Thulium Laser Endoscopic En Bloc Enucleation of Nonmuscle-Invasive Bladder Cancer

En-bloc resection of non-muscle invasive urinary bladder tumors using low power Holmium laser-A new promise

INTRODUCTION

Urinary bladder tumors are one of the most common urological malignancies. Traditionally, it has been initially managed with conventional trans-urethral resection of urinary bladder tumors (cTURBT) which has certain drawbacks and complications. Efforts have been made to find newer methods for management. In this study, we have used low power Holmium laser en-bloc resection and have assessed its safety, efficacy and feasibility.

MATERIALS AND METHODS

Forty patients have been included in this prospective observational study who underwent low power Holmium laser en-bloc resection of urinary bladder tumor after taking Institutional ethical committee clearance and informed consent from all the patients. Intra-operative and post-operative data were collected.

RESULTS

The average tumor size was 21.68 ± 9.55 mm. Out of those, 65% of the patients had a tumor less than 3 cm in size. Fourteen patients (35%) had tumors at multiple sites. The average duration of resection per tumor was 24.84 ± 6.83 min. None of the cases required conversion to cTURBT. There was no obturator reflex or urinary bladder perforation in any of the cases. Detrusor muscle was present in the histopathology reports of 92.5% patients. The average duration of catheterization was 1.82 ± 0.61 days.

CONCLUSION

For NMIBC's, low power Holmium laser en-bloc resection is a safe procedure with minimum risk of complications. High rate of detrusor-positive specimens indicates its efficacy and feasibility.

The State-of-the-Art and Perspectives of Laser Ablation for Tumor Treatment

Tumors significantly impact individuals' physical well-being and quality of life. With the ongoing advancements in optical technology, information technology, robotic technology, etc., laser technology is being increasingly utilized in the field of tumor treatment, and laser ablation (LA) of tumors remains a prominent area of research interest. This paper presents an overview of the recent progress in tumor LA therapy, with a focus on the mechanisms and biological effects of LA, commonly used ablation lasers, image-guided LA, and robotic-assisted LA. Further insights and future prospects are discussed in relation to these aspects, and the paper proposed potential future directions for the development of tumor LA techniques.

Safety, feasibility, and quality of thulium laser en-bloc resection for treatment of non-muscle invasive bladder cancer

BACKGROUND

Trans-Urethral Resection of Bladder Tumors (TURBT) is a critical step in diagnosis, staging and treatment of bladder tumors. Conventional TURBT (cTURBT) involves the electro-resection of the tumor into small fragments. This technique leads to concerns about the completeness of resection, under-staging, bleeding, cancer cell implantation, and most importantly, risk of tumour recurrence. To circumvent this, laser en-bloc resection of bladder tumors has been introduced.

OBJECTIVES

Assessment of the safety, feasibility, and quality of Thulium Laser En-bloc Resection of Tumors (TmL-ERBT) for treatment of Non-Muscle Invasive Bladder Cancer (NMIBC) in various urinary bladder walls as a primary endpoint. The secondary endpoints were to investigate the feasibility of thulium laser use in the re-staging cystoscopy and to evaluate the learning curve of TmL-ERBT.

METHODS

This is a prospective observational study including all newly diagnosed patients, above 18 years old, with a urinary bladder mass ≤ 4 cm in maximal dimension (measured via bladder ultrasound or CT or MRI). All patients underwent TmL-ERBT under regional anaesthesia in a lithotomy position. All intraoperative complications such as obturator nerve reflex, bladder perforation, and significant bleeding were recorded. Postoperative variables such as the mean catheterization time, bladder irrigation fluid volume and duration, and the mean of hospital stay as well as the postoperative complications were recorded. All patients were risk stratified and managed according to EUA guidelines then followed by a surveillance regimen per 3 months for 6 months.

RESULTS

The study included 23 patients with a mean age of 53 ± 15.8 years. While 15 patients (65%) had a single tumor, the rest had multiple tumors, ranging from 2 to 3 in number with a total of 36 lesions. No cases required conversion to cTURBT and none of them experienced obturator nerve reflex or bladder perforation. Only one patient (4.3%) had an attack of clot urine retention. The mean hospitalization time was 31.2 ± 14.4 h and the mean catheterization time was 20.4 ± 13.3 h. The Detrusor muscle was present in 20 patients (87%) and the remaining 3 patients required a re-staging cystoscopy which was performed efficiently using thulium laser. None of the treated patients developed tumour recurrence during the follow-up period. In analysis, the duration of complete resection of 2-4 cm tumours was 23-27 min after the 7th case with a resection rate of 0.12-0.15 cm/min.

CONCLUSION

TmL-ERBT is safe and feasible for complete resection of NMIBC with a short learning curve and adequate cancer control.

Advances in lasers for the minimally invasive treatment of upper and lower urinary tract conditions: a systematic review

PURPOSE

Technological advancements in laser lithotripsy are expanding into numerous fields of urology, like ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), and benign and malignant soft-tissue treatments. Since the amount of research regarding lasers in urology has grown exponentially, we present a systematic review of the most recent and relevant advances encompassing all lasers used in urological endoscopic treatment.

METHODS

We performed a literature search using PubMed (May 2023) to obtain information about lasers for urological purposes. We included only recent data from published articles between 2021 and 2023 or articles ahead of print.

RESULTS

Lasers are widely used in lithotripsy for ureteric, renal, and bladder stones, benign prostate surgery, and bladder and upper tract tumor ablation. While the holmium (Ho:YAG) laser is still predominant, there seems to be more emphasis on pulse modulation and newer lasers such as thulium fiber laser (TFL) and pulsed Tm:YAG laser.

CONCLUSION

The use of lasers and related technological innovations have shown increasing versatility, and over time have proven to be invaluable in the management of stone lithotripsy, treatment of benign and malignant prostate diseases, and urothelial tumors. Laser endoscopic treatment is heavily based on technological nuances, and it is essential to know at least the basics of these technologies. Ultimately the choice of laser used depends on its availability, cost, surgeon experience and expertise.

A 10-year renaissance of en bloc resection of bladder tumors (ERBT): Are we approaching the peak or is it back to the trough?

BACKGROUND

The number of studies suggesting that en bloc resection of bladder tumor (ERBT) is superior to transurethral resection of bladder tumor (TURBT) for non-muscle-invasive bladder cancer (NMIBC) management is growing. The aim of this review is to discuss the features of these procedures and to determine the prospects of en bloc in NMIBC management.

MATERIALS AND METHODS

We conducted a literature search using two databases (Medline and Scopus) and included any research which reported ERBT outcomes.

RESULTS

The lasers with minimal tissue penetration depth are becoming the main tool for ERBT. Unfortunately, most of the systematic reviews continue to be characterized by high heterogeneity. However, recent studies indicate that ERBT may have the edge when it comes to the detrusor muscle rate and the quality of the histological specimen. ERBT may favor in terms of in-field relapse, but its rate in the studies varies greatly. As for out-field relapse-free survival, the data are still lacking. The strongest evidence supports that ERBT is superior to TURBT in complications rate (bladder perforation). ERBT is feasible irrespective to tumor size and location.

CONCLUSIONS

ERBT has gained in momentum with the increasingly widespread use of this kind of laser surgery. The introduction of novel sources (TFL and Thulium:YAG pulsed laser) will definitely affect how the field develops and will result in further improvements in safety and precision. The latest trials make us more certain in our belief that ERBT will be beneficial in terms of histological specimen quality, relapse rate and complications rate.

Combined use of a 980‑nm diode laser and preoperative intravesical instillation of pirarubicin for the prevention of short‑term recurrence of non‑muscle invasive bladder cancer: A pilot study

At present, transurethral resection of bladder tumors (TURBT) is the main surgical method for treating non-muscle invasive bladder cancer (NMIBC), but its postoperative recurrence needs to be prevented. The aim of the present study was to investigate the efficacy of a 980-nm diode laser combined with preoperative intravesical instillation of pirarubicin (THP) for the prevention of NMIBC recurrence. The data of 120 patients with NMIBC who underwent transurethral resection between May 2021 and July 2022 were retrospectively collected, and these patients were followed up. The patients were divided into four groups based on the surgical method used and preoperative intravesical instillation of THP as follows: i) 980-nm diode laser with THP (LaT); ii) 980-nm diode laser alone (La); iii) TURBT with THP (TUT); and iv) TURBT alone (TU). Clinicopathological variables, postoperative complications and short-term outcomes among the aforementioned groups were analyzed. The blood loss volume and the incidence of perforation and delayed bleeding were significantly lower in the LaT and La groups compared with those in the TUT and TU groups. The days of bladder irrigation, catheter extubation and postoperative hospitalization were significantly shorter in the LaT and La groups compared with the TUT and TU groups. The detection rate of suspicious lesions was significantly higher in the THP irrigation groups (LaT and TUT) compared with that in the saline irrigation groups (La and TU). Tumor diameter and number, 980-nm laser and THP irrigation were shown to be independent risk factors in the Cox regression analysis. In addition, the recurrence-free survival (RFS) rate of the LaT group was significantly higher than that of the other three groups. In conclusion, a 980-nm diode laser can effectively reduce intraoperative blood loss and the incidence of perforation, and accelerate postoperative recovery. Preoperative intravesical instillation of THP is conducive to identifying suspicious lesions. The combination of a 980-nm laser with preoperative THP intravesical instillation can significantly prolong RFS time.

Thulium laser enucleation of bladder tumour (Thulebt): Changing paradigm in the management of nonmuscle invasive urinary bladder carcinoma

OBJECTIVES

To analyse the safety and efficacy of Thulium laser en bloc enucleation of bladder tumour (ThuLEBT) in comparison to transurethral resection of bladder tumour (TURBT) for treatment of non-muscle invasive bladder cancer (NMIBC).

METHODS

Prospective observational study involving 30 patients in each group of ThuLEBT and TURBT admitted in tertiary care centre from 1st January 2021 to December 2021.

RESULTS

Significant difference was found in terms of less operative time (p-0.01468), less intraoperative blood loss, a lower incidence of obturator nerve reflex (p-0.00006), bladder perforation (p-0.0455) and bladder irrigation (p-0.0027), better acquisition of detrusor muscle (p-0.0466), less recurrence rate (p-0.0455) in favour of ThuLEBT over TURBT group. The analysis also demonstrated faster postoperative recovery in terms of the duration of catheterisation, bladder irrigation and hospitalisation time in ThuLEBT group.

CONCLUSIONS

ThuLEBT is an efficient and safe treatment for non-muscle invasive bladder cancer and it can be a better alternative choice in place of TURBT.

Precise diagnosis and treatment of non-muscle invasive bladder cancer - A clinical perspective

According to the guidelines, transurethral resection of bladder tumor (TURBT) followed by intravesical therapy remains the standard strategy for the management of non-muscle invasive bladder cancer (NMIBC). However, even if patients receive standard strategy, the risk of postoperative recurrence and progression is high. From the clinical perspective, the standard strategy needs to be optimized and improved. Compared to conventional TURBT, the technique of en bloc resection of bladder tumor (ERBT) removes the tumor tissue in one piece, thus following the principles of cancer surgery. Meanwhile, the integrity and spatial orientation of tumor tissue is protected during the operation, which is helpful for pathologists to make accurate histopathological analysis. Then, urologists can make a postoperative individualized treatment plan based on the patient's clinical characteristics and histopathological results. To date, there is no strong evidence that NMIBC patients treated with ERBT achieve better oncological prognosis, which indicates that ERBT alone does not yet improve patient outcomes. With the development of enhanced imaging technology and proteogenomics technology, en bloc resection combined with these technologies will make it possible to achieve precise diagnosis and treatment of bladder cancer. In this review, the authors analyze the current existing shortcomings of en bloc resection and points out its future direction, in order to promote continuous optimization of the management strategy of bladder cancer.

Long-term effect of transurethral partial cystectomy with a 2-micrometer continuous-wave laser for non-muscle-invasive bladder cancer

Purpose

We have reported the efficacy and safety of 2-micrometer continuous-wave laser cystectomy of non-muscle invasive bladder tumor (NMIBC) (J Urol. 2009;182:66-9). In this study, we evaluated the long-term outcomes of patients with NMIBC who underwent transurethral partial cystectomy with a 2-micrometer continuous-wave laser, and explored the risk factors for tumor recurrence.

Methods

This was a retrospective study of patients with NMIBC planned to undergo transurethral partial cystectomy with a 2-micrometer continuous-wave laser at the Fourth Medical Center of the PLA General Hospital between January 2012 and December 2014. The primary outcome was bladder cancer recurrence.

Results

A total of 75 patients were enrolled. Sixty-two (82.7%) were male. The patients were 59.8 ± 12.9 years of age. The mean operation time was 38.7 ± 20.4 min. No Clavien grade >2 complications occurred. The duration of catheter indwelling was 3.6 ± 1.8 days. The hospital stay was 6.0 ± 2.3 days. The median follow-up was 80 months. A total of 17 patients had a recurrence during follow-up, and the recurrence-free survival (RFS) rate was 77.3%. In the multivariable analysis, the tumor risk group were independently associated with the recurrence of NMIBC (p = 0.026).

Conclusions

After TURBT with a 2-micrometer continuous-wave laser, RFS was 77.3% at the median follow-up of 80 months. All complications were mild. Only tumor risk group was independently associated with the recurrence of NMIBC.

En bloc versus standard transurethral resection of bladder tumors for non‐muscle‐invasive bladder cancer patients

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To assess the effects of en bloc resection compared with conventional transurethral resection of the bladder tumor (conventional TURBT) in patients with non‐muscle‐invasive bladder cancer.

Can a reresection be avoided after initial en bloc resection for high-risk nonmuscle invasive bladder cancer? A systematic review and meta-analysis

Background

This study aims to evaluate the effectiveness of en bloc resection for patients with nonmuscle invasive bladder cancer (NMIBC) and explore whether a reresection can be avoided after initial en bloc resection.

Material and methods

We conducted research in PubMed, EMBASE, Cochrane Library, and Web of Science up to October 12, 2021, to identify studies on the second resection after initial en bloc resection of bladder tumor (ERBT). R software and the double arcsine method were used for data conversion and combined calculation of the incidence rate.

Results

A total of 8 studies involving 414 participants were included. The rate of detrusor muscle in the ERBT specimens was 100% (95%CI: 100%–100%), the rate of tumor residual in reresection specimens was 3.2% (95%CI: 1.4%–5.5%), and the rate of tumor upstaging was 0.3% (95%CI: 0%–1.5%). Two articles compared the prognostic data of the reresection and non-reresection groups after the initial ERBT. We found no significant difference in the 1-year recurrence-free survival (RFS) rate (OR = 1.44, 95%CI: 0.67–3.09, P = 0.35) between the two groups nor in the rate of tumor recurrence (OR = 0.72, 95%CI: 0.44–1.18, P = 0.2) or progression (OR = 0.98, 95%CI: 0.33–2.89, P = 0.97) at the final follow-up.

Conclusions

ERBT can almost completely remove the detrusor muscle of the tumor bed with a very low postoperative tumor residue and upstaging rate. For high-risk NMIBC patients, an attempt to appropriately reduce the use of reresection after ERBT seems to be possible.

