Comparison of deep biopsy tissue damage from transurethral resection of bladder tumors between bipolar and monopolar devices

[Transurethral resection of the urinary bladder : Status quo and outlook on new developments]

BACKGROUND

Transurethral resection of the urinary bladder (TURB) is the standard intervention in the diagnostic workup and treatment of non-muscle invasive bladder cancer. In order to minimize cancer recurrence and potential complications, continuous technical development of TURB is of high clinical interest.

OBJECTIVES

Presentation of the current standards and discussion of technological changes.

MATERIALS AND METHODS

Analysis of the current guideline recommendations and literature research.

RESULTS

The limitations of classic monopolar TURB is supplemented by new resection methods (en bloc) and technologies (bipolar and laser resection). Along with improved visualization through partially established technologies of photodynamic and digital image enhancement, there is potential for optimization regarding the likelihood of recurrences and complications as well as the histological quality of the resected material.

CONCLUSION

A positive impact on the oncological value and safety of TURB seems possible through the use of modern technologies. Further establishment up to evidence-based guideline recommendations are necessary.

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.

Does bipolar energy provide any advantage over monopolar surgery in transurethral resection of non-muscle invasive bladder tumors? A systematic review and meta-analysis

OBJECTIVE

To provide most recent and high quality evidence concerning the comparison between monopolar and bipolar transurethral resection of non-muscle invasive bladder tumors.

MATERIALS AND METHODS

Two researchers performed a systematic review of the current literature independently, to identify studies published in English language. MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews were searched from inception to 31st May 2019. The included primary endpoints of the study were: detrusor muscle sampling rates, cautery artifact occurrence among specimens and 1- or 2-year recurrence rates, overall complication rate, transfusion rate, obturator reflex and bladder perforation rates. Secondary endpoints were length of hospital stay, operation room time, hemoglobin drop, urinary tract infections, TUR-syndrome, serum sodium drop and acute urinary retention rates.

RESULTS

23 studies (14 RCTs and 9 observational) were included for qualitative and quantitative synthesis, recruiting 9815 patients in monopolar resection group and 10,112 patients in bipolar resection group (experimental). We found significant differences in favor of bipolar energy in terms of cautery artifact and length of stay with bladder perforation rates were found to be significantly better in bipolar system even though these results did not sustain when RCT's only analysis was performed. No differences were found in rates of obturator reflex (even though RCT's analysis advised differently), tumor recurrence and most of the secondary endpoints.

CONCLUSIONS

Bipolar transurethral bladder tumor resection is as safe and efficient as its monopolar counterpart. Bipolar technology is related to less obturator nerve contractions and less tissue thermal artifacts during resection and may result in less hospital stay.

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

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

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

BACKGROUND AND PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Safety and efficacy of bipolar energy for transurethral resection of bladder tumours: a prospective quasi-randomized study

OBJECTIVE

The primary aim of the study was to evaluate the safety and efficacy of bipolar energy in resecting bladder tumors.

MATERIAL AND METHODS

The study was done between March 2012 and February 2013. This is a prospective quasi-randomized study evaluating the safety and efficacy of bipolar energy in transurethral resection of bladder tumours (TURBT). Institutional Ethics Committee approval was obtained. Informed consent was taken from all patients. Patients were randomized into two groups of 50 each to undergo either monopolar TURBT or bipolar TURBT using glycine and saline irrigation solutions, respectively.

RESULTS

Most important of all, the means of variables were compared between the two energy sources to know the difference between them and its significance. Hematocrit level, resection time and obturator jerks had significant values.

CONCLUSION

The results of this study indicated that bipolar resection of bladder tumours have lower incidence of complications especially bleeding, TUR syndrome, obturator jerks and bladder perforation. Bipolar TURBT is safe and efficacious in managing bladder tumours.

Normalization of gene expression measurement of tissue samples obtained by transurethral resection of bladder tumors

Background

Sample processing is a crucial step for all types of genomic studies. A major challenge for researchers is to understand and predict how RNA quality affects the identification of transcriptional differences (by introducing either false-positive or false-negative errors). Nanotechnologies help improve the quality and quantity control for gene expression studies.

Patients and methods

The study was performed on 14 tumor and matched normal pairs of tissue from patients with bladder urothelial carcinomas. We assessed the RNA quantity by using the NanoDrop spectrophotometer and the quality by nano-microfluidic capillary electrophoresis technology provided by Agilent 2100 Bioanalyzer. We evaluated the amplification status of three housekeeping genes and one small nuclear RNA gene using the ViiA 7 platform, with specific primers.

Results

Every step of the sample handling protocol, which begins with sample harvest and ends with the data analysis, is of utmost importance due to the fact that it is time consuming, labor intensive, and highly expensive. High temperature of the surgical procedure does not affect the small nucleic acid sequences in comparison with the mRNA.

Conclusion

Gene expression is clearly affected by the RNA quality, but less affected in the case of small nuclear RNAs. We proved that the high-temperature, highly invasive transurethral resection of bladder tumor procedure damages the tissue and affects the integrity of the RNA from biological specimens.

Comparing the Efficiency and Safety of Bipolar and Monopolar Transurethral Resection for Non-Muscle Invasive Bladder Tumors: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the efficacy and safety of bipolar and monopolar transurethral resection of bladder tumor (TURBT) procedures for non-muscle invasive bladder cancer (NMIBC) patients.

MATERIALS AND METHODS

We searched for all studies investigating bipolar TURBT and monopolar TURBT for NMIBC patients in PubMed, Web of Knowledge, and the Cochrane Central Search Library. A systematic review and meta-analysis were performed. Efficacy was assessed by catheterization time, resection time, pathology, and recurrence rate. Safety was assessed by obturator nerve reflex, bladder perforation, hemoglobin decrease, and transfusion.

RESULTS

Our searches identified eight studies. Bipolar TURBT is associated with decreased resection time, catheterization time, and hemoglobin changes. There were no statistically significant differences between bipolar TURBT and monopolar TURBT for rates of obturator nerve reflex, bladder perforation, and transfusion. The grade of cautery artifact had no different between the two procedures or even was lower in the bipolar arm. There was no significant difference in recurrence rate when comparing the two procedures.

CONCLUSIONS

This systematic review indicates that the bipolar technique is more efficacious and safer for NMIBC patients. More large-scale, multicenter, randomized controlled studies are needed before final clinical recommendations can be made.

Bipolar Versus Monopolar Transurethral Resection of Nonmuscle-Invasive Bladder Cancer: A Meta-Analysis

BACKGROUND AND PURPOSE

Bipolar energy has recently been used as a common alternative to conventional monopolar transurethral resection of the bladder (TURB) while managing nonmuscle-invasive bladder cancer (NMIBC). We established a meta-analysis comparing the safety and efficacy of plasmakinetic bipolar and monopolar TURB for NMIBC.

METHODS

A systematic search of PubMed, MEDLINE, Web of Science, and China National Knowledge Infrastructure was performed up to March 1, 2015. Outcomes of interest assessing the two techniques included demographic and clinical baseline characteristics, perioperative variables, and complications.

RESULTS

Eight eligible trials evaluating bipolar TURB (bTURB) versus monopolar TURB (mTURB) for NMIBC were identified including six randomized controlled trials (RCTs), one prospective study, and one retrospective study. The bTURB was associated with shorter operative time (P = 0.002), shorter hospital stay (P < 0.001), less established blood loss (P < 0.001), and shorter catheterization time (P = 0.004). There were fewer complications such as obturator nerve reflex (P < 0.001) and bladder perforation (P = 0.003) in the bTURB group. The postoperative recurrence rate in 2 years also showed advantages of bTURB over mTURB.

CONCLUSION

Our data showed that bTURB appeared to be a safe and efficient method and had presented several advantages when compared with conventional mTURB in the management of NMIBC. As a promising technique, bTURB may be used as a preferable choice instead of mTURB for superficial bladder tumor.

Prospective evaluation of plasma kinetic bipolar resection of bladder cancer: comparison to monopolar resection and pathologic findings

OBJECTIVE

To determine whether the Gyrus ACMI plasma kinetic bipolar device (Gyrus ACMI, Southborough, MA) improves pathologic specimen preservation and clinical outcomes compared to standard monopolar electrocautery.

PATIENTS AND METHODS

In our prospective study, 83 patients underwent monopolar or bipolar transurethral resection of bladder tumors between April 2006 and February 2007 at Memorial Sloan-Kettering Cancer Center. Dedicated genitourinary oncology pathologists blinded to resection type and assessed pathologic features including stage and grade, presence of muscularis propria, fragment size, presence and thickness of thermal artifacts within the specimen, layer of tissue most affected, severity of tissue distortion, and diagnostic impact of thermal artifacts. Clinical outcomes including, perforation, obturator reflex, need for muscle paralysis, a catheter, or admission, were recorded. Clinical and pathologic outcomes between resection modality were compared.

RESULTS

There were no significant thermal artifacts in 9/38 (23.7 %) and 11/45 (24.4 %) monopolar and bipolar specimens, respectively. The layer of bladder tissue most affected by thermal artifacts was readable in 18/38 (47.4 %) monopolar and 27/45 (60.0 %) bipolar specimens. Tissue distortion from thermal artifacts led to areas within 11/38 (28.9 %) monopolar and 7/45 (15.6 %) bipolar specimens being unreadable. Ultimately, thermal artifacts caused moderate diagnostic difficulty in 2/38 (5.3 %) specimens of the monopolar group and severe diagnostic difficulty in 1/45 (2.2 %) bipolar specimens. Clinically, there was no major difference between resection methods.

CONCLUSION

Plasma kinetic bipolar equipment appears to cause less tissue distortion and has the potential to facilitate staging and grading of bladder tumors. No differences in clinical outcomes were appreciated between resection methods. If these results can be repeated in larger studies, the bipolar device represents a small advancement in transurethral resection.

The Direct Anti-Cancer Effect of a Single Instillation of Epirubicin after Transurethral Resection of Bladder Tumor for Non-Muscle-Invasive Bladder Cancer

Purpose

To evaluate the direct anti-cancer effect of a single instillation of epirubicin (SIE) after transurethral resection of bladder tumor (TURBT) for non-muscle-invasive bladder cancer (NMIBC) by analysis of immediate urine cytology (IUC).

Materials and Methods

We reviewed the records of 158 patients who had IUC after TURBT for NMIBC. Fifty-six patients were treated with SIE after TURBT and 102 patients were not treated with SIE. The direct anti-cancer effect of SIE was compared in the two groups according to the result of IUC. The relationship between SIE and IUC in NMIBC was analyzed by use of multivariate Cox proportional hazards regression models.

Results

The IUC-positive rate was 33.9% in the SIE group and 42.1% in the non-SIE group (p=0.005). The IUC-positive rate was lower in the SIE group than in the non-SIE group for each factor, including tumor stage, tumor grade, tumor size, tumor multiplicity, and preoperative urine cytology. Multivariate Cox proportional hazards regression analysis revealed that SIE was significantly associated with a negative IUC result in patients with NMIBC (HR, 0.163) (p<0.001).

Conclusions

These results indicate the direct anti-cancer effect of SIE in patients who undergo TURBT for NMIBC.