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

En Bloc Versus Conventional Transurethral Resection of Bladder Tumors: A Systematic Review and Meta-analysis of Oncological, Histopathological, and Surgical Outcomes

BACKGROUND AND OBJECTIVE

En bloc resection of bladder tumor (ERBT) has been introduced to enhance the quality of resection of bladder cancer. This review aims to compare the perioperative and oncological outcomes of ERBT and conventional transurethral resection of bladder tumor (cTURBT).

METHODS

A literature search was conducted using the PubMed/Medline, Embase, and Web of Science databases to identify randomized controlled trials published until May 2024. The primary outcomes were the risk of recurrence and progression. The secondary outcomes were detrusor muscle (DM) presence, muscularis mucosae (MM) detectability, bladder perforation and obturator nerve reflex rates, operative time, length of catheterization and hospitalization, and residual tumor at repeat transurethral resection of bladder tumor (reTURBT).

KEY FINDINGS AND LIMITATIONS

Seventeen studies met our inclusion criteria. No statistically significant difference was observed in 12-mo recurrence (risk ratio [RR] 0.81, 95% confidence interval [CI]: 0.65-1.02; p = 0.08), 24-mo recurrence (RR 1.02, 95% CI: 0.85-1.22; p = 0.8), and 12-mo progression (RR 0.68, 95% CI: 0.05-10.14; p = 0.8) rates. ERBT was significantly associated with a higher DM presence (RR 1.10, 95% CI: 1.01-1.20; p = 0.02), while no statistically significant difference emerged in the residual tumor at reTURBT and MM detectability (all p > 0.05). ERBT was significantly associated with a lower risk of bladder perforation (p = 0.002) and obturator nerve reflex (p < 0.001). Finally, ERBT was significantly associated with longer operative time, lower catheterization time, and lower length of hospital stay. The main limitation was heterogeneity among the included studies.

CONCLUSIONS AND CLINICAL IMPLICATIONS

ERBT is safer due to fewer intraoperative events, but there was no significant difference in oncological outcomes compared with cTURBT. Higher DM detection with ERBT enhances initial disease stratification, potentially improving clinical decision-making and care delivery.

PATIENT SUMMARY

En bloc resection of bladder tumors is associated with lower intraoperative complications than and superior histopathological information to the conventional resection technique. However, the absence of a difference in oncological outcomes underscores the influence of factors such as tumor characteristics, surgeon expertise, and postoperative care on subsequent events.

An updated systematic review, meta-analysis, and trial sequential analysis of the efficacy and safety of en bloc transurethral resection vs. conventional transurethral resection for nonmuscle-invasive bladder tumor

OBJECTIVE

En bloc transurethral resection of bladder tumor (ERBT) for nonmuscular-invasive bladder tumor (NMIBC) has been used in clinical practice, but its efficacy and safety have not been conclusional. We aimed to evaluate the efficacy and safety of ERBT and conventional transurethral resection of bladder tumor (cTURBT) for NMIBC.

METHODS

Randomized controlled trials (RCTs) comparing ERBT and cTURBT in the treatment of NMIBC were searched in Pubmed, Embase, Clinicaltrials.gov, and Cochrane; 12 RCTs were included for systematic review and meta-analysis using RevMan 5.4.

RESULTS

A total of 12 RCTs involving 2097 patients with NMIBC were included and analyzed. The results showed the rate of identification of detrusor muscle in specimens [odds ratio (OR) 1.90; P = 0.03] was higher in ERBT group, and bladder perforation (OR 0.30; P = 0.004), obturator nerve reflex (OR 0.18; P = 0.001), catheter indwelling time (MD -0.64; P = 0.002), length of hospital stay (MD -0.58; P = 0.002), tumor recurrence rate 3 months after surgery (OR 0.42; P = 0.03), tumor recurrence rate 6 months after surgery (OR 0.21; P = 0.007), the recurrence rate of the same site 1 year after surgery (OR 0.23; P < 0.0001) and bleeding rate (OR 0.30; P = 0.0005) were significantly lower in ERBT group than that in cTURBT group. There was no significant difference in residual tumor (OR 0.62; P = 0.07), Re-TURBT (OR 0.71; P = 0.19), hemoglobin deficit (MD -0.81; P = 0.29), urethral stricture (OR 0.67; P = 0.42), resection time (MD 2.31; P = 0.16), operative time (MD 1.17; P = 0.49), 1 year (OR 0.61; P = 0.13), 2 years (OR 0.94; P = 0.76), 3-year tumor recurrence rate (OR 1.03; P = 0.86) and the risk of progression at 12 month (OR 0.68; P = 0.79) between the two groups.

CONCLUSIONS

Our results showed that ERBT can improve the rate of identification of detrusor muscle in specimens and reduce the 3-month, 6-month tumor recurrence rate and recurrence rate of the same site 1 year after surgery. In addition, ERBT has fewer complications, and shorter catheter indentation time and hospital stay. The laser ERBT can also decrease tumor residual rate and re-TURBT.