A Systematic Review on the Role of Repeat Transurethral Resection after Initial en Bloc Resection for Non-Muscle Invasive Bladder Cancer

International guidelines recommend repeat transurethral resection of bladder tumors (reTURB) for selected patients with high-risk non-muscle invasive bladder cancer to remove possible residual tumors, restage tumors and improve the therapeutic outcome. However, most evidence supporting the benefits of reTURB is from conventional TURB. The role of reTURB in patients receiving initial En bloc resection of bladder tumor (ERBT) is still unknown. PubMed, Embase, Web of Science, The Cochrane Library, and China National Knowledge Infrastructure (CNKI) were systematically searched. Finally, this systematic review and meta-analysis included twelve articles, including 539 patients. The rates of residual tumor and tumor upstaging detected by reTURB after ERBT were 5.9% (95%CI, 2.0%–11.1%) and 0.0% (95%CI, 0.0%–0.5%), respectively. Recurrence-free survival, tumor recurrence and progression were comparable between patients with and without reTURB after initial ERBT. The pooled hazard ratios of 1-year, 2-year, 3-year and 5-year recurrence-free survival were 0.74 (95%CI, 0.36–1.51; p = 0.40), 0.76 (95%CI, 0.45–1.26; p = 0.28), 0.83 (95%CI, 0.53–1.32; p = 0.43) and 0.83 (95%CI, 0.56–1.23; p = 0.36), respectively. The pooled relative risks of recurrence and progression were 0.87 (95%CI, 0.64–1.20; p = 0.40) and 1.11 (95%CI, 0.54–2.32; p = 0.77), respectively. Current evidence demonstrates that reTURB after ERBT for bladder cancer can detect relatively low rates of residual tumor and tumor upstaging and appears not to improve either recurrence or progression.

En bloc resection of bladder tumors: challenges and unmet needs in 2021

Non-muscle invasive bladder cancer accounts for the majority of new bladder cancer diagnoses, and endoscopic transurethral resection of bladder tumor (TURBT) represents the standard-of-care. Although a relatively safe and common procedure, TURBT is often hampered by the questionable quality of resection. The evolution of surgical techniques has brought en bloc resection of bladder tumor (ERBT) to the forefront. ERBT has emerged as an alternative to conventional TURBT, incorporating a more delicate en bloc sculpting and tumor excision, in contrast to 'piecemeal' resection by conventional TURBT. ERBT appears safe, feasible and effective with demonstrably higher rates of detrusor muscle in the pathologic specimen, all while providing better staging and obviating the need for a re-TURBT in selected patients. However, the method's adoption in the field is still limited. This review summarizes the recent evidence relevant to ERBT while further highlighting the technique's limitations and unmet needs.

[Interpretation of biopsy material after transuretral and laser en bloc resection of non-muscle-invasive bladder cancer]

Bladder cancer is one of the most common onco-urological diseases, ranked second in frequency among all tumors of the urinary system after prostate cancer. At the time of detection of the primary tumor, approximately 75% of patients have no invasion into the muscularis layer (non-muscle-invasive carcinoma), with tumor growth limited to the basal membrane (stage Ta) or submucosal base (stage T1). Removal of the tumor in a «unified block» (laser en-bloc resection or L-ERBT), unlike routine transurethral resection, allows to obtain qualitative biopsy material for precise pathomorphological staging of the tumor process. In order to accurately stratify a patient into one or another risk group, verification of the following morphological parameters is required: degree of tumor differentiation and its malignancy, depth of invasion, foci of carcinoma in situ at resection margins, presence or absence of lymphovascular invasion. Identification of tumor variant histology is also recommended. Information on presence or absence of detrusor elements in the specimen is necessary in the morphological report, as this parameter is considered as a criterion of radically performed tumor removal. According to ICCR recommendations (International Collaboration on cancer reporting), it is recommended to use subclassification of T1 stage using all possible criteria: volume and/or depth of invasion (assessed in mm), and/or width of invasion «spot» (assessed in mm), and/or involvement of anatomical structure - muscularis mucosae. Full morphological examination of the material obtained during the primary resection of the tumor is an important step in the diagnosis and treatment of bladder cancer, as it allows to stratify the patient into one or another risk group and, accordingly, allows to develop a personalized postoperative management.

[Safety and efficacy of en bloc vs. conventional transurethral resection of bladder tumors: a meta-analysis and systematic review]

BACKGROUND

En bloc tumor resection of bladder tumors (ERBT) is a novel alternative procedure to conventional resection of bladder tumor (cTURBT), which might help to address common problems of the standard method, such as inadequate detrusor muscle in specimens, high re-resection rates and high recurrence rates.

OBJECTIVE

To analyze current data on ERBT in efficacy and safety compared to cTURBT.

DATA SOURCES

PubMed.

STUDY SELECTION

Two independent authors identified trials based on keywords and inclusion criteria. A third author was consulted in case of discrepancies. Screening keywords: ERBT, en bloc transurethral resection of bladder tumor, TURBT en bloc. A meta-analysis of 13 studies was performed. The effect size was estimated based on odds ratios and mean differences including their corresponding two-sided 95% confidence intervals.

DATA SYNTHESIS

The analyzed studies comprised a homogenous collective in terms of tumor size, tumor multiplicity and tumor stage. Operation time did not significantly differ between the methods. Differences were observed in hospitalization and catheterization time in favor of ERBT. Reported complications did not show clear differences. There was significantly more detrusor muscle in the specimens in the ERBT group. No significant differences were found in recurrence up to 2 years of follow-up.

CONCLUSION

ERBT is a safe alternative to conventional TURBT with promising features regarding effective resection of detrusor muscle. More standardized data on recurrence rates, different resection modalities and resection margin results are needed.

En bloc resection, is this the future of non-muscle invasive bladder cancer management? Presentation of our technique and brief review of the literature

INTRODUCTION

The quality of the initial transurethral resection of bladder tumors (TURBT) plays a key role in accurate local staging thus affecting treatment decision-making and disease prognosis. TURBT is still the gold standard for non-muscle invasive bladder cancer (NMIBC). However, en bloc resection of bladder tumors (ERBT) gradually expanded as a promising alternative to TURBT, aiming to overcome certain inherent limitations of conventional resection. We hereby describe a step-by-step bipolar ERBT technique and briefly review the current trends surrounding the role of various en bloc techniques in the field.

CASE PRESENTATION

We present the case of a 65-year old patient undergoing bipolar ERBT for a single, approximately 2 cm, papillary bladder mass. An experienced urologist completed the procedure within 17 min and without any intra- or postoperative complications. No conversion to TURBT was needed, and an adequate specimen for histological assessment was obtained. The patient made an uneventful recovery, and no recurrence was noted at 12-months.

CONCLUSION

Our initial experience demonstrates that ERBT via bipolar current is relatively quick, safe, and reliable. Prospective comparative clinical trials will examine its efficacy, and long-term oncological superiority in managing NMIBC.

Laser technology in urologic oncology

Laser technology has been used in Urology since the 80s with a lot of different applications in endoscopic and open surgery. With the developments of the technology and the introduction of new active medium and source of laser energy, this technology have become the gold standard not only in stone surgery but even in benign prostate enlargement (BPE) surgical treatment. Regarding urologic oncology, laser energy has now reached an important role in focal therapy and in conservative treatment. The possibility of having better functional outcomes without any relevant impact on oncological results led to an increased use of laser in penile surgery, with a significant mention in urological guidelines for this option. In urothelial cancers as well, both in conservative management of upper tract tumors that in the treatment of non muscle invasive bladder cancer, a clear role of these relatively new source of energy have been demonstrated. Finally, both in prostate that in renal cancer the strategy of focal therapy may take advantage from this precise and fine technology. In this review we analyzed and described the applications of laser energy in urological cancers with a specific focus on penile, urothelial and prostate cancer.

Wavelength-stabilized tunable mode-locked thulium-doped fiber laser beyond 2 µm

We report the development of a widely tunable mode-locked thulium-doped fiber laser based on a robust chirped fiber Bragg grating (CFBG). By applying mechanical tension and compression to the CFBG, an overall tunability of 20.1 nm, spanning from 2022.1 nm to 2042.2 nm, was achieved. The observed mode-locked pulse train from this fiber laser has a repetition rate of 9.4 MHz with an average power of 12.6 dBm and a pulse duration between 9.0 ps and 12.8 ps, depending on the central wavelength. To the best of our knowledge, this is the first demonstration of a tunable mode-locked thulium-doped fiber laser operating beyond 2 µm using a CFBG as a wavelength-selective element.

En bloc resection for nonmuscle-invasive bladder cancer: selecting a proper laser

PURPOSE OF REVIEW

To discuss the most recent surgical lasers that have been made available to us and to evaluate their potential in performing en bloc resection of nonmuscle invasive bladder cancer.

RECENT FINDINGS

Laser en bloc resection of bladder tumors (ERBT) can be performed with a number of laser systems including Ho:YAG, GreenLight, diode, Tm:YAG and thulium fiber lasers (TFL). The data that is currently available suggests that the water-targeting devices (utilizing water as a primary chromophore - Ho:YAG, Tm:YAG, TFL) may have a number of advantages over hemoglobin-targeting systems (potassium titanyl phosphate:YAG, lithium triborate:YAG). One recent addition to the surgical armamentarium Moses effect enhanced Ho:YAG and the TFL (being able to work both in quasi-continuous and SuperPulsed modes) necessitates careful discussion and comparison with the other available devices.

SUMMARY

The majority of available lasers have proven to be safe to use and compared to electrocautery allow for lower rates of obturator nerve reflex and result in fewer bleeding complications. The minimal penetration depth and decreased peak power of Tm:YAG and TFLs render them the devices of choice when it comes to ERBT. Unfortunately, more studies on ERBT with TFL are needed in order for us to make a sound assessment of the respective pros and cons.

Medical Image Diagnostic Value of Computed Tomography for Bladder Tumors

OBJECTIVE

To study computed tomography (CT) imaging characteristics of bladder tumors, to explore the value of CT in tumor diagnosis, and to identify the relevant factors of CT missed diagnosis so that medical staff can be more accurate in the diagnosis of bladder tumors.

METHODS

To retrospectively analyze the CT manifestations of 153 bladder tumor cases confirmed by paraffin pathology in our hospital and to study the difference between the benign and CT imaging features. CT indicators mainly include the number, location, morphology, calcification, bladder wall smoothness, CT value, degree of enhancement, and invasion of surrounding tissues and organs. Then, we retrospectively analyze 17 cases of CT missed diagnosis of bladder tumors, analyze related factors, and discuss the role of CT in the diagnosis of bladder tumors.

RESULTS

This study has shown that with the help of CT images, the diagnosis rate of bladder tumors has been greatly improved. Of the 153 patients studied, noninvasive urothelial carcinoma accounted for 18.95% of all benign and malignant bladder tumors, invasive urothelial carcinoma accounted for 67.93%, prostatic metastatic carcinoma and inflammatory myofibroblastoma accounted for 8.47%, pheochromocytoma accounted for 1.31%, inverted papilloma accounted for 1.31%, tubular choriocarcinoma accounted for 0.63%, and endocystitis accounted for 1.31%. In addition, the blood supply level, CT index bladder wall smoothness, and CT value are also statistically significant (P < 0.05).

CONCLUSIONS

CT is of high value in the diagnosis of bladder tumors, and benign and malignant bladder tumors have CT and CT imaging features. The size of bladder tumors is related to the missed diagnosis rate of CT. The application of CT examination technology can improve the accuracy of diagnosis of bladder tumors.

Green-light laser en bloc resection versus conventional transurethral resection for initial non-muscle-invasive bladder cancer: A randomized controlled trial

OBJECTIVE

To compare the safety and outcomes between green-light laser en bloc resection and transurethral resection of bladder tumor.

METHODS

A single-center, randomized controlled trial was carried out from August 2014 to September 2018. Patients with initial non-muscle-invasive bladder cancer were randomized to green-light laser en bloc resection or transurethral resection of bladder tumor. The primary outcomes were pathological findings and perioperative events. The secondary outcome was tumor recurrence.

RESULTS

A total of 233 patients were randomized to the transurethral resection of bladder tumor group (117 patients) and the green-light laser en bloc resection group (116 patients). The resection time was longer in the green-light laser en bloc resection group (P = 0.022); however, no differences were identified in overall operative time (P = 0.255). Nine patients (7.7%) had an obturator nerve reflex during transurethral resection of bladder tumor. The estimated volume of blood loss was significantly lower in the green-light laser en bloc resection group (P = 0.012). The green-light laser en bloc resection group had a higher rate of T1 bladder cancer (P = 0.031). A total of 104 patients (89.7%) treated with green-light laser en bloc resection had detrusor muscle presence in the specimen, whereas 37 (31.9%) patients had the presence of muscularis mucosae, which was significantly higher than the corresponding number of transurethral resection of bladder tumor patients (P = 0.005 and 0.002, respectively). After a median follow-up period of 48 months, just five patients had tumor recurrence (three in the transurethral resection of bladder tumor group and two in the green-light laser en bloc resection group), and there was no difference between these two groups.

CONCLUSIONS

Compared with transurethral resection of bladder tumor, green-light laser en bloc resection is more effective due to less obturator nerve reflex and the same recurrence rate. Most importantly, green-light laser en bloc resection can provide better tumor specimens for pathological examinations.

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.

Non-muscle-invasive bladder cancer: An overview of potential new treatment options

AIM

This review article summarizes the current clinical practice guidelines around disease definitions and risk stratifications, and the treatment of non-muscle-invasive bladder cancer (NMIBC). Recently completed and ongoing clinical trials of novel and investigational therapies in Bacillus Calmette-Guérin (BCG)-naïve, BCG-recurrent, and BCG-unresponsive patient populations are also described, e.g., those involving immune checkpoint inhibitors, targeted therapies, other chemotherapy regimens, vaccines, and viral- or bacterial-based treatments. Finally, a brief overview of enhanced cystoscopy and drug delivery systems for the diagnosis and treatment of NMIBC is provided.

BACKGROUND

A global shortage of access to BCG is affecting the management of BCG-naïve and BCG-recurrent/unresponsive NMIBC; hence, there is an urgent need to assist patients and urologists to enhance the treatment of this disease.

METHODS

Searches of ClinicalTrials.gov, PubMed, and Google Scholar were conducted. Published guidance and conference proceedings from major congresses were reviewed.

CONCLUSION

Treatment strategies for NMIBC are generally consistent across guidelines. Several novel therapies have demonstrated promising antitumor activity in clinical trials, including in high-risk or BCG-unresponsive disease. The detection, diagnosis, surveillance, and treatment of NMIBC have also been improved through enhanced disease detection.

Surgery for Bladder and Upper Tract Urothelial Cancer

The cornerstone for diagnosis and treatment of bladder and upper tract urothelial carcinoma involves surgery. Transurethral resection of bladder tumors forms the basis of further management. Radical cystectomy for invasive bladder carcinoma provides good oncologic outcomes. However, it can be a morbid procedure, and advances such as minimally invasive surgery and early recovery after surgery need to be incorporated into routine practice. Diagnostic ureteroscopy for upper tract carcinoma is needed in cases of doubt after cytology and imaging studies. Low-risk cancers can be managed with conservative endoscopic surgery without compromising oncological outcomes; however, high-risk disease necessitates radical nephroureterectomy.

