Comparison of the safety and efficacy of conventional monopolar and 2-micron laser transurethral resection in the management of multiple nonmuscle-invasive bladder cancer

Efficiency of transurethral en-bloc resection vs. conventional transurethral resection for non-muscle-invasive bladder cancer: An umbrella review

BACKGROUND

En-Bloc transurethral resection of bladder tumor (ERBT) was clinically used to resect non-muscle-invasive bladder cancer (NMIBC). However, discrepancies persist regarding the comparisons between ERBT and conventional transurethral resection of bladder tumor (cTURBT).

METHODS

We conducted a comprehensive search in PubMed, Embase, Web of Science, Cochrane Database of Systematic Reviews, and performed manual searches of reference lists to collect and extract data. Data evaluation was carried out using Review Manager 5.4.0, Rx64 4.1.3, and relevant packages.

RESULTS

There were nine eligible meta-analyses and nine eligible RCTs in our study. NMIBC patients undergoing ERBT were significant associated with a lower rate of bladder perforation and obturator nerve reflex compared to those receiving cTURBT. Our pooled result indicated that ERBT and cTURBT required similar operation time. Regarding postoperative outcomes, ERBT demonstrated superior performance compared to cTURBT in terms of detrusor muscle presence, catheterization time, and residual tumor. ERBT exhibited a higher rate of three-month recurrence-free survival (RFS) compared to those receiving cTURBT (p < 0.05; I2 = 0%). In bipolar subgroup, ERBT had a significant better 12-month RFS than cTURBT (p < 0.05; I2 = 0%). Simultaneously, the exclusion of Hybrid Knife data revealed a significant improvement in 12-month RFS associated with ERBT (p < 0.05; I2 = 50%).

CONCLUSION

Using a combination of umbrella review and meta-analysis, we demonstrated that ERBT had better or comparable perioperative outcome and improved 3 and 12 month RFS than cTURBT. We suggest that ERBT maybe a better surgical method for patients with NMIBC compared with cTURBT.

Experts' recommendations in laser use for the treatment of bladder cancer: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training and Research in Urological Surgery and Technology (TRUST)-Group

PURPOSE

To identify laser settings and limits applied by experts during laser vaporization (vapBT) and laser en-bloc resection of bladder tumors (ERBT) and to identify preventive measures to reduce complications.

METHODS

After a focused literature search to identify relevant questions, we conducted a survey (57 questions) which was sent to laser experts. The expert selection was based on clinical experience and scientific contribution. Participants were asked for used laser types, typical laser settings during specific scenarios, and preventive measures applied during surgery. Settings for a maximum of 2 different lasers for each scenario were possible. Responses and settings were compared among the reported laser types.

RESULTS

Twenty-three of 29 (79.3%) invited experts completed the survey. Thulium fiber laser (TFL) is the most common laser (57%), followed by Holmium:Yttrium-Aluminium-Garnet (Ho:YAG) (48%), continuous wave (cw) Thulium:Yttrium-Aluminium-Garnet (Tm:YAG) (26%), and pulsed Tm:YAG (13%). Experts prefer ERBT (91.3%) to vapBT (8.7%); however, relevant limitations such as tumor size, number, and anatomical tumor location exist. Laser settings were generally comparable; however, we could find significant differences between the laser sources for lateral wall ERBT (p = 0.028) and standard ERBT (p = 0.033), with cwTm:YAG and pulsed Tm:YAG being operated in higher power modes when compared to TFL and Ho:YAG. Experts prefer long pulse modes for Ho:YAG and short pulse modes for TFL lasers.

CONCLUSION

TFL seems to have replaced Ho:YAG and Tm:YAG. Most laser settings do not differ significantly among laser sources. For experts, continuous flow irrigation is the most commonly applied measure to reduce complications.

Energy source comparison in en-bloc resection of bladder tumors: subanalysis of a single-center prospective randomized study

PURPOSE

Different energy sources are employed to perform en-bloc transurethral resection of bladder tumor (ERBT). No study compared different energy sources in ERBT. The aim is to compare the different ERBT sources in terms of pathological, surgical and postoperative outcomes.

METHODS

This is a sub-analysis of a prospective randomized trial enrolling patients submitted to ERBT vs conventional TURBT from 03/2018 to 06/2021 (NCT04712201). 180 patients enrolled in ERBT group were randomized 1:1:1 to receive monopolar (m-ERBT), bipolar (b-ERBT) or thulium laser (l-ERBT). Endpoints were the comparison between energies in term of pathological analysis, intra, and post-operative outcomes.

RESULTS

49 (35%) m-ERBT, 45 (32.1%) b-ERBT, and 46 (32.9%) l-ERBT were included in final analysis. The rate of detrusor muscle (DM) presence was comparable between the energies used (p = 0.796) or the location of the lesion (p = 0.662). Five (10.2%), 10 (22.2%) and 0 cases of obturator nerve reflex (ONR) were recorded in m-ERBT, b-ERBT and I-ERBT groups, respectively (p = 0.001). Conversion to conventional TURBT was higher for lesions located in the anterior wall/dome/neck (p < 0.001), irrespective from the energy used. The presence of artifact in the pathological specimen was higher for lesions at the posterior wall (p = 0.03) and trigone (p = 0.03).

CONCLUSIONS

In our study, no difference in staging feasibility among energies was found. Laser energy might be beneficial in lateral wall lesions to avoid ONR. Since there is an increased risk of ERBT conversion to conventional TURBT for lesions of the anterior wall, electrocautery might be preferred over laser to avoid waste of material.