Association of energy source with outcomes in en bloc TURB: secondary analysis of a randomized trial

PURPOSE

To comprehensively evaluate the efficacy of different energy sources used for en-bloc transurethral resection of bladder tumors (ERBT) on perioperative outcomes.

METHODS

This sub-analysis derived from a prospective randomized study that enrolled patients undergoing ERBT vs conventional transurethral resection of the bladder (cTURB) from January 2019 to January 2022 (NCT03718754). Endpoints were pathological specimen quality and perioperative outcomes after either monopolar (m-ERBT) or bipolar (b-ERBT) or laser (l-ERBT) ERBT.

RESULTS

237 bladder tumors resected in 188 patients included in the analyses: 29 (12.2%) m-ERBT, 136 (57.4%) b-ERBT and 72 (30.4%) l-ERBT. Detrusor muscle (DM) was detected in 191 (80.6%) specimens. Per-tumor analysis revealed comparable rate of DM in the specimens obtained via different energy modalities (p = 0.7). Operative time was longer in the l-ERBT cohort compared to m-ERBT and b-ERBT (p = 0.02) and no obturator nerve reflex (ONR) onset was reported. On logistic regression analysis, b-ERBT was associated with negative lateral resection margins (OR 2.81; 95% CI 1.02-7.70; p = 0.04). There was no significant association of the resection technique with perforation and conversion rates (all p > 0.05). Within a median follow up of 22mo (IQR 11-29), a total of 35 (18.6%) patients had a local recurrence. On Cox regression analysis, patients resected with b-ERBT were less likely to have a recurrence (HR 0.34; 95% CI 0.15-0.78; p = 0.01); When adjusting for established confounders, this association was confirmed (HR 0.24; 95% CI 0.10-0.60; p = 0.002).

CONCLUSIONS

Different energy sources might achieve comparable perioperative outcomes. Further perspectives involve the assessment of long-term differential oncological outcomes associated with various energy modalities.

The Role of Morcellation in En Bloc Resection of Large Bladder Tumors

Background/Objectives: Conventional transurethral resection of bladder tumor (TURBT) for non-muscle invasive bladder cancer (NMIBC) is usually performed in a piecemeal manner, leading to difficulties in accurate pathological assessment. En bloc resection of bladder tumor (ERBT) has been developed to address these limitations, offering improved specimen quality. So far, ERBT has been restricted to small bladder tumors due to difficulties in en bloc extraction of large ones (>3 cm). Recently, the morcellation technique has been proposed to facilitate the removal of large bladder tumors during ERBT. This narrative review aims to evaluate the feasibility of ERBT with subsequent morcellation for large bladder tumors, focusing on its role in tumor extraction and its impact on pathological assessment. Methods: A comprehensive literature search was conducted across multiple databases to identify studies evaluating the use of morcellation in ERBT for large bladder tumors. Inclusion criteria comprised studies reporting recurrence rates, detrusor muscle (DM) presence in pathological specimens, and perioperative complications. Additionally, we offered uropathologists a questionnaire to gather their perspectives on the use of morcellation following ERBT, focusing on its impact on pathological assessment, margin evaluation, and staging accuracy. Results: While there is limited evidence on the use of morcellation in ERBT for tumors larger than 3 cm and its impact on oncologic outcomes, morcellation has shown potential in facilitating the retrieval of large tumor specimens, ensuring clear resection margins and accurate staging. However, the learning curve for morcellation techniques and the need for specialized equipment may limit widespread adoption. Conclusions: Morcellation in ERBT for large bladder tumors represents a promising advancement in the management of these challenging cases, offering adequate pathological assessment and oncologic outcomes. Pathologists' reviews of morcellated specimens will likely further validate the technique. Continued research and technological innovations are necessary to optimize its implementation in clinical practice.

Optimal energy source selection strategies for en bloc resection in non-muscle invasive bladder cancer: a systematic review and network meta-analysis

OBJECTIVE

This research aimed to identify the most effective energy source for en bloc resection of non-muscle-invasive bladder cancer (NMIBC) by a systematic review and network meta-analysis of randomized controlled trials (RCTs) and observational studies. We assessed and contrasted the effectiveness and safety of various energy modalities used in en bloc resection (ERBT) with those employed in conventional transurethral resection of bladder tumor (cTURBT).

METHODS

A thorough search was conducted in PubMed, EMBASE, Cochrane, and Web of Science (WOS) to discover relevant articles published till August 29, 2024. Research comparing en bloc resection using various energy sources (such as hybrid knife, holmium laser, thulium laser, green-light laser, monopolar, and bipolar devices) to conventional transurethral resection of bladder tumor (cTURBT) was included. A network meta-analysis was performed using Stata/MP 18.0. Standardized mean differences (SMD) were computed for continuous outcomes, whilst relative risks (RR) were used for dichotomous outcomes. Nine clinical outcomes were assessed: duration of surgery, length of hospital stay, catheterization duration, irrigation duration, volume of intraoperative blood transfusion, 12-month recurrence rate, bladder perforation rate, incidence of obturator nerve reflex, and presence of detrusor muscle in the resected specimen. (PROSPERO ID: CRD42024623881).

RESULTS

The study included 37 research, including 8 randomized controlled trials (RCTs) and 29 high-quality non-randomized controlled trials (NRCTs), with a total of 4973 patients involved. The network meta-analysis revealed that ERBT was much better than cTURBT in the majority of outcomes. Hybrid knife and laser technologies (holmium, thulium, and green-light lasers) shown superior efficacy regarding decreased surgical length, diminished 12-month recurrence rates, and fewer problems. Hybridknife proved to be the most advantageous energy source for various results, while cTURBT consistently exhibited the least effective performance across all metrics.

CONCLUSION

En bloc resection surpasses traditional TURBT in the management of NMIBC, with various energy modalities exhibiting distinct benefits. Among the assessed energy sources, laser technologies and hybrid knives regularly surpassed monopolar and bipolar devices. These findings provide critical direction for urologists in selecting the most suitable energy source for en bloc resection in NMIBC, emphasizing the need for individualized decision-making based on the patient's distinct variables and tumor attributes.

Comparison of the mid-term outcomes of laparoscopic and percutaneous nephroscopic laser unroofing for the treatment of single renal cyst: a single-center retrospective study

PURPOSE

Renal cysts are the most common benign disease of the kidneys, and their increasing size cause compression symptoms that require surgical intervention. In this study, we compared the safety, efficacy and prognosis of percutaneous nephroscopic laser unroofing (PNLU) with those of laparoscopic unroofing (LU) for simple renal cysts.

METHODS

Data from patients with single renal cysts who underwent PNLU or LU between Jan 2018 and Dec 2023 were collected and followed up thereafter. Baseline characteristics, perioperative events, blood test results and postoperative complications were compared. Recurrence-free survival (RFS) was also compared via survival analysis. Subgroup analyses were conducted in the PNLU group, including the 980 nm laser and Holmium laser groups.

RESULTS

A total of 75 patients were included, 35 of whom underwent PNLU and 40 of whom underwent LU. Compared with LU, PNLU requires only one surgical incision and is a shorter procedure, causes less blood loss, requires fewer urinary catheter days, is known for quicker drainage tube removal, requires a shorter postoperative hospital stay, has lower hospitalization costs, induces a weaker postoperative inflammatory response, and is associated with a lower incidence of abdominal distension. There was no significant difference in RFS between the PNLU and LU groups. In the subgroup analyses of PNLU, no significant differences were observed between the 980 nm laser and Holmium laser groups.

CONCLUSION

PNLU is safe, effective and cost-effective for single renal cysts and known for a low complication rate, and its mid-term prognosis is similar to that of laparoscopic surgery.

En bloc resection of large bladder tumor: is it feasible and reasonable?

PURPOSE OF REVIEW

Transurethral resection of bladder tumor (TURBT) remains the basis of bladder tumor diagnosis and an effective means of treating nonmuscle invasive bladder cancer (NMIBC). There are several limitations to this procedure: TURBT may cause free floating of malignant cells in the bladder and as a result re-implantation and early recurrence. Also, it does not allow the pathologist to define the correct spatial orientation of the specimen. The development of en bloc resection of bladder tumor (ERBT) has helped overcome the abovementioned key disadvantages of TURBT. However, many urologists doubt whether this approach is feasible for treating larger tumors.

RECENT FINDINGS

In this review, it is shown that ERBT of large bladder tumor (>3 cm) is in fact a feasible and well tolerated method. Although there is a lack of comparative data proving its advantages over TURBT, en bloc in large tumor seems to result in better local cancer control (due to higher prevalence of detrusor specimen, lower need for re-TURBT), lower rate of relapse outside the resection area (due to lower risk of tumor cells circulation), and higher quality of pathology specimen.

SUMMARY

Despite the skepticism of some surgeons, potential difficulties caused by larger tumor size may be overcome easily, and most agree that tumor size should not limit the implementation of the method in their daily practice.

Current opinions regarding the clinical utility of en bloc resection in the treatment of non-muscle invasive bladder cancer-a review of the literature

Non-muscle invasive bladder cancer (NMIBC) is currently mainly treated with the approach of transurethral resection of bladder tumor (TURBT) followed by pathology investigation of the obtained specimens. However, this approach-TURBT-has a few drawbacks, owing to the inherent technical defect-"piecemeal" resection. With development of medical science and surgical techniques, a new kind of surgical operation-"en bloc" resection of bladder tumor (ERBT)-emerged, hoping to completely remove bladder tumor with surrounding normal tissue. The detrusor muscle layer beneath the tumor is removed, and the surgical quality of bladder tumor is enhanced, with a better pathological outcome, reduced intraoperative complications and lower recurrence rate eventually. This paper reviews current literature concerning a brief history of ERBT developing, surgical steps, its indications, advantages on surgical margin, recurrence during follow-up, pathological performance-presence of detrusor muscle, residual tumor and upstage, as well as such issue as "is reTURBT necessary after ERBT?" and the guiding significance of ERBT in substaging of T1 bladder cancer.

Thulium laser en bloc resection reduces recurrence rates in NMIBC patients with tumor diameters ≥3cm compared to transurethral resection: a non-randomized controlled study

PURPