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

Rotatable Bi-Channel En Bloc Resection of Bladder Tumor for Non-Muscle-Invasive Bladder Cancer in an Ex Vivo Porcine Model

En bloc resection of bladder tumor (ERBT) is a promising alternative for non-muscle-invasive bladder cancer management. However, the tumor characteristics and surgeon's experience influence its application. Therefore, in this pilot study, we developed a technique called "rotatable bi-channel en bloc resection of bladder tumor (RBC-ERBT)" and assessed its feasibility, efficacy, and safety compared with those of conventional ERBT. In an ex vivo porcine bladder model, 160 bladder lesions of varying morphologies (exophytic and flat) and sizes (1 and 2 cm) were created and evenly distributed across different locations. A total of 160 procedures were performed, with the ERBT and RBC-ERBT group each exhibiting 80 lesions. RBC-ERBT had a significantly higher technical success rate than ERBT (98.8% vs. 77.5%) for exophytic and flat lesions of both sizes and dome lesions. The procedure time was significantly shorter in the RBC-ERBT group, particularly for flat lesions, lesions with a 2 cm diameter, and lesions located at the dome. RBC-ERBT had a significantly lower piecemeal resection rate than ERBT (0% vs. 18.8%). The incidence of perforation or detrusor muscle sampling did not differ between the groups. Compared with conventional ERBT, RBC-ERBT offered improved success rates, reduced resection times, and effective management of challenging lesions.

High-power green-light laser endoscopic submucosal dissection for non-muscle-invasive bladder cancer: A technical improvement and its initial application

Background

The technique of laser en bloc resection of bladder tumor (ERBT) has been a valuable alternative technique to transurethral resection of bladder tumor (TURBT). However, the combination of laser ERBT and endoscopic submucosal dissection (ESD) technique has not been well studied. Here, a novel technique integrating a high-power green-light laser with ESD was presented. This study aimed to evaluate the safety and efficacy of high-power green-light laser endoscopic submucosal dissection (HPL-ESD) for the treatment of primary non-muscle-invasive bladder cancer (NMIBC).

Materials and Methods

From January 2015 to December 2018, a total of 56 patients with NMIBC underwent HPL-ESD. All tumors were transurethral en bloc resected in the ESD technique. Perioperative clinical data were retrospectively collected and analyzed.

Results

All operations were safely performed by the technique of HPL-ESD without blood transfusion. The mean tumor diameter was 2.04 ± 0.65 cm, ranging from 0.5 to 3.5 cm. The mean operative time was 28.39 ± 16.04 min. The average serum hemoglobin decrease was 0.88 ± 0.54 g/dL. The mean postoperative catheterization time was 2.88 ± 0.94 days. The pathologic stages included pTa (32 cases), and pT1 (24 cases). Double-J stent indwelling was not performed for four patients whose tumors were adjacent to the ureteral orifice and no postoperative hydronephrosis was observed. Only one case of ectopic bladder tumor recurred due to irregular bladder irrigation during the 36-month follow-up.

Conclusion

HPL-ESD is a safe and effective alternative for the treatment of primary NMIBCs, especially for tumors adjacent to the ureteral orifice.

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.

Immunotherapy for Bladder Cancer: Latest Advances and Ongoing Clinical Trials

For nearly 50 years, immunotherapy has been used in patients with bladder cancer in the form of Mycobacterium bovis Bacillus Calmette-Guerin (BCG), which is still the first-line therapy for non-muscle invasive disease. However, the remarkable results obtained with checkpoint inhibitor drugs, including Pembrolizumab and Atezolizumab, have fueled the quest to optimize these and other forms of immunotherapy for both non-muscle invasive as well as advanced bladder cancer. In this review we summarize the current state of the rapidly evolving field of immunotherapy in bladder cancer highlighting novel approaches and ongoing trials in this exciting area of research.

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.

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.