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.

Development of a dynamic risk system for predicting the risk of recurrence and progression in patients with non-muscle-invasive bladder cancer after thulium laser resection of bladder tumor or transurethral resection of bladder tumor followed by intravesical BCG instillation

Background

The high recurrence rate of non-muscle-invasive bladder cancer (NMIBC) after tumor resection brings huge physical and financial burdens for patients. Several predictive models that predict the recurrence of patients with NMIBC have drawbacks in clinical practice. With the rapid development of therapeutic methods, more factors should be taken into consideration when constructing predictive model.

Methods

We retrospectively enrolled 90 patients who were diagnosed as intermediate- or high-risk NMIBC and received a Thulium laser resection of bladder tumor (TmLRBT) or transurethral resection of bladder tumor (TURBT) followed by BCG instillation. Univariate Cox regression analysis and multivariate Cox regression analysis were performed to screen out the independent prognostic factors of recurrence free survival (RFS). A nomogram and risk index were constructed using these prognostic factors.

Results

In this study, 22 patients suffered recurrence; 37 patients (41%) received TmLRBT, and over 90% patients completed intravesical BCG instillation for one year. The univariate Cox regression showed that surgery (TURBT vs TmLRBT), previous bladder tumor, tumor number, pathological stage, post-operative catheterization and number of BCG therapy were associated with RFS. The multivariate Cox regression revealed that surgery (TURBT vs TmLRBT) (HR = 3.16, 95%CI [1.02 - 9.83]); previous bladder tumor (HR = 4.03, 95%CI [1.41 - 11.54]); number of BCG therapy (HR = 0.89, 95%CI [0.84 - 0.95]) were independent prognostic factors. A nomogram was constructed and exhibited excellent capability in predicting the RFS with an AUC of 0.789, 0.848, 0.806 at 6-, 12- and 24-months respectively and a c-index of 0.822. Also, the calibration curve and decision curve analysis were performed to verify the predictive efficacy. The risk index was derived from the nomogram and also exhibited favorable capability in predicting the progression free survival (PFS) of patients.

Conclusions

Patients who received TmLRBT, without previous bladder tumor history and had more intravesical BCG instillations are likely to have better RFS. The nomogram and the risk index which were constructed to predict the RFS and PFS of patients may help urologists to make clinical decisions and aid in precision medicine.

The Impact of En-bloc Transurethral Resection of Bladder Tumour on Clinical, Pathological and Oncological Outcomes: A Cohort Study

Background En-bloc transurethral resection of bladder tissue (ETURBT) has recently been proposed as a good alternative technique to trans-urethral resection of bladder tissue (TURBT) in terms of outcomes for bladder carcinoma. This study aims to assess the effectiveness of the technique in terms of clinical, pathological and oncological outcomes. Methodology In this prospective study, data was collected from patients who underwent ETURBT for bladder space-occupying lesions between June 2021 and June 2022. Demographic characteristics, tumour characteristics, and postoperative outcomes were recorded. Results A total of 52 patients were studied with the majority being male and a mean age of 50.87 years. Smoking was recorded in 22 (38.5%) patients and 8 (15.4%) were on antiplatelet therapy. The majority fell in the American Society of Anesthesiology (ASA) class I (59.6%). Most of the tumours were solitary (90.4%), primary (82.8%), papillary architecture (73.1%), and between 1-3 cm in size. The lateral wall was the most common position, and detrusor muscle was seen in 98.1% of the specimens. T1 stage (57.7%) and low grade (67.3%) were the common characteristics noted. 76.9% of the ETURBT was conducted using monopolar cautery. Recurrence was noted in 3 (5.8%) and bladder perforation in 1 patient (1.9%). Cautery artifact was seen in six patients (11.5%) and obturator jerk in nine patients (17.3%). Conclusion Our study suggests that ETURBT is a technique with a good success rate for bladder tumours less than 3 cm in size. The benefits include high chances of detrusor sampling while minimising crush artefacts and cautery damage. Specimen retrieval was challenging when the bladder tumour was solid and over 2 cm.

En-bloc transurethral resection vs. conventional transurethral resection for primary non-muscle invasive bladder cancer: A meta-analysis

INTRODUCTION

We performed a meta-analysis to evaluate the effect of en-bloc transurethral resection vs. conventional transurethral resection for primary non-muscle invasive bladder cancer.

METHODS

A systematic literature search up to January 2022 was done and 28 studies included 3714 primary non-muscle invasive bladder cancer subjects at the start of the study; 1870 of them were en-bloc transurethral resection, and 1844 were conventional transurethral resection for primary non-muscle invasive bladder cancer. We calculated the odds-ratio (OR) and mean-difference (MD) with 95% confidence-intervals (CIs) to evaluate the effect of en-bloc transurethral resection compared with conventional transurethral resection for primary non-muscle invasive bladder cancer by the dichotomous or continuous methods with random or fixed-effects models.

