection of Bladder Tumor: Electrosurgical and Laser

Transurethral resection of bladder tumor (TURBT) is still the gold standard for the diagnosis, treatment, and staging of nonmuscle invasive bladder cancer. En bloc resection of bladder tumor (EBRT) has been recently introduced to overcome the limitations of conventional TURBT. EBRT potential advantages are (1) complete resection, (2) a more precise and controlled resection (potentially fewer complications), (3) better sample orientation for histopathology analysis, (4) presence of detrusor in the specimen, and (5) less tumor seeding on normal urothelium by tumor fragments. This article aimed to present a step-by-step technique of conventional TURBT and EBRT with thulium laser support. We also aimed to provide tips and tricks for a correct surgical procedure and postoperative patient care. Finally, clinical outcomes of TURBT versus EBRT were reviewed.

Therapeutic options to reduce intravesical recurrence in newly diagnosed Ta high-grade bladder cancer according to risk stratification: A multicenter retrospective study

OBJECTIVES

To evaluate the risk factors for intravesical recurrence in patients with newly diagnosed Ta high-grade non-muscle-invasive bladder cancer and the optimal management to reduce the risk of recurrence.

METHODS

We retrospectively evaluated Ta high-grade bladder cancer in patients who were newly diagnosed by transurethral resection from January 2007 through October 2018. Using multivariate analyses, we evaluated the risk factors and therapeutic options affecting intravesical recurrence and stratified the patients according to the risk numbers.

RESULTS

We included 390 patients and the median follow-up period was 31 months after the initial transurethral resection. According to multivariate analysis, having a previous history of upper urinary tract carcinoma, and multiple and sessile tumors were risk factors for intravesical recurrence (P = 0.001, P = 0.02 and P = 0.01, respectively). Risk groups were stratified according to these risk factors into favorable, intermediate and poor. In the entire cohort, induction and immediate intravesical instillation therapy were treatment options to reduce intravesical recurrence (P < 0.01 and P = 0.02, respectively). Analyses in each risk group showed that a second transurethral resection was the only therapeutic option to reduce intravesical recurrence in the favorable group (P = 0.048), whereas induction intravesical instillation therapy was effective in the intermediate and poor risk groups (P = 0.01 and P < 0.01, respectively), as was immediate intravesical instillation for the poor risk group (P < 0.001).

CONCLUSIONS

Sessile, multiple tumors and a history of upper urinary tract carcinoma are risk factors for intravesical recurrence in Ta high-grade bladder cancer patients.

Novel transurethral resection technologies and training modalities in the management of nonmuscle invasive bladder cancer: a comprehensive review

PURPOSE OF REVIEW

Conventional transurethral resection (TURBT) with tumor fragmentation is the primary step in the surgical treatment of nonmuscle invasive bladder cancer. Recently, new surgical techniques and training modalities have emerged with the aim to overcome short-comings of TURBT and improve oncologic outcomes. In this review, we provide a comprehensive update of recent techniques/techniques that aim to improve upon conventional TURBT and beyond.

RECENT FINDINGS

A systemic approach during conventional TURBT that features the use of a surgical checklist has been shown to improve recurrence-free survival. Several simulators have been developed and validated to provide additional training opportunities. However, transfer of improved simulator performance into real world surgery still requires validation. While there is no convincing data that demonstrate superior outcomes with bipolar TURBT, en-bloc resection already promises to offer lower rates of complications as well as potentially lower recurrence probabilities in select patients.

SUMMARY

TURBT remains the quintessential procedure for the diagnosis and treatment of bladder cancer. Urologists need to be aware of the importance and challenges of this procedure. Aside of embracing new resection techniques and a conceptual-systematic approach, training opportunities should be expanded upon to improve patient outcomes.

