Innovative Technique in Nonmuscle Invasive Bladder Cancer—Bipolar Plasma Vaporization

Systematic review and meta-analysis of narrow band imaging for non-muscle-invasive bladder cancer

To assess the effect of narrow band imaging-guided transurethral resection of bladder tumor compared with white light on recurrence rates in non-muscle-invasive bladder cancer. A systematic review of the literature from inception to November 2020 using Medline, EMBASE and CENTRAL was undertaken. Randomized controlled trials comparing transurethral resection of bladder tumor undertaken with narrow band imaging with those undertaken with white light that reported recurrence rates of at least 12 months were included in the analysis. Primary outcomes were recurrence rates at 12 and 24 months. Secondary outcomes were reported adverse effects. A total of 387 abstracts were screened, of which 14 full text identified and three studies included in the meta-analysis (921 patients). Meta-analysis did not show a statistically significant benefit to narrow band imaging at 12 months; risk ratio 0.75 (95% confidence interval 0.50-1.14, P = 0.18, I²  = 61%). No included studies provided recurrence data beyond 12 months. Adverse effects were reported in one study and no significant difference of complication rate was observed between the two groups. Risk of bias was assessed to be generally low, and grading of recommendations assessment development and evaluations were of high certainty. This meta-analysis of randomized controlled trials shows no difference in recurrence rates using narrow band imaging, although a trend in its favor was identified. Limitations include the varied reporting and administration of adjuvant therapies. Further well-designed trials are required to examine the benefit of this technology.

Outcomes and Complications of Bipolar vs. Monopolar Energy for Transurethral Resection of Bladder Tumors: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Bipolar and monopolar transurethral resections have a stable status for non-muscle invasive bladder cancer (NMIBC). We conducted a meta-analysis to analyze the outcomes and complications of bipolar vs. monopolar energy for transurethral resection of bladder tumors (TURB).

Methods: The Preferred Reporting Items for Systematic Reviews and Meta-analyses was followed. Based on the Population, Intervention, Comparator, Outcomes, and Study Designs (PICOS) strategy, randomized controlled trials were searched in MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. The reference lists of the associated articles were also retrieved. The data were calculated by Rev Man v5.3.0.

Results: Eleven publications containing an amount of 2, 099 patients were involved in the study. Two groups did not show a significant difference in the mean age and the number of bladder tumors. The results showed that m-TURB had a greater decrease in postoperative hemoglobin level [mean difference (MD) −0.26, 95% confidence interval (CI) −0.48 to −0.04, P = 0.02] and sodium level (MD −0.36, 95% CI −0.62 to −0.10, P = 0.007) compared with b-TURB. B-TURB spent relatively little in hospitalization time (MD −0.52, 95% CI −0.88 to −0.15, P = 0.005) than m-TURB with the exception of operation time (P = 0.47) and catheterization time (P = 0.19). B-TURB did not show a significant difference in the incidence rate of obturator reflex (P = 0.10), bladder perforation (P = 0.32), postoperative blood transfusion (P = 0.28), and clot retention (P = 0.21) compared with the b-TURB group. Besides, there were no significant difference in terms of muscle tissue sampling (P = 0.43), recurrence-free survival at 6 months (P = 0.68) and 12 months (P = 0.78).

Conclusions: B-TURB was more effective than m-TURB in minimizing intraoperative or postoperative bleeding with the smaller loss of hemoglobin and the shorter hospitalization time for patients with NMIBC.

Can bipolar energy serve as an alternative to monopolar energy in the management of large bladder tumours >3 cm? A prospective randomised study

Objectives: To assess the safety and the effectiveness of bipolar energy in the transurethral resection of primary large bladder tumours (TURBT) and compare it to conventional monopolar energy. Patients and methods: From November 2015 to June 2017, 80 patients underwent endoscopic resection primarily for large bladder cancer tumours of >3 cm. They were randomly assigned into two groups: 40 patients underwent a TURBT with conventional monopolar current (M-TURBT) and 40 were treated with bipolar current (B-TURBT). Results: There were no statistically significant differences between the two groups for the patients' demographic and tumour characteristics. There was a significant difference between M-TURBT and B-TURBT for resection time, obturator reflex, hospital stay, and catheterisation time, which were all higher in the M-TURBT group; the mean (SD) resection time was 26.45 (5.73) vs 22.85 (7.52) min (P = 0.048), the obturator reflex was 25% vs 5% (P = 0.025), the median hospital stay and catheterisation times were 2 vs 1 day (P = 0.012 and P = 0.023, respectively). No statistically significant difference was found between the groups for bladder perforation, TUR syndrome, drop in haemoglobin level, and blood transfusion rate. However, there was statically significant difference in the postoperative haematuria rate, which was higher in the M-TURBT group, at 24 patients vs eight in the B-TURBT group (60% vs 20%; P = 0.01). After 1-year follow-up, there was no significant difference in the recurrence rate between the groups. Conclusion: B-TURBT is a safe and effective alternative procedure to M-TURBT for the management of primary large bladder tumours of >3 cm. Abbreviations: CONSORT: consolidated standards of reporting Trials; Hb: haemoglobin; NMIBC: non-muscle-invasive bladder cancer; TUR: transurethral resection; (B-)(M-)TURBT: (bipolar) (monopolar) transurethral resection of bladder tumour.

Bipolar Transurethral Resection of Bladder Tumor Provides Better Tissue for Histopathology But Has No Superior Efficacy and Safety: A Randomized Controlled Trial

BACKGROUND AND PURPOSE

Bipolar transurethral resection of bladder tumors (TURBTs) has been claimed to have lesser complications and better specimen quality, but recent studies have contradictory results, and hence, we conducted this study to compare the clinical efficacy and safety of monopolar and bipolar electrosurgical modalities in TURBTs.

MATERIALS AND METHODS

A total of 287 patients were enrolled in the study and underwent TURBTs between July 2015 and September 2016. Patients undergoing surgery under general anesthesia and restage procedure were excluded from the study. Patient demographic profile, tumor characteristics, and complications of the procedures such as obturator jerk, bladder perforation, blood loss, need for resurgery, and transurethral resection syndrome were recorded. Tumor specimens were analyzed for stage, grade, deep muscle invasion, and quantity and quality of thermal artifacts.

RESULTS

A total of 160 patients were block randomized and analyzed with 80 patients in either group. Patient demographics and tumor characteristics were comparable between the groups. Change in hemoglobin levels and incidence of bladder perforation were comparable between the groups. A higher proportion of patients in bipolar group had obturator jerk compared with those in monopolar group, however, it was not statistically significant (24% vs 14%; p = 0.23). A higher proportion of patients in bipolar group did not have thermal artifacts when compared with monopolar group (27.5% vs 5%; p < 0.0001).

CONCLUSIONS

The operative risks of bipolar TURBT such as obturator jerk, bladder perforation, and blood loss are comparable with monopolar resection. However, less thermal artifacts in tissue samples obtained with bipolar resection may be helpful to the pathologist in interpretation of histopathologic findings.

Can tumor recurrence be reduced with plasma-kinetic vaporization of the area around the tumor in nonmuscle invasive bladder cancer?

Purpose

To investigate the effect on recurrence of vaporization of the tumor surroundings and suspicious areas with a plasma-kinetic (PK) system after transurethral resection (TUR) of nonmuscle invasive bladder cancer.

Materials and Methods

The study included 121 patients with a primary superficial bladder tumor who were randomized as those who underwent TUR with the PK system (Group 1, n=62) and those who underwent TUR with the monopolar system (Group 2, n=59). The vaporization procedure was performed by suppressing the cutting option of the PK system for a period, which would accumulate energy sufficient to make swelling-waves on the mucosa very close to the area of the loop to be vaporized.

Results

A total of 121 patients who met the study criteria were included for evaluation. Recurrence was determined in 21 patients in Group 1 (33.87%) and in 29 patients in Group 2 (49.15%) (p=0.088). Recurrence was close to the old resection site in 6 of 21 patients in Group 1, and in 13 patients in Group 2 (p=0.028); the difference was statistically significant. No statistically significant difference was determined between the two groups with respect to age, gender, number of tumor foci, rate or range of additional treatments applied, cigarette smoking rate, repeat TUR rate and rate of tumor en- countered in repeat TUR, T-stage, and tumor grade.

Conclusions

The effect of vaporization on recurrence by the PK system may seem similar to the effect of standard TUR, the recurrence- lowering effect surrounding nonmuscle invasive bladder cancers is better.

Transurethral en bloc resection with bipolar button electrode for non-muscle invasive bladder cancer

PURPOSE

Transurethral resection of bladder tumor (TURBT) using a wire loop is considered the gold standard for staging and treating non-muscle invasive bladder cancer (NMIBC). TURBT is associated with serious disadvantages that facilitate tumor recurrence. The present study evaluated the safety and efficacy of the bipolar button electrode for en bloc resection of NMIBC.

METHODS

From January 2013 to July 2016, 82 consecutive patients newly diagnosed with NMIBC received transurethral en bloc resection with bipolar button electrode. Operative details, pathological result, and intraoperative and postoperative complications regarded as safety outcomes were documented. Each patient was followed up for ≥ 18 months.

RESULTS

A total of 118 neoplasms were removed en bloc from 82 patients. The mean tumor diameter was 2.42 ± 1.34 cm. The average operation time was 35 ± 14 min. No complications such as bladder bleeding, vesicle perforation, and obturator nerve reflex occurred during the treatment. Pathological evaluations showed urothelial carcinoma with stage Ta low grade in 26 patients, T1 high grade in 51 patients, and T2 high grade in 5 patients. In addition, the bladder detrusor muscle layer was provided in all cases. The 18-month recurrence-free survival was 88.5% (23/26) and 74.5% (38/51) for Ta and T1 patients, respectively.

CONCLUSIONS

The current results demonstrated that transurethral en bloc resection with bipolar button electrode is an effective, feasible, and safe treatment for NMIBC.

Plasmakinetic bipolar versus monopolar transurethral resection of non-muscle invasive bladder cancer: a single center randomized controlled trial

OBJECTIVES

To compare the safety and the efficacy of plasmakinetic bipolar resectoscope versus conventional monopolar in the transurethral resection of primary non-muscle invasive bladder cancer.

METHODS

From January 2007 to December 2009, 132 patients underwent endoscopic resection for primary non-muscle invasive bladder cancer. They were randomly assigned to two groups: 67 patients underwent a transurethral resection of the bladder with bipolar plasmakinetic energy transurethral resection of the bladder and 65 were treated with conventional monopolar transurethral resection.

RESULTS

The mean operative time was 27 min for bipolar plasmakinetic energy transurethral resection of the bladder and 31 min for monopolar transurethral resection of the bladder. No significant differences in the mean change of hemoglobin and serum sodium level were observed. Mean catheterization time was 1.3 days and 2.3 days for bipolar plasmakinetic energy transurethral resection of the bladder and monopolar transurethral resection of the bladder, respectively. The mean hospital stay was shorter in the bipolar plasmakinetic energy transurethral resection of the bladder. Bladder perforation was reported in two cases for the monopolar transurethral resection of the bladder group and obturator nerve reflex occurred in a single case for both procedures. None of the patients experienced transurethral resection syndrome. The median time of bladder tumor recurrence after initial transurethral resection of the bladder was 12.4 months and 11.9 months for bipolar plasmakinetic energy transurethral resection of the bladder and monopolar transurethral resection of the bladder, respectively. No significant differences in the overall recurrence-free survival rate were observed comparing the two procedures.

CONCLUSIONS

Plasmakinetic bipolar transurethral resection represents a safe and effective procedure in the management of non-muscle invasive bladder cancer.