RESULTS

En-bloc transurethral resection had significantly lower twenty-four-month recurrence (OR: 0.63; 95%CI: 0.50-0.78; p < 0.001), catheterization-time (MD: -0.66; 95%CI: -1.02-[-0.29]; p < 0.001), length of hospital stay (MD: -0.95; 95%CI: -1.55-[-0.34]; p = 0.002), postoperative bladder irrigation duration (MD: -6.06; 95%CI: -9.45-[-2.67]; p < 0.001), obturator nerve reflex (OR: 0.08; 95%CI: 0.02-0.34; p = 0.03), and bladder perforation (OR: 0.14; 95%CI: 0.06-0.36: p < 0.001) and no significant difference in the 12-month-recurrence (OR: 0.79; 95%CI: 0.61-1.04; p = 0.09), the operation time (MD: 0.67; 95%CI: -1.92 to 3.25; p = 0.61), and urethral stricture (OR: 0.46; 95%CI: 0.14-1.47; p = 0.0.19) compared with conventional transurethral resection for primary non-muscle invasive bladder cancer subjects.

CONCLUSIONS

En-bloc transurethral resection had a significantly lower twenty-four-month recurrence, catheterization time, length of hospital stay, postoperative bladder irrigation duration, obturator nerve reflex, bladder perforation, and no significant difference in the twelve-month recurrence, operation time, and urethral stricture compared with conventional transurethral resection for primary non-muscle invasive bladder cancer subjects. Further studies are required.

Comparison of Pathological Outcome and Recurrence Rate between En Bloc Transurethral Resection of Bladder Tumor and Conventional Transurethral Resection: A Meta-Analysis

Current treatment for non-muscle invasive bladder cancer (NMIBC) is the conventional transurethral resection of bladder tumor (CTURBT), but the en bloc transurethral resection of bladder tumor (ERBT) has been gaining more attraction in recent years considering better specimen integrity. Thus, we conducted this meta-analysis to compare the safety and efficacy of ERBT versus CTURBT. Trials were collected from an online database. The primary outcomes included identification of detrusor muscle in specimen, residual tumor, 3, 12, and 24-month recurrence rates and same-site recurrence rate. A total of 31 trials were included. The ERBT group had a higher rate of identification of detrusor muscle in specimens (p = 0.003) and lower residual tumor (p < 0.001). Other than that, lower rates of 3-month (p = 0.005) and 24-month recurrence rate (p < 0.001), same-site recurrence rate (p < 0.001) and complications were also observed. For perioperative outcomes, shorter hospitalization time (HT) (p < 0.001), and catheterization time (CT) (p < 0.001) were also revealed in the ERBT group. No significant difference was found in operative time (OT) (p = 0.93). The use of ERBT showed better pathological outcomes and fewer complications, so it could be considered a more effective treatment option for NMIBC.

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.

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.

Efficacy and safety of 2-micron laser versus conventional trans-urethral resection of bladder tumor for non-muscle-invasive bladder tumor: A systematic review and meta-analysis

Aim

To compare the clinical efficacy and safety of 2-micron laser and conventional trans-urethral resection of bladder tumor (TURBT) in the treatment of non-muscle-invasive bladder tumor (NMIBT), providing evidence-based evidence for clinical treatment.

Materials and Methods

PubMed, Embase, Cochrane Library, CMB, CNKI, and WanFang databases were searched since their inception until December 2021 for all eligible randomized controlled trials (RCTs) related to 2-micron laser and TURBT for treating NMIBT. Two researchers independently screened the literature, extracted outcome indicators, and assessed the risk of bias according to the inclusion and exclusion criteria. Binary and continuous variables were calculated by relative risk (RR) and mean difference (MD) with 95% confidence interval (95%CI), respectively. RevMan 5.4 and Stata 15.0 software were used for all statistical analysis.

Results

A total of ten RCTs involving 1,163 patients were included: 596 cases in the 2-micron laser group and 567 cases in the TURBT group. The results of the meta-analysis revealed that 2-micron laser has advantages over the TURBT in operative duration (MD = -2.94, 95% confidence interval (CI) [-8.55, 2.68], P = 0.31), operative blood loss (MD = -19.93, 95%CI [-33.26, -6.60], P = 0.003), length of hospital stay (MD = -0.94, 95%CI [-1.38, -0.50], P < 0.001), post-operative bladder irrigation time (MD = -28.60, 95%CI [-50.60, -6.59], P = 0.01), period of catheterization days (MD = -1.07, 95%CI [-1.73, -0.40], P = 0.002), obturator nerve reflex (RR = -0.06, 95%CI [0.02, 0.15], P < 0.001), bladder perforation (RR = 0.14, 95%CI [0.06, 0.35], P < 0.001), and bladder irritation (RR = 0.30, 95%CI [0.20, 0.46], P < 0.001). There was no significant difference between the two surgical methods in post-operative urethral stricture and short-term recurrence of NMIBT.

Conclusion

Compared with TURBT, 2-micron laser may be safer and more effective for NMIBT management. However, these conclusions need to be validated through more high-quality RCTs because of the quality limitations and publication bias of the included studies.

Clinical utility of vesical imaging-reporting and data system (VI-RADS) in non-muscle invasive bladder cancer (NMIBC) patients candidate for en-bloc transurethral resection: A prospective study

OBJECTIVES

To assess accuracy of vesical imaging-reporting and data system (VI-RADS) 5-point score in detection of muscle invasive bladder cancer and avoiding second look transurethral resection of the tumors (TURBT). Additionally, to assess safety and efficacy of bipolar en-block transurethral urethral resection of bladder tumor.

METHODS

Patients with bladder mass up to 5 cm were included in the study. VI-RADS 5-point score was done preoperative for all cases and postoperatively before second look TURBT. Patients were followed up for 12 months.

RESULTS

In all, 80 cases were eligible for the study. Preoperative VI-RADS score at cutoff of 3 had sensitivity of 89.3 %, specificity 83.3 %, postive predective value (PPV) 92.6 %, negative predictive value (NPV) 76.9 %, accuracy of 87.5 %, while at cutoff 2 sensitivity was 82.1%, specificity 91.7%, PPV 95.8%, NPV 68.8%, accuracy of 85.0%. Operative time 28.8 ± 9.4 minutes, hemoglobin drop 0.3 ± 0.05 g/dl, catheterization time 2.8 ± 0.8 days, hospital stay 1.4 ± 0.4 days. No complications occurred. Recurrence in field of resection 3.75%. Detrusor muscle was available in 76 cases (95%). Postoperative VI-RADS score at cutoff of 3 had sensitivity of 78.6%, specificity 77.8%, PPV 84.6%, NPV 70.0%, accuracy of 78.3%. At cutoff 2 VI-RADS score sensitivity was 71.4%, specificity 77.8%, PPV 83.3%, NPV 63.6%, accuracy of 73.9%.

CONCLUSION

VI-RADS 5-point score showed high sensitivity and specificity in preoperative discrimination of non-muscle invasive bladder cancer (NMIBC) from muscle invasive bladder cancer cases and in avoiding unnecessary second look TURBT. Bipolar en-block TURBT technique is both safe and efficacious in resecting NMIBC cases with low recurrence rate.

The Safety and Efficacy of Vela Laser En-Bloc Endoscopic Resection versus Conventional Transurethral Resection of Bladder Tumor-A Single Center Experience

(1) Background: The current gold standard treatment of bladder cancer is conventional transurethral resection of the bladder tumor (CTURBT) using monopolar or bipolar resectoscopes. Laser en-bloc resection of the bladder tumor (LERBT) could achieve a higher quality of the specimen, reduce perioperative complications, and decrease the recurrence rate. Here, we compare the efficacy and safety of en-bloc Vela laser resection versus the conventional monopolar/bipolar resection; (2) Methods: A total of 100 clinically cT1-2 patients with bladder cancer were retrospectively reviewed in this study. Among these patients, 50 patients received LERBT, and 50 patients received CTURBT. The baseline characteristics, operation variables, and clinical outcomes were collected. The primary performance was the presence of muscle layer in the specimen. Perioperative complications and recurrence-free survival (RFS) were also compared. Independent t-test, Chi-square test, Kaplan–Meier curves, and the Cox-regression model were used in the analysis; (3) Results: The median age of the patients in the laser and resectoscope groups was 69.2 and 68.0 years old, respectively. The statistical difference in the presence of the detrusor muscle was 92.0% in the laser group and 70.0% in the CTURBT group (p = 0.005). A lower incidence of bladder perforation (p = 0.041) and major surgical complications (p = 0.046) in the LEBRT group was observed. We found no differences in operation duration, catheterization time, and hospitalization time after adjustment. Additionally, there was no statistical difference in RFS after a median follow-up time of 25 months; (4) Conclusions: Endoscopic laser en-bloc resection of bladder tumor with Vela laser is an effective method with higher muscle inclusion rate and fewer complications.

Systematic review and meta-analysis of randomized controlled trials of perioperative outcomes and prognosis of transurethral en-bloc resection vs. conventional transurethral resection for non-muscle-invasive bladder cancer

OBJECTIVES

This article aimed to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) of perioperative outcomes and prognosis of transurethral en-bloc resection versus conventional transurethral resection for non-muscle-invasive bladder cancer (NMIBC).

METHODS

We searched MEDLINE, Web of Science, and the Cochrane Controlled Register of Trials (CENTRAL) to find eligible RCTs. The studies were classified by version 2 of the Cochrane risk-of-bias tool for randomized trials. Review Manager 5.4.0 was used to evaluate the data. The certainty of the evidence was assessed using the Guideline Development Tool by GRADEpro GDT.

RESULTS

Seven RCTs with 1142 patients was included in the present study. The results indicated that bladder perforation (OR = 0.17; 95% CI 0.05 to 0.67; P = 0.01), obturator nerve reflex (OR = 0.03; 95% CI 0.01 to 0.13; P < 0.00001), residual tumor (OR = 0.24; 95% CI 0.08 to 0.77; P = 0.02) and repeat transurethral resection of bladder tumor (re-TURBT) (OR = 0.54; 95% CI 0.34 to 0.85; P = 0.008) were significantly reduced in the en-bloc resection group than the conventional resection group. However, there were no significant differences in hemoglobin deficit (p = 0.31), urethral stricture (p = 0.47), and detrusor muscle presence (P = 0.16) between both groups. Besides, resection time (p = 0.25), operative time (p = 0.20), catheter dwell time (p = 0.24), and length of hospital stay (p = 0.16) were similar in the two groups. Meanwhile, en-bloc resection yielded no advantage for the 3-month (P = 0.11), 6-month (P = 0.05), 1-year (P = 0.61), 2-year (P = 0.53), and 3-year (P = 0.26) tumor recurrence rates.

CONCLUSIONS

Our meta-analysis shows that transurethral en-bloc resection is associated with comparable outcomes to conventional transurethral resection for recurrence-free survival in NMIBC patients. En-bloc resection is more feasible and safer than conventional resection for NMIBC, with fewer intraoperative complications, less residual tumor, and less re-TURBT.

[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 Versus Conventional Transurethral Resection of Bladder Tumors: A Single-center Prospective Randomized Noninferiority Trial

BACKGROUND

It has been proposed that en bloc resection of bladder tumor (ERBT) improves the quality of tumor resection. A recent international collaborative consensus statement on ERBT underlined the lack of high-quality prospective studies precluding the achievement of solid conclusion on ERBT.

OBJECTIVE

To compare conventional transurethral resection of bladder tumor (cTURBT) and ERBT.

DESIGN, SETTING, AND PARTICIPANTS

This study (NCT04712201) was a prospective, randomized, noninferiority trial enrolling patients diagnosed with bladder cancer (BC) undergoing endoscopic intervention. Inclusion criteria were: tumor size ≤3 cm, three or fewer lesions, and no sign of muscle invasion and/or ureteral involvement. For a noninferiority rate in BC staging of 5% (α risk 2.5%; β risk 20%), a total of 300 subjects were randomized to ERBT treatment at a 1:1.5 allocation ratio.

INTERVENTION

TURBT and ERBT.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was the presence of detrusor muscle at final histology. Secondary outcomes include BC staging, T1 substaging, artifacts, complications, the rate of adjuvant treatment, and oncological outcomes.

RESULTS AND LIMITATIONS

From April 2018 to June 2021, 300 patients met the inclusion criteria. Of these, 248 (83%) underwent the assigned intervention: 108 patients (44%) underwent cTURBT and 140 (57%) underwent ERBT. The rate of detrusor muscle presence for ERBT was noninferior to that for TURBT (94% vs 95%; p = 0.8). T1 substaging was feasible in 80% of cTURBT cases versus 100% of ERBT cases (p = 0.02). Complication rates, rates of postoperative adjuvant treatment, catheterization time, and hospital stay were comparable between the two groups (p > 0.05). The recurrence rate at median follow-up of 15 mo (interquartile range 7-28) was 18% for cTURBT versus 13% for ERBT (p = 0.16). Limitations include the single high-volume institution and the short-term follow-up.

CONCLUSIONS

Our study has the highest level of evidence for comparison of ERBT versus TURBT. ERBT was noninferior to TURBT for BC staging. The rate of T1 substaging feasibility was significantly higher with ERBT.

PATIENT SUMMARY

We compared two techniques for removing tumors from the bladder. The en bloc technique removes the tumor in one piece and is not inferior to the conventional method in terms of the quality of the surgical resection and cancer staging assessment.

Thulium Laser Resection of Bladder Tumors vs. Conventional Transurethral Resection of Bladder Tumors for Intermediate and High Risk Non-Muscle-Invasive Bladder Cancer Followed by Intravesical BCG Immunotherapy

Background: Thulium laser resection of bladder tumors (TmLRBT) is recently considered as a common treatment option for non-muscle-invasive bladder cancers (NMIBC), but whether it is superior to Transurethral resection of bladder tumors (TURBT) are still undetermined.

Materials and Methods: We retrospectively screened our institution database to identify patients who were treated by conventional TURBT or TmLRBT for NMIBC and followed by intravesical bacillus Calmette-Guérin (BCG) immunotherapy. The preoperative characteristics, perioperative outcomes, and recurrence-free survival were compared to assess the safety and efficacy of the two procedures.

Results: Eventually, 90 patients who underwent TmLRBT (n = 37) or TURBT (n = 53) followed by intravesical BCG immunotherapy were included. Two groups were similar in baseline characteristics except for the smaller tumor size of the TmLRBT group(1.7 cm vs. 2.2 cm; P = 0.036). Obturator nerve reflex occurred in eight patients in the TURBT group and 3 of them suffered from bladder perforation while none happened in the TmLRBT group. The TmLRBT also had a shorter irrigation duration. In the multivariate Cox regression, the TmLRBT was related to less recurrence risk (HR: 0.268; 95% CI, 0.095–0.759; P = 0.013).

Conclusion: Our results suggested that TmLRBT is safer than conventional TURBT with fewer perioperative complications, and it offers better cancer control, therefore might be a superior option for NMIBC patients with intermediate and high recurrence risk.

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.

Comparison of Clinicopathologic and Oncological Outcomes Between Transurethral En Bloc Resection and Conventional Transurethral Resection of Bladder Tumor: A Systematic Review, Meta-Analysis and Network Meta-Analysis with Focus on Different Energy Sources

Introduction: It has been hypothesized that transurethral en bloc (TUEB) of bladder tumor offers benefits over conventional transurethral resection of bladder tumor (cTURBT). This study aimed to compare disease outcomes of TUEB and cTURBT with focus on the different energy sources. Methods: A systematic search was performed using PubMed and Web of Science databases in June 2021. Studies that compared the pathological (detrusor muscle presence), oncological (recurrence rates) efficacy, and safety (serious adverse events [SAEs]) of TUEB and cTURBT were included. Random- and fixed-effects meta-analytic models and Bayesian approach in the network meta-analysis was used. Results: Seven randomized clinical trials (RCTs) and seven non-RCTs (NRCT), with a total of 2092 patients. The pooled 3- and 12-month recurrence risk ratios (RR) of five and four NRCTs were 0.46 (95% CI 0.29-0.73) and 0.56 (95% CI 0.33-0.96), respectively. The pooled 3- and 12-month recurrence RRs of four and seven RCTs were 0.57 (95% CI 0.25-1.27) and 0.89 (95% CI 0.69-1.15), respectively. The pooled RR for SAEs such as prolonged hematuria and bladder perforation of seven RCTs was 0.16 (95% CI 0.06-0.41) in benefit of TUEB. Seven RCTs (n = 1077) met our eligibility criteria for network meta-analysis. There was no difference in 12-month recurrence rates between hybridknife, laser, and bipolar TUEB compared with cTURBT. Contrary, laser TUEB was significantly associated with lower SAEs compared with cTURBT. Surface under the cumulative ranking curve ranking analyses showed with high certainty that laser TUEB was the best treatment option to access all endpoints. Conclusion: While NRCTs suggested a recurrence-free benefit to TUEB compared with cTURBT, RCTs failed to confirm this. Conversely, SAEs were consistently and clinically significantly better for TUEB. Network meta-analyses suggested laser TUEB has the best performance compared with other energy sources. These early findings need to be confirmed and expanded upon.