Comparison of Thulium Laser Resection of Bladder Tumors and Conventional Transurethral Resection of Bladder Tumors for Non-Muscle-Invasive Bladder Cancer

INTRODUCTION

The thulium laser resection of bladder tumors (TmLRBT) was increasingly used in the treatment of non-muscle-invasive bladder cancer (NMIBC) recently, and here we report the relevant outcomes of our institution to evaluate its efficacy and safety.

METHODS

We retrospectively collected the data of NMIBC patients who underwent either TmLRBT or transurethral resection of bladder tumor (TURBT). The baseline characteristics and perioperative outcomes were compared in these 2 groups.

RESULTS

The TmLRBT had a higher rate of detrusor identification than TURBT (97.4 vs. 87.6%, p = 0.001). After screening, 134 patients who underwent TmLRBT and 152 patients who received TURBT were enrolled in the analysis, and their baseline characteristics were similar. During the TURBT, 24 (15.8%) obturator nerve reflexes and 9 (5.9%) bladder perforations occurred, while none happened during the TmLRBT. After surgery, TmLRBT patients had fewer postoperative gross hematuria (38.1 vs. 96.7%, p < 0.001) and postoperative irrigation (27.6 vs. 92.7%, p < 0.001), and its irrigation duration was significantly shorter (2.3 vs. 3.3 day, p < 0.001). During the follow-up, no significant difference in the recurrence rate was detected (p = 0.315).

CONCLUSIONS

TmLRBT is a safer technique than conventional TURBT in the treatment of NMIBC, and it could offer better specimens for pathologic assessment while the cancer control was not compromised.

Feasibility and accuracy of pathological diagnosis in en-bloc transurethral resection specimens versus conventional transurethral resection specimens of bladder tumour: evaluation with pT1 substaging by 10 pathologists

AIMS

En-bloc transurethral resection (TUR) of bladder tumour (ERBT) is designed to provide more accurate pathological diagnosis of specimens than conventional TUR of bladder tumour (cTURBT). Some studies have reported that T1 bladder cancer substage could be a prognostic factor in assessing tumour progression, but such substaging has not been widely adopted because of problems with pathological diagnosis using cTURBT specimens. The aim of this study was to evaluate the possible advantages of en-bloc TUR specimens in T1 substaging following assessment by a panel of 10 pathologists.

METHODS AND RESULTS

We assessed the substages in 123 patients (cTURBT, n = 91; ERBT, n = 32) who were diagnosed with pT1 bladder cancer. We randomly selected 10 ERBT specimens and 10 cTURBT specimens with cancer invasion areas equivalent to those of their corresponding ERBT specimens. Ten pathologists performed pT1 substaging for pT1a/b/c and pT1m/e in 20 patients (cTURBT, n = 10; ERBT, n = 10). We evaluated diagnostic times and rates of diagnostic concordance among these pathologists, comparing cTURBT and ERBT. The median diagnostic times per slide were 87.7 s [interquartile range (IQR) 71.9-109.2 s) for cTURBT and 54.7 s (IQR 46.0-59.6 s) for ERBT (P = 0.009). The rate of diagnostic concordance was significantly better for ERBT specimens. For pT1a/b/c, the median concordance rates were 50% for cTURBT and 80% for ERBT (P = 0.02); for pT1m/e, the median concordance rates were 70% for cTURBT and 90% for ERBT (P = 0.05). For pT1a/b/c, the average κ-values between the pathologist and the standard diagnosis were 0.04 for cTURBT and 0.47 for ERBT.

CONCLUSIONS

The use of ERBT specimens shortened the diagnostic time and minimised interobserver variability for T1 substaging compared with the use of cTURBT specimens.

En Bloc Tumor Resection, Optical Molecular Imaging, and the Potential Synergy of the Combination of the Two Techniques in Bladder Cancer

Although transurethral resection of bladder tumor is the golden standard for the treatment of non-muscle invasive bladder cancer, this surgical procedure still has some serious drawbacks. For example, piecemeal resection of tumor tissue results in exfoliated tumor cells dissemination and implantation, and fragmented tumor specimens make it difficult for pathologists to accurately assess the pathological stage and histologic grade. En bloc tumor resection follows the basic principle of oncological surgery and provides an intact tumor specimen containing detrusor muscle for pathologists to make accurate histopathological assessment. However, there is no robust clinical evidence that en bloc tumor resection is superior to conventional resection in terms of oncological outcomes. Considering the high recurrence rate, small or occult tumor lesions may be overlooked and incomplete tumor resection may occur during white light cystoscopy-assisted transurethral resection. Molecular fluorescent tracers have the ability to bind tumor cells with high sensitivity and specificity. Optical molecular imaging mediated by it can detect small or occult malignant lesions while minimizing the occurrence of false-positive results. Meanwhile, optical molecular imaging can provide dynamic and real-time image guidance in the surgical procedure, which helps urologists to accurately determine the boundary and depth of tumor invasion, so as to perform complete and high-quality transurethral tumor resection. Integrating the advantages of these two technologies, optical molecular imaging-assisted en bloc tumor resection shows the potential to improve the positive detection rate of small or occult tumor lesions and the quality of transurethral resection, resulting in high recurrence-free and progression-free survival rates.

Safety and efficacy of thulium laser resection of bladder tumors versus transurethral resection of bladder tumors: a systematic review and meta-analysis

The thulium laser resection of bladder tumor (TmLRBT) is widely used in the treatment of non-muscle-invasive bladder cancer (NMIBC), and we conduct this study to compare the safety and efficacy of TmLRBT with transurethral resection of bladder tumor (TURBT). A comprehensive literature research was conducted using multiple databases, and comparative studies evaluating the safety and efficacy of TmLRBT and TURBT were included. For continuous outcomes, the weighted mean difference (WMD) was used to measure the difference, whereas the risk ratio (RR) with a 95% confidence interval (CI) was calculated for binary variables. Overall, ten studies with 1558 patients enrolled were included in the meta-analysis. The baseline characteristics of two groups were comparable. The operative time (p = 0.24) and catheterization time (p = 0.41) of two groups were similar but the TmLRBT group had a shorter length of hospital stay (p = 0.04). TmLRBT was related to fewer intraoperative complications including obturator nerve reflex (p < 0.001) and bladder perforation (p < 0.001). Although the rate of postoperative irrigation did not significantly differ in our analysis (p = 0.28), the TmLRBT was related to a significantly shorter duration of irrigation (p = 0.004). Besides, the TmLRBT group had a higher rate of identification of detrusor (p = 0.02). However, TmLRBT did not suggest significantly better cancer control than TURBT including the overall recurrence (p = 0.052), 1-year recurrence (p = 0.23), and 2-year recurrence (p = 0.40). Compared with conventional TURBT, the TmLRBT showed superior safety and non-inferior efficacy in cancer control. TmLRBT could also provide high-quality specimens for pathology diagnosis; therefore, it is an as effective option for NMIBC.

Outcomes of stratified transurethral resection of bladder tumor: A propensity score-matched analysis

BACKGROUND/PURPOSE

Several strategies have been reported for improving the integrity of transurethral resection of bladder tumor (TURBT). However, no standard has been established. Stratified TURBT (SR) is one of protocols for TURBT, wherein exophytic tumors are first resected and retrieved, and tumor bases are then resected. In this study, we aimed to evaluate the outcomes of SR in patients with nonmuscle invasive bladder cancer (NMIBC).

METHODS

From January 2012 to December 2017, patients newly diagnosed as having NMIBC with a follow-up period of more than 2 years were enrolled and categorized into SR and conventional TURBT (CR) groups. Propensity score matching at a 2:1 ratio was performed. Outcomes were the detrusor muscle sampling rate, recurrence-free survival (RFS), and progression-free survival (PFS).

RESULTS

In total, 205 patients were included in our study. The detrusor muscle sampling rate was higher in the SR group (P = 0.043). After propensity score matching, 162 patients were selected for outcome analysis, with 108 and 54 patients undergoing SR and CR, respectively. Compared with the CR group, the SR group showed a lower recurrence rate (P = 0.015) and better RFS in univariate (P = 0.010) and multivariate (P = 0.006) Cox proportional hazards regression. Progression rate and PFS were not significantly different between the two groups.

CONCLUSION

SR results in a higher detrusor muscle sampling rate and better disease outcomes. Our findings suggest that SR is a promising strategy for TURBT in patients with NMIBC.

Prognosis of patients with T1 bladder cancer after en bloc transurethral resection of bladder tumor stratified by invasion to the level of the muscularis mucosa

PURPOSE

To evaluate the prognosis of patients with pT1 bladder cancer who underwent en bloc resection of bladder tumors (ERBTs), stratified by invasion to the muscularis mucosa (MM) level.

METHODS

Among 64 specimens obtained by ERBT with bipolar energy from patients with pT1 bladder cancer, MM was detected in 61 specimens. Thus, 61 specimens were included in this retrospective study. Patients were stratified by invasion to the MM level (pT1a, invasion above the MM level; pT1b, invasion within the MM level; and pT1c, invasion beyond the MM level). In specimens with discontinuous MM, invasion to the MM level was predicted from the dispersed MM in the specimen. The primary endpoints were progression-free survival (PFS) and cancer-specific survival (CSS).

RESULTS

Progression occurred in 2/39 patients with pT1a (5.1%), 1/6 patients with pT1b (16.7%), and 6/16 patients with pT1c cancer (37.5%). Cancer death occurred in 1/39 patients with pT1a (2.6%), 0/7 patients with pT1b, and 3/16 patients with pT1c cancer (18.8%). Patients with pT1a or pT1b cancer had a significantly better prognosis than those with pT1c cancer. On univariate analysis, tumor size ≥ 3 cm and pT1c were significantly associated with shorter PFS. On multivariate analysis, only pT1c was independently associated with shorter PFS.

CONCLUSION

This is the first study evaluating the prognosis by T1 substaging based on invasion to the MM level using ERBT specimens. ERBT provided high-quality specimens for diagnosing the MM and showed poor prognosis in pT1c bladder cancer. ERBT could be an appropriate surgical approach for an accurate diagnosis and prognosis of the T1 bladder cancer substage.

Holmium Laser En-bloc Resection Versus Conventional Transurethral Resection of Bladder Tumors for Treatment of Non-muscle-invasive Bladder Cancer: A Randomized Clinical Trial

BACKGROUND

En-bloc resection of bladder tumors achieves complete tumor removal, improves the quality of resection, decreases perioperative complication, and potentially improves recurrence rates.

OBJECTIVE

To assess the efficacy and safety of holmium laser en-bloc resection (HolERBT) versus conventional transurethral resection of bladder tumor (cTURBT).

DESIGN, SETTING, AND PARTICIPANTS

Between September 2015 and September 2018, 100 patients with non-muscle-invasive bladder cancer were randomly allocated to cTURBT or HolERBT.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was detection of residual tumor in reTURBT specimens at 4 wk after the primary resection. Operative parameters, specimen quality, perioperative complications, and recurrence-free survival (RFS) were compared. Independent sample t tests, χ² tests, and Kaplan-Meier curves were used, as appropriate.

RESULTS AND LIMITATIONS

The patient and tumor baseline characteristics were comparable between the groups. Residual tumors were detected in 7% and 27.7% of cases after HolERBT and cTURBT, respectively (p=0.01). Detrusor muscle was sampled in 98% of HolERBT and 62% of cTURBT cases (p<0.001). Lamina propria invasion substaging was feasible in only 68.2% of HolERBT and 18.4% of cTURBT cases (p<0.001). Following HolERBT, catheterization time (p<0.001) and hospital stay (p=0.001) were shorter when compared to cTURBT. Immediate postoperative instillation of chemotherapy in indicated cases was feasible for 100% of the HolERBT group and 91.5% of the cTURBT group (p=0.04). After follow-up of 20 ± 9.9 mo (13-36), RFS was 31.76 mo (95% confidence interval [CI] 28.67-34.86) in the HolERBT group and 28.25 mo (95% CI 24.87-31.64) in the cTURBT group (hazard ratio 0.43, 95% CI 0.17-1.1; p=0.07). However, this study was not powered to detect a difference in RFS.

CONCLUSIONS

Compared to cTURBT, HolERBT is a safer procedure for bladder tumor resection. It fulfills the oncological criteria of optimized resection with less residual tumor and better specimen quality.

PATIENT SUMMARY

En-bloc resection of bladder cancer tumors using a holmium laser is safer than the conventional technique. It has the advantages of less residual tumor and better specimen quality, with a similar tumor recurrence rate. This study is registered at ClinicalTrials.gov as NCT02555163.

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.

Efficacy and Safety of Transurethral Laser Surgery Versus Transurethral Resection for Non-Muscle-Invasive Bladder Cancer: A Meta-Analysis and Systematic Review

OBJECTIVE

To compare the efficacy and safety of transurethral laser surgery and transurethral resection of a bladder tumor (TURBT) for non-muscle-invasive bladder cancer (NMIBC).

MATERIAL AND METHODS

A research was carried out in Medline via PubMed, EMBASE, the Cochrane Library, and Web of Science up to October 20, 2019, to identify articles related to transurethral laser surgery and TURBT for NMIBC. All analyses were done using RevMan5.3 and Stata14.

RESULTS

A total of 17 studies involving 2,439 participants were included. The analysis showed no significant difference in operation times (mean difference = -0.2; 95% CI -2.29 to 1.89; p = 0.85) or occurrences of urethral stricture (OR = 0.7; 95% CI 0.24-2.06; p = 0.52). Transurethral laser surgery was associated with a lower incidence of obturator nerve reflex (OR = 0.04; 95% CI 0.02-0.09; p < 0.00001) and bladder perforation (OR = 0.09; 95% CI 0.04-0.23; p < 0.00001), a higher rate of detrusor muscle acquisition (OR = 5.28; 95% CI 2.42-11.49; p < 0.0001), shorter catheterization (mean difference = -1.05; 95% CI -1.41 to -0.68; p < 0.00001) and hospitalization times (mean difference = -0.96; 95% CI -1.59 to -0.33; p = 0.003), and lower rates of bladder irrigation (OR = 0.21; 95% CI 0.13-0.35; p < 0.00001) and recurrence both at 12 months (OR = 0.66; 95% CI 0.48-0.9, p = 0.008) and at 24 months (OR = 0.6; 95% CI 0.41-0.86; p = 0.005).

CONCLUSIONS

Transurethral laser surgery for NMIBC, as compared to TURBT, is associated with a lower incidence of complications, a lower recurrence rate, and faster postoperative recovery.

Safety, feasibility, and quality of holmium laser en-bloc resection of nonmuscle invasive bladder tumors - A single-center experience

Introduction:

Conventional transurethral resection of bladder tumor (cTURBT), despite its piecemeal resection and associated limitations, remains the most widely practiced technique of TURBT. Resecting the tumor in a single piece would avoid most of the drawbacks of cTURBT. Our objective was to assess the feasibility, safety, and quality of Holmium (Ho) laser en-bloc resection (ERBT) for nonmuscle-invasive bladder cancer (NMIBC).

Materials and Methods:

We retrospectively studied 67 patients who underwent Ho laser EBRT for primary NMIBC. Data were collected regarding tumor size, number and location, intraoperative complications, and postoperative course. Patients were grouped as first 20, next 20 (21–40), and last 27 cases to assess how the quality of resection improved with increasing experience.

Results:

The mean tumor size was 28.7 ± 7.9 mm, with 34.3% of the patients having a tumor larger than 3 cm. While 43 patients (64.17%) had a single tumor, the rest had multiple tumors, ranging from 2 to 9 in number. The mean total duration of resection was 38.7 ± 11.6 min. No case required conversion to cTURBT. No patient experienced obturator reflex or bladder perforation. Detrusor muscle was present in 85.07% of the resections. With increasing experience, requirement for bladder irrigation and the incidence of postoperative clot evacuation decreased (P < 0.0001 and P = 0.31, respectively), and the detrusor-positive rate in the specimen increased (P = 0.24). The mean duration of catheterization was 1.76 ± 0.54 days.

Conclusion:

Ho laser ERBT is safe and feasible for complete resection of NMIBCs with no risk of obturator-nerve reflex and a high rate of detrusor-positive specimens.

Outcome of simultaneous thulium laser enucleation of bladder tumor and prostate in patients with non-muscle invasive bladder tumor and benign prostatic hyperplasia: a matched-pair comparison with a long-term follow-up

OBJECTIVE

To access the surgical and oncological outcomes of simultaneous thulium laser enucleation of bladder tumor (ThuLEBT) and thulium laser enucleation of prostate (ThuLEP) in patients with non-muscle invasive bladder tumor (NMIBC) and benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

Between June 2009 and June 2017, 118 men with NMIBC who underwent simultaneous ThuLEBT and ThuLEP and fulfilled the inclusion criteria were matched with 118 patients who received ThuLEBT alone. Clinicopathological parameters, surgical outcome data and oncological outcomes were retrospectively analyzed and compared.

RESULTS

The patients who underwent simultaneous ThuLEBT and ThuLEP experienced a longer length of operation time (70.4 vs. 25.5 min; p < 0.001), but there were no statistically significant differences in catheterization period, hospital stay and complication between the two groups. At a mean follow-up of 58.7 and 55.8 months in ThuLEBT/ThuLEP group and ThuLEBT group, no significant differences in overall recurrence rates, progression rates, recurrence in the bladder neck/prostatic fossa and mean elapsed time to recurrence were detected. The 5-year recurrence-free probability was 73.2% for ThuLEBT/ThuLEP and 69.2% for ThuLEBT (p = 0.361).

CONCLUSIONS

Our results indicate that simultaneous ThuLEBT and ThuLEP can be safely performed without increasing the surgical risk and the risk of tumor recurrence and progression in patients with NMIBC and BPH, and it may be preferred alternative for select patients.

Can a second resection be avoided after initial thulium laser endoscopic en bloc resection for non-muscle invasive bladder cancer? A retrospective single-center study of 251 patients

Background

This study aimed to evaluate the efficacy of transurethral thulium laser en bloc resection of the bladder tumor (TmLRBT) in patients with non-muscle invasive bladder cancer (NMIBC) and to investigate whether a second resection can be avoided.

Methods

From June 2012 to June 2018, 251 newly diagnosed patients with NMIBC were enrolled in this retrospective study; all patients received regular administration of pirarubicin after the initial resection. A second transurethral resection (TUR) was performed in patients within 2–6 weeks after the initial TmLRBT in group 1. Patients in group 2 only underwent cystoscopy at 3 months.

Results

Second surgery results indicate that recurrence was detected histopathologically in 6/108 and 11/143 patients in group 1 and 2, respectively (P = 0.52); Progression was observed in 2 patients in each group (P = 0.34). The mean follow-up duration was 40.1 months, with no significant difference between the groups (P = 0.32). Recurrence was observed in 23 (21.3%) and 39 (27.3%) patients in groups 1 and 2 during the follow-up, respectively (P = 0.34); disease progression occurred in 4 (3.8%) patients in group 1 compared with 7 (4.0%) in group 2 (P = 0.20).

Conclusion

Complete removal of tumors can be achieved by TmLRBT. This technique may decrease the number of second TURs.

Safety and efficacy of en bloc transurethral resection versus conventional transurethral resection for primary nonmuscle-invasive bladder cancer: a meta-analysis

Background

The purpose of this meta-analysis is to compare the safety and efficacy of en bloc transurethral resection of bladder tumor (EBRT) versus conventional transurethral resection of bladder tumor (CTURBT).

Methods

We performed a meta-analysis of relevant articles through November 2019 using PubMed, Embase, and Cochrane Central Register to compare the safety and efficacy of EBRT versus CTURBT. The main endpoint included the operation time (OT), hospitalization time (HT), catheterization time (AT), perioperative period complications, bladder detrusor muscle found in the specimen, the residual tumor on the base, the ratio of the same site recurrence, and 12/24/36-month recurrence rate. Cochrane Collaboration’s Revman software, version 5.3, was used for statistical analysis.

Results

A total of 19 studies with 2651 patients were included, 1369 underwent EBRT and 1282 underwent CTURBT. Patients treated with EBRT had a significantly lower AT, HT, obturator nerve reflex, bladder perforation, bladder irritation, postoperative complications, and 24-month recurrence rate than those who underwent CTURBT. While no significant difference was found in terms of OT, the ratio of bladder detrusor muscle found in the specimen, the residual tumor on the base, 12-month recurrence rate, 36-month recurrence rate, and the ratio of the same site recurrence. In mitomycin subgroup, EBRT was superior to CTURBT in terms of 12/24-month recurrence rate. Similarly, in the prospective subgroup and retrospective subgroup, EBRT had a lower 24-month recurrence rate than CTURBT. However, no significant difference was found in the low, intermediate, and high-risk group in the light of 12–36-month recurrence rate.

Conclusions

Based on the included 19 articles, EBRT had a significantly lower AT, HT, intraoperative and postoperative complications, and 24-month recurrence rate than those treated with CTURBT. Well-designed randomized controlled trials were needed to reevaluate these outcomes.

Trial registration

This meta-analysis was reported in agreement with the PRISMA statement and was registered on PROSPERO 2019 CRD42019121673.

Technical developments in transurethral resection of bladder tumours

Bladder cancer is one of the most common malignancies worldwide. The transurethral resection of bladder tumour (TURB) remains the gold standard in both diagnostics and treatment. Because of the importance of TURB in bladder cancer management and the fact that TURB is one of the most commonly performed urologic procedures, it is the subject of continuous technological development. The latest advances in the field of endourology are aimed at increasing surgical accuracy and thus reducing the risk of bladder tumour recurrence and progression. However, despite the constant progress in technology and technique, there are still a lack of good quality data showing the superiority of any of the methods. The aim of this paper is to present available data on new technological developments in surgical technique of TURB. Advantages and disadvantages of currently available methods are discussed, and literature showing their effectiveness and safety is shown.

A pilot study to assess the safety and usefulness of combined transurethral endoscopic mucosal resection and en-bloc resection for non-muscle invasive bladder cancer

Background

Transurethral resection (TUR) is the standard operation used for non-muscle invasive bladder cancer (NMIBC). Although most solid tumors are principally removed via single block resection without incising the mass, disruption of the lesion is unavoidable in traditional TUR. Furthermore, pathological diagnosis is often difficult due to heat-related denaturation of tissues in TUR. Although transurethral en-bloc resection is useful for judging tumor invasion, it is associated with a prolonged operative duration. We attempted to show the safety and usefulness of combined endoscopic mucosal resection (EMR) and en-bloc resection in NMIBC patients.

Methods

We investigated 39 patients with clinical NMIBC who were treated using our original EMR + en-bloc resection technique, which involved removal of the tumor mass that protruded from the mucosa, using a polypectomy snare similar to that used for EMR. The residual lesion was removed using en-bloc resection. The operative period, duration of hospitalization, and recurrence rates were compared with those of conventional TUR (n = 31).

Results

The mean (standard deviation, range) time interval for EMR and total operative duration were 1.6 (1.1, 1–5) min and 18.3 (10.5, 3–48) min, respectively. The total operative duration was comparable to that of TUR (17.3 min, p = 0.691). The mean duration of catheterization in the EMR + en-bloc resection group (4.2 days) was also similar to that in the TUR group (3.7 days; p = 0.285). No severe complications were observed with EMR + en-bloc resection. The pathologists were able to determine tumor invasiveness with considerable certainty in all specimens obtained via the EMR + en-bloc procedure than via TUR, and the difference in the ease of diagnosis was statistically significant (p = 0.016). Recurrence rates were comparable (p = 0.662) between the EMR + en-bloc (15.4%) and TUR groups (19.4%).

Conclusions

Our results demonstrated that the EMR + en-bloc resection technique is feasible, safe, and useful for treating patients with NMIBC. Furthermore, this technique helps provide a more accurate pathological diagnosis.

The rational and benefits of the second look transurethral resection of the bladder for T1 high grade bladder cancer

The second look transurethral resection of the bladder (TURB) represents a fundamental step in the treatment of papillary non-muscle invasive bladder cancer (NMIBC); it is therefore recommended by all guidelines. However, not all the literature agrees on its staging value and its ability to improve oncological outcomes of patients. Therefore, the purpose of this review is to evaluate the strengths and weaknesses of second look TURB, trying to depict its evolving role in the management of high grade NMIBC. Using Medline, a non-systematic review was performed including articles between January 2000 and June 2018. English language original articles, reviews and editorials were selected based on their clinical relevance. To date, TURB seems to be largely inadequate in retrieving a correct diagnosis and in removing all tumor tissue. Second look TURB maximizes staging accuracy, allows to clear residual cancer and yields prognostic advantages allowing key information to identify possible candidates 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. Therefore, future studies trying to identify the criteria that may better allow which patients to select for a second look TURB while avoiding an unnecessary intervention with possible risks and associated cost are needed to allow a personalized approach to even this one size fits all strategy.

A retrospective comparison of thulium laser en bloc resection of bladder tumor and plasmakinetic transurethral resection of bladder tumor in primary non-muscle invasive bladder cancer

Bladder cancer is currently considered the most common malignancy of the urinary tract. Thulium laser en bloc resection of bladder tumor (TmLRBT) and plasmakinetic transurethral resection of bladder tumor (PK-TURBT) are two alternative common procedures used in our department to manage patients with primary non-muscle invasive bladder cancer (NMIBC) over the past decade. In this work, the safety and efficacy of TmLRBT were retrospectively compared to those of PK-TURBT in patients with primary NMIBC. From January 2013 to December 2015, 256 patients diagnosed with primary NMIBC were selected for this retrospective study. A total of 136 consecutive patients diagnosed with primary NMIBC were enrolled in the TmLRBT group. A similar historical cohort of 120 consecutive patients who underwent PK-TURBT was used to compare the two procedures. Clinical data, including age, gender, tumor characteristics, operation duration, hospitalization, irrigation, catheterization, and intraoperative and postoperative complications, were recorded. There were no significant differences in age, gender, mean tumor size, mean tumor number, tumor location, or risk between the TmLRBT and PK-TURBT groups. The TmLRBT group was associated with a significantly shorter operation duration (25.96 ± 21.19 min vs 37.18 ± 25.77 min, P = 0.018) and a shorter hospitalization time (3.11 ± 1.05 days vs 5.24 ± 2.06 days, P = 0.036). The postoperative irrigation time (6.33 ± 4.05 h vs 14.76 ± 6.28 h, P = 0.027) and catheterization time (2.03 ± 1.61 days vs 4.27 ± 1.17 days, P = 0.035) in the TmLRBT group were lower than those in the PK-TURBT group. No significant differences in fever and rebleeding were found in the TmLRBT and PK-TURBT groups. There were no significant differences in the overall, low-risk, intermediate-risk, and high-risk recurrence-free rates between the two groups (P = 0.43, P = 0.68, P = 0.71, and P = 0.24, respectively). The proportion of bladder detrusor muscle (BDM) identified in pathologic specimens of the TmLRBT group was higher than that in the PK-TURBT group (P = 0.006). TmLRBT may reduce operation duration time, hospitalization time, postoperative irrigation time, and catheterization time. TmLRBT is considered safer and more effective in treating primary NMIBC. Recurrence-free rates did not differ between groups.

A novel transurethral resection technique for superficial bladder tumor: retrograde en bloc resection

BACKGROUND

Transurethral resection of bladder tumor (TURBT) is the standard approach to bladder tumors but suffers from several disadvantages. The aim of this study was to evaluate the safety and efficacy of a novel procedure of retrograde en bloc resection of bladder tumor (RERBT) with conventional monopolar resection electrode for the treatment of superficial bladder tumors.

METHODS

RERBT and conventional TURBT (C-TURBT) were conducted, respectively, in 40 and 50 patients diagnosed with superficial papillary bladder tumors. In the RERBT group, the tumors were en bloc removed retrogradely under direct vision using a conventional monopolar electrode. Patients' clinicopathological, intraoperative, and postoperative data were compared retrospectively between the RERBT and C-TURBT groups.

RESULTS

Of the 90 patients, 40 underwent RERBT and 50 underwent C-TURBT. Both groups were comparable in clinicopathological characteristic. RERBT could be performed as safely and effectively as C-TURBT. There were no significant differences in operative time and surgical complications. The cumulative recurrence rates between groups were similar during up to 18 months follow-up. The detrusor muscle could be identified pathologically in 100% of RERBT tumor specimens and the biopsy of tumor bases, but only in 54 and 70%, respectively, of C-TURBT samples (P < 0.01).

CONCLUSIONS

The RERBT technique is feasible and safe for superficial bladder tumors using conventional monopolar resection setting, with the advantages of adequate tumor resection and the ability to collect good quality tumor specimens for pathological diagnosis and staging compared to conventional TURBT.

En Bloc Transurethral Resection of Bladder Tumors: A New Standard?

OBJECTIVE

To assess safety and efficacy, namely pathological assessment of the specimen and recurrence rate, of en bloc transurethral resection (EBTUR) of bladder tumor.

MATERIALS AND METHODS

We performed a systematic review of the available literature on PubMed. Seventeen articles, mainly prospective case series, were found. EBTUR is performed with a great variety of equipments, whereas the resection technique is similar.

RESULTS

Overall, 895 patients have been submitted to EBTUR, accounting for 1191 lesions. Forty complications (4%) were computed. Only 10 (1%) were grade III, mostly bladder perforation or bleeding. Fifty-nine conversions (6.5%) to conventional transurethral resection (TUR) have been reported because of difficult locations of tumors or failure to extract the specimen. Several series, accounting for 763 patients, report about incidence of detrusor muscle in the specimen. Overall, 731 (96%) cases with detrusor muscle were computed. Tumor stage remained uncertain only in 12 (1.5%) cases. Follow-up data were available for 544 patients. Mean follow-up ranged from 9.3 to 40 months. Recurrence rate varied from 6% to 55%. Most of the recurrence occurred outside primary tumor site. Mean weighted follow-up across all series was 20 months, whereas overall recurrence rate was 23%.

CONCLUSIONS

Irrespective of the technique adopted, EBTUR is a safe procedure. The presence of detrusor muscle in the specimen is high if compared with historical series of conventional TUR. Indeed, recurrence rate is comparable. The objective advantage of a proper histological assessment suggests to perform EBTUR instead of conventional TUR, when feasible.