Diagnosis and Staging of Bladder Cancer

Cystoscopic examination remains the gold standard technique for initial diagnosis of bladder cancer (BCa). Despite significant progress in enhanced cystoscopic techniques, blue light cystoscopy and narrow band imaging are the only ones well supported by high-level evidence and, if available, should be used during initial staging of BCa. Multiparametric MRI could be an important imaging tool in local staging of BCa. With ever-expanding targeted therapy and immunotherapy options in both muscle-invasive and non-muscle-invasive BCa, molecular subtyping could become an essential part of initial histologic staging in the near future.

En bloc transurethral resection of bladder tumor: A review of the literature

Bladder cancer remains one of the most common malignancies of the genitourinary tract. Transurethral resection of the bladder tumor (TURBT) via cystoscopy with examination under anesthesia remains the primary method for determining the diagnosis and clinical stage of bladder cancer. Given the substantial cost of treatment and risk of bladder cancer recurrence after TURBT, novel approaches to transurethral resection, such as the en bloc technique, have been developed in an attempt to address these limitations. In this review, we examined the postoperative and oncological outcomes of en bloc TURBT compared to traditional resection techniques. Further prospective clinical studies, however, are still necessary to determine whether these alternative technologies or surgical techniques may improve treatment in bladder cancer patients.

Level of evidence: Not applicable.

Transurethral resection of bladder tumour (TURBT)

The goals of transurethral resection of bladder tumour (TURBT) are to identify and eradicate visualized bladder tumour if technically safe and feasible and to obtain a specimen of satisfactory quality to enable accurate histological diagnosis. In the setting of high grade bladder tumour this generally entails the inclusion of detrusor muscle and assessment for the presence of associated carcinoma in situ (CIS), lymphovascular involvement or any variant form of bladder cancer. This will assist in determining risk stratification and prognostication of the bladder cancer and guides further treatment planning. Conversely, if suboptimal TURBT is performed there will be detrimental consequences on patient outcomes in regards to undergrading or understaging, increased recurrence or progression, and subsequently need for further treatments including more invasive interventions. This review article firstly summarises the key principles and complications of TURBT, as well as significance of re-TURBT. We also discuss a number of modifications and advances in detection technology and resection techniques that have shown to improve perioperative as well as pathological and oncological outcomes of bladder cancer. They include enhanced cystoscopy such as blue light cystoscopy (BLC), narrow band imaging (NBI) and en bloc resection of bladder tumour (ERBT) technique using various types of energy source.

Best Practices to Optimise Quality and Outcomes of Transurethral Resection of Bladder Tumours

CONTEXT

Transurethral resection of bladder tumour (TURBT) for bladder cancer (BC) is an underappreciated common urological procedure. TURBT outcomes are highly variable, and results are dependent on judgement and surgical skill.

OBJECTIVE

To perform a narrative review and identify optimal best practice in TURBT including preparation, choice of equipment, procedural steps, surgical technique, and management of difficult scenarios and complications.

EVIDENCE ACQUISITION

Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched. Important studies were identified and reviewed by an international panel of urologists representing major urological societies and guideline panels with a record of academic publication in this field. In areas where the group identified a lack of evidence or agreement, discussions took place until a consensus was reached.

EVIDENCE SYNTHESIS

A total of 814 studies were identified and 43 were included. The majority were retrospective (level of evidence 3), with only two prospective randomised trials. Four broad themes were identified, which formed the basis for the review: (1) the role of TURBT within the overall management of BC, (2) TURBT techniques, (3) measurement of outcomes including quality control and checklists, and (4) postoperative management. Familiarity with all aspects of the procedure is necessary to minimise morbidity and improve oncological outcomes. Development of new instruments and techniques, and prospective audit of TURBT outcomes are important future goals.

CONCLUSIONS

TURBT is a common and challenging operation with known variable outcomes. To reduce these variations and optimise outcomes, best practice based on evidence and expert opinion is recommended.

PATIENT SUMMARY

Transurethral resection of bladder tumour (TURBT) is a common but deceptively difficult urological operation. Optimal outcomes depend on experience and surgical skill. An international group of experienced TURBT surgeons review critical aspects of the procedure and share best practice to stimulate further discussion.