A 25-year perspective on advances in an understanding of the biology, evaluation, treatment and future directions/challenges of urothelial cancer

The Urologic Oncology Journal was founded 25 years ago and we reviewed the literature since that time in the area of urothelial cancer to see the progress and pitfalls we have made over this time period. A comprehensive literature search was conducted by the authors involved who are all actively involved in research, clinical trials, and treatment for urothelial cancer and the results were summarized over the past 25 years. The field of urothelial cancer has evolved tremendously in the last 25 years with the incorporation of molecular subtyping, novel imaging, immunotherapy, and robotic surgery. However, treatments such as BCG and radical cystectomy have remained steadfast over the last 25 years. Although we have a better understanding of the biology of bladder cancer, we still have a long way from being able to cure patients with bladder cancer and eliminate morbidity from treatments. Nevertheless, considerable progress has been made since the founding of the Urologic Oncology Journal 25 years ago.

Potential candidates for en bloc resection among patients with primary and recurrent bladder tumours

INTRODUCTION

Transurethral resection (TURB) is the gold standard treatment for non-muscle invasive bladder cancer (NMIBC). However, conventional TURB is possibly part of the mechanism leading to the high recurrence rate in NMIBC and the need for repeated procedures, as the method with piecemeal resection of the tumour violates basic oncological principles and compromises pathological examination. En bloc resection (EBR) could potentially overcome these flaws by improving pathological quality and thereby reducing the need for re-resections and could potentially also lower the risk of tumour seeding leading to early recurrences. With this study, we aimed to evaluate tumour characteristics in a consecutive cohort of patients undergoing conventional TURB in order to estimate the proportion of procedures eligible for EBR, findings at re-resection, and early recurrence rate.

METHODS

All TURBs performed at a single large University Hospital in a 12 month period were manually reviewed. Based on tumour size and appearance, patients were registered as candidates or non-candidate for EBR.

RESULTS

A total of 600 TURBs were reviewed. Overall, 25% of procedures were found to be eligible for EBR. The most frequent reason for not being a candidate was tumour diameter <1 cm. Re-resections were done after 10.5% of the procedures, where the residual tumour was found in 28.6% of these. Within 6 months, 21.2% had a recurrence.

CONCLUSION

We found approximately 25% of all TURBs to be eligible for EBR. Based on a relatively low recurrence rate, we conclude that future studies on EBR with recurrence rate as the primary endpoint will require large patient cohorts.

Bladder perforation during transurethral resection of the bladder: a comprehensive algorithm for diagnosis, management and follow up

INTRODUCTION

Despite bladder perforation (BP) is a frequent complication during transurethral resection of bladder (TURB) for bladder cancer (BCa), literature lacks systematic reviews focusing on this issue. We aimed to investigate incidence, diagnosis, therapy, and prognosis after BP during TURB for BCa; therapy was distinguished between conservative (without the need for bladder repair) and surgical management (requiring bladder wall closure).

EVIDENCE ACQUISITION

A systematic search was conducted up to April 2021 using PubMed, Scopus, Cochrane Database of Systematic Reviews, and Web of Science to identify articles focusing on incidence, detection, management, or survival outcomes after iatrogenic BP. The selection of articles followed the Preferred Reporting Items for Systematic Review and Meta-Analyses process.

EVIDENCE SYNTHESIS

We included 41 studies, involving 21,174 patients. Overall, 521 patients experienced BP during TURB for BCa, with a mean incidence of 2.4%, up to 58.3% when post-operative cystography is routinely performed after all TURB procedures. Risk factors were low body mass index (BMI) (p=0.01), resection depth (p=0.006 and p=0.03), and low surgical experience (p=0.006). Extraperitoneal BP (68.5%) were treated conservatively in 97.5% of patients; intraperitoneal BP were managed with surgical bladder closure in 56% of cases. Overall, three immediate BP-related deaths were recorded due to septic complications. Extravesical tumour seeding was observed after 6 intraperitoneal and 1 extraperitoneal BP (median time: 6.2 months). Intraperitoneal BP (p=0.0003) and bladder closure (p<0.001) were found as independent predictors of extravesical tumour recurrence.

CONCLUSIONS

BP is more frequent than expected when proper diagnosis is routinely performed after all TURB procedures. Risk factors include low BMI, resection depth, and unexperienced surgeon. The risk of sepsis after BP suggests empirical antibiotic prophylaxis after BP.

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.

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.

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.

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.

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.

Cold en bloc excision (CEBE) of bladder tumours using Zedd excision scissors: a prospective, pilot, safety and feasibility study

Background:

Transurethral resection of bladder tumour (TURBT) is the traditional technique of choice for endoscopically suspected bladder tumours. Cold En Bloc Excision (CEBE) using novel Zedd scissors is proposed for endoscopic treatment of patients with non-muscle invasive bladder cancer (NMIBC). The aim of this study was to evaluate feasibility and safety of CEBE of bladder tumours using Zedd scissors.

Methods:

A pilot prospective study of patients who underwent a CEBE of suspicious bladder tumours using Zedd scissors was conducted. A total of 23 patients underwent CEBE for suspected bladder tumours using Zedd scissors. New and recurrent tumours <3 cm were included in the study. The outcome measures were the presence of detrusor muscle (DM) and obturator nerve reflex (ONR), bladder perforation rates, specimen cautery artefacts, recurrence rates and complication rates. The mean age was 64 years ± 10.41 (range: 49–83 years). The median follow up was 4 months (range 1–9 months). The mean tumour size was 1.8 cm ± 0.40 (range: 0.8–2.6 cm). Tumours were located in the lateral wall (n = 11), dome (n = 2), posterior wall (n = 6), trigone (n = 2), anterior wall (n = 4) and the junction of lateral and posterior wall (n = 4).

Results:

There was no ONR or bladder perforation and none of the patients had any complications. DM was present in 21 patients (91%). There was no tumour identified at the circumferential margins. There was no cautery artefact reported in any case. No patients had a recurrence at first follow up cystoscopy and two patients had out of field recurrence at subsequent cystoscopies.

Conclusion:

CEBE with Zedd scissors is a promising en bloc excision technique for bladder tumour. It is a safe and feasible for excision of tumours less than 3 cm. The early oncological outcomes are comparable with existing en bloc resection techniques (ERBT) for NMIBC.

[Complication management for TUR of the bladder]

Transurethral resection of bladder cancer is a standard procedure in urology which requires complete resection. Knowledge of the possible complications and their management is essential for practicing urologists. The most common complications are catheter related bladder symptoms, bleeding, infections and perforation of the bladder. Resection of the orifice and positional damage are seldom but severe complications which need immediate treatment. In this review, we summarise the above mentioned complications as well as their management.

Transurethral en bloc submucosal hydrodissection vs conventional resection for resection of non-muscle-invasive bladder cancer (HYBRIDBLUE): a randomised, multicentre trial

OBJECTIVE

To determine whether transurethral en bloc submucosal hydrodissection of bladder tumours (TUEB) improves the quality of the resection compared to conventional transurethral resection of bladder tumour (TURBT) in patients with non-muscle-invasive bladder cancer (NMIBC).

PATIENTS AND METHODS

A randomised, multicentre trial (HYBRIDBLUE) was conducted with a superiority design. Six German academic centres participated between September 2012 and August 2015. Based on literature analysis, a sample size for accurate histopathological assessment concerning muscle invasion was assumed to be feasible in 50% (P₀ = 0.5) of TURBT and 80% of TUEB cases. After pre-screening of a total of 305 patients, participants were allocated to two study arms: Group I: hexaminolevulinate (HAL)-guided TUEB; Group II: conventional HAL-guided TURBT. The primary endpoint was the proportion of specimens that could be reliably evaluated pathologically concerning muscle invasiveness. Secondary endpoints included rates of histopathological completeness of the resection, muscularis propria content, recurrence, and complication rates.

RESULTS

A total of 115 patients (TUEB 56; TURBT 59) were eligible for final analysis. Adequate histopathological assessment, which included muscularis propria content and tumour margins (R0 vs R1), was present in 48/56 (86%) TUEB patients compared to 37/59 (63%; P = 0.006) in the TURBT group. R0 was confirmed in 30/56 TUEB patients (57%) and five of 59 TURBT patients (9%; P < 0.001). No complications of Grade ≥III were observed in both arms. At 3 and 12 months, three and 19 patients recurred in the TUEB group vs seven and 11 patients in the TURBT group, respectively (P = 0.33 and P = 0.08).

CONCLUSIONS

In this randomised study, TUEB was shown to be clinically safe regarding perioperative endpoints. An adequate histopathological assessment concerning muscle invasion was significantly better assessable in the TUEB arm compared to standard TURBT. This finding indicates the clinical potential for reducing the rate of early re-resections. Yet, a larger study with recurrence-free survival as the primary endpoint is needed to assess the oncological efficacy between both techniques.

Safety and Short-Term Oncological Outcomes of Thulium Fiber Laser En Bloc Resection of Non-Muscle-Invasive Bladder Cancer: A Prospective Non-Randomized Phase II Trial

BACKGROUND: Ongoing efforts aim at overcoming the challenges of conventional transurethral resection of bladder tumor (TURBT) such as the high recurrence rate, difficulty of pathologic interpretation and complications including wall injury. OBJECTIVE: To prospectively assess the safety and efficacy of Thulium fiber en bloc resection of bladder tumor (Tm-fiber ERBT) compared to TURBT. MATERIALS AND METHODS: The prospective non-randomized study included 129 patients with non-muscle-invasive bladder cancer (NMIBC) divided into two groups: 58 patients underwent conventional TURBT and 71 –Tm-fiber ERBT with FiberLase U1 (NTO IRE-Polus, Russia). Relapse-free survival (RFS), detrusor presence and complication rates were assessed. For multivariable analysis we used the Pearson chi-squared Hosmer-Lemeshow goodness of fit test; to compare survival –Cox regression analysis; for operative data comparison –chi-square test with Fisher’s correction; for survival analysis –the Kaplan–Meier method and logrank test. RESULTS: RFS rates at 3 and 6 months were 84.5% and 67.2% for conventional TURBT versus 97.2% and 91.5% for Tm-fiber ERBT (p = 0.011 and p < 0.001, respectively). Detrusor muscle was present in 58.6% of cases treated with conventional TURBT vs 91.6% for the Tm-fiber ERBT group (p < 0.001). The obturator nerve reflex and bleeding were noted in 17.2% and 10.3% of TURBT cases, respectively; and in none of cases treated with Tm-fiber ERBT. Limitations included the non–randomized nature and the small sample size. CONCLUSIONS: Tm-fiber ERBT seems to be a safe and efficacious treatment option for NMIBC. Tm-fiber ERBT had fewer adverse events, was more likely to secure detrusor muscle in the specimen and resulted in better RFS rates than conventional TURBT. Based on these promising data, we have started a prospective randomized clinical trial comparing en bloc TURBT with conventional TURBT (ClinicalTrials.gov NCT03718754).