UNC5B mediates G2/M phase arrest of bladder cancer cells by binding to CDC14A and P53

UNC5B is a known tumor suppressor gene in a variety of cancers. As a transmembrane protein, UNC5B also induces apoptosis in a P53-dependent manner. In this study, we demonstrate that UNC5B inhibits proliferation through G2/M phase arrest by mass spectrometry and bioinformatics analysis in bladder cancer cells. By combing with CDC14A and P53, UNC5B dephosphorylated P53 at Ser-315 site. This dephosphorylation facilitated G2/M phase arrest by reducing the expression of cyclin B1 and increasing the expression of p-CDK1, thus inhibiting tumor proliferation. Knockdown of CDC14A suppressed the G2/M phase arrest induced by UNC5B in vitro, and eliminated the inhibitory effect of UNC5B on tumor proliferation in vivo. Our results show that UNC5B-mediated cell cycle arrest may act as a potential treatment for bladder cancer.

Current and innovative approaches in the treatment of non-muscle invasive bladder cancer: the role of transurethral resection of bladder tumor and organoids

Background Bladder cancer is the 7th most common cancer in men. About 75% of all bladder cancer are non-muscle invasive (NMIBC). The golden standard for definite diagnosis and first-line treatment of NMIBC is transurethral resection of bladder tumour (TURB). Historically, the monopolar current was used first, today bipolar current is preferred by most urologists. Following TURB, depending on the tumour grade, additional intravesical chemo- or/and immunotherapy is indicated, in order to prevent recurrence and need for surgical resection. Development of new technologies, molecular and cell biology, enabled scientists to develop organoids - systems of human cells that are cultivated in the laboratory and have characteristics of the tissue from which they were harvested. In the field of urologic cancers, the organoids are used mainly for studying the course of different diseases, however, in the field of bladder cancer the data are scarce. Conclusions Different currents - monopolar and bipolar, have different effect on urothelium, that is important for oncological results and pathohistological interpretation. Specimens of bladder cancer can be used for preparation of organoids that are further used for studying carcinogenesis. Bladder organoids are step towards personalised medicine, especially for testing effectiveness of chemo-/immunotherapeutics.

[Optical coherence tomography of bladder resection specimen]

INTRODUCTION

The diagnosis of bladder urothelial tumors is based on bladder resection and histological analysis of the specimen. The time to obtain the results of the histological analysis increases the treatment delay. Furthermore, the lack of muscle on the specimen forces the surgeon to practice on other procedure. Full field optical coherence tomography (FFOCT) is a recent imaging technique to analyze tissue. The aim of our study was to evaluate the feasibility and diagnostic accuracy of FFOCT to detect muscle and tumor in bladder resection specimen.

PATIENTS AND METHODS

We analyzed with the FFOCT technique bladder resection specimen of 24 consecutives patients. Three readers did the blind analyze of the images, looking for the presence of muscle and tumor on each specimen. Their results were compared with histological analysis to calculate diagnostic accuracy for each reader.

RESULTS

Mean sensibilities for the detection of muscle and tumor were respectively 75% and 81%. Mean specificities for the detection of muscle and tumor were respectively 78.3% and 55.3%.

CONCLUSIONS

Our results suggest that the FFOCT is feasible to analyze bladder resection specimen. Sensibilities and specificities calculated are encouraging for the detection of muscle and tumor. The accuracy of this detection and early-staging tool should be validated by larger studies.

LEVEL OF EVIDENCE

3.

Surgical checklist impact on recurrence-free survival of patients with non-muscle-invasive bladder cancer undergoing transurethral resection of bladder tumour

OBJECTIVES

To evaluate the impact of an eight-item surgical checklist (SC) on the recurrence-free survival (RFS) of patients with non-muscle-invasive bladder cancer (NMIBC) undergoing transurethral resection of bladder tumour (TURBT).

PATIENTS AND METHODS

A group of urologists at two tertiary referral centres, with expertise in bladder cancer, identified eight critical items that should be performed in every high-quality TURBT. An eight-item SC was prospectively implemented into clinical practice and the operative reports of TURBTs performed before and after implementation were reviewed. Results from both institutions were combined to estimate the impact of introducing the SC on oncological outcomes. Multivariable logistic and Cox hazards regression analyses were performed to evaluate the impact of the SC on the presence of detrusor muscle in the TURBT specimen and on RFS, respectively.

RESULTS

The operative reports of 266 TURBTs performed after the SC implementation were reviewed and compared to those of 281 TURBTs performed prior to the SC introduction. The SC was independently associated with a significant improvement in RFS (P = 0.02). However, the introduction of the SC was not significantly associated with the presence of detrusor muscle in the surgical specimen (P = 0.4).

CONCLUSION

The use of an eight-item SC during TURBT in clinical practice increases the quality of operative reports thereby potentially improving individualised risk-stratification and care resulting in lower disease recurrence rates. Therefore, the introduction of a SC can be recommended to enhance oncological outcomes by improving surgical standardisation and operative reporting.

Virtual Reality and Simulation for Progressive Treatments in Urology

In urology technologies and surgical practices are constantly evolving and virtual reality (VR) simulation has become a significant supplement to existing urology methods in the training curricula of urologists. However, new developments in urology also require training and simulation for a wider application. In order to achieve this VR and simulation could play a central role. The purpose of this article is a review of the principal applications for VR and simulation in the field of urology education and to demonstrate the potential for the propagation of new progressive treatments. Two different cases are presented as examples: exposure therapy for paruresis and virtual cystoscopy for diagnosis and surgery of bladder cancer. The article uses research and publications listed in openly accessible directories and is organized into 3 sections: The first section covers features of VR and simulation technologies. The second one presents confirmed applications of current technologies in urology education and showcases example future applications in the domain of bladder treatment and surgery. The final section discusses the potential of the technology to improve health care quality.

Enhanced Endoscopy in Bladder Cancer

PURPOSE OF REVIEW

Endoscopy coupled with targeted resections represents a cornerstone in the diagnosis, staging, and treatment of patients with bladder cancer. Direct visualization can be challenging and imprecise due to patient-, tumor-, and surgeon-specific factors. We will review contemporary endoscopic technologies and techniques used to improve our ability to safely identify and resect malignant lesions in patients with bladder cancer.

RECENT FINDINGS

Enhanced endoscopic imaging technology may improve detection rates for bladder cancer throughout the upper and lower urinary tract, which may lead to improvements in recurrence and progression rates for non-muscle invasive bladder cancer (NMIBC). New techniques including narrow-band imaging (NBI), photodynamic diagnosis (PDD), Storz Professional Image Enhancement System (SPIES), optical coherence tomography (OCT), and others have shown benefit and may further improve our ability to detect and stage bladder tumors. Enhanced endoscopy technologies have already demonstrated value in improving the sensitivity of bladder cancer detection and early results suggest they may improve short- and long-term oncologic outcomes.

Image-Guided Transurethral Resection of Bladder Tumors - Current Practice and Future Outlooks

Transurethral resection of bladder tumor (TURBT) under white light cystoscopy (WLC) is the cornerstone for the diagnosis, removal and local staging of non-muscle invasive bladder cancer (NMIBC). Despite technological improvements over the decades, significant shortcomings remain with WLC for tumor detection, thereby impacting the surgical quality and contributing to tumor recurrence and progression. Enhanced cystoscopy modalities such as blue light cystoscopy (BLC) and narrow band imaging (NBI) aid resections by highlighting tumors that might be missed on WLC. Optical biopsy technologies such as confocal laser endomicroscopy (CLE) and optical coherence tomography (OCT) characterize tissue in real-time to ensure a more thorough resection. New resection techniques, particularly en bloc resection, are actively under investigation to improve the overall quality of resections and aid pathologic interpretation. Moreover, new image processing computer algorithms may improve perioperative planning and longitudinal follow-up. Clinical translation of molecular imaging agents is also on the horizon to improve optical diagnosis of bladder cancer. This review focuses on emerging technologies that can impact the quality of TURBT to improve the overall management of NMIBC.