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.

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.

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.

Preliminary study of 1940 nm thulium laser usage in peroral endoscopic myotomy for achalasia

Esophageal achalasia is a type of motility disorder characterized by incomplete relaxation of lower esophageal sphincter (LES) and absence of esophageal peristalsis. Peroral endoscopic myotomy (POEM) is a new treatment option for achalasia that is less invasive, more effective, and safe as compared to surgery. High-frequency electrotome is commonly used in POEM, but takes longer time to make the tunnel in the esophagus and causes many complications. The thulium laser decreases the risk of bleeding and perforation in endoscopy but has not been reported in digestive diseases, especially in POEM. Therefore, the aim of this study is to evaluate the feasibility of the 1940 nm thulium laser in POEM. From March 2015 to August 2015, five patients with achalasia at the Digestive department, Beijing Friendship Hospital, Capital Medical University, Beijing, China were included. Before the procedure, the patients' gender, age, and duration of symptoms were recorded. Eckardt symptom score and LES thickness, which measured by endoscopic ultrasonography, were recorded. While the subtypes of achalasia (according to the Chicago classification), lower esophagus sphincter resting pressure (LESRP) and integrated relaxation pressure (IRP) were measured by HRM for all patients. Barium esophagram was also used to rule out anatomical lesions, esophageal varices, or neoplasia, which may cause similar symptoms. All examinations were performed one week before POEM. POEM was performed with the 1940 nm thulium laser under general anesthesia. Eckardt score, procedure duration, myotomy length, and complications were recorded one week after POEM. All the patients were followed-up at two weeks and four weeks after POEM. POEM was successfully performed in all five patients. The mean age of the patients was 38.8 years (24-54 years). Achalasia subtypes were type I (n = 1), II (n = 2), and III (n = 2). The operation duration was 186, 180, 111, 75, and 126 minutes for the five cases. Pre/postprocedure Eckardt scores were 3/0, 7/0, 5/1, 6/0, and 9/0. Pre/postprocedure LESRP (mmHg) were 45.3/26.4, 18.0/1.1, 25.8/10.4, 16.5/11.2, and 24.2/20.8. Pre/postprocedure IRP (mmHg) were 27.3/15.5, 15.4/4.2, 5.7/6.8, 15.5/10.1, and 13.1/14, respectively. No adverse events occurred during the procedure. After POEM, subcutaneous emphysema occurred in case 1 on the first day, which relieved spontaneously after two days without special intervention. Infection occurred in case 5 on the day of POEM was healed with antibiotics three days later. The 1940 nm thulium laser is feasible for POEM procedure. Further studies are needed to determine whether the 1940 nm thulium laser is better than high-frequency electrotome.

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.

Comparison of the efficacy and feasibility of en bloc transurethral resection of bladder tumor versus conventional transurethral resection of bladder tumor: A meta-analysis

BACKGROUND

The aim of this meta-analysis was to compare the feasibility of en bloc transurethral resection of bladder tumor (ETURBT) versus conventional transurethral resection of bladder tumor (CTURBT).

METHODS

Relevant trials were identified in a literature search of MEDLINE, EMBASE, Cochrane Library, Web of Science, and Google Scholar using appropriate search terms. All comparative studies reporting participant demographics, tumor characteristics, study characteristics, and outcome data were included.

RESULTS

Seven trials with 886 participants were included, 438 underwent ETURBT and 448 underwent CTURBT. There was no significant difference in operation time between 2 groups (P = 0.38). The hospitalization time (HT) and catheterization time (CT) were shorter in ETURBT group (mean difference[MD] -1.22, 95% confidence interval [CI] -1.63 to -0.80, P < 0.01; MD -0.61, 95% CI -1.11 to -0.11, P < 0.01). There was significant difference in 24-month recurrence rate (24-month RR) (odds ratio [OR] 0.66, 95% CI 0.47-0.92, P = 0.02). The rate of complication with respect to bladder perforation (P = 0.004), bladder irritation (P < 0.01), and obturator nerve reflex (P < 0.01) was lower in ETURBT. The postoperative adjuvant intravesical chemotherapy was evaluated by subgroup analysis, and 24-month RR in CTURBT is higher than that in ETURBT in mitomycin intravesical irrigation group (P = 0.02).

CONCLUSION

The first meta-analysis indicates that ETURBT might prove to be preferable alternative to CTURBT management of nonmuscle invasive bladder carcinoma. ETURBT is associated with shorter HT and CT, less complication rate, and lower recurrence-free rate. Moreover, it can provide high-qualified specimen for the pathologic diagnosis. Well designed randomized controlled trials are needed to make results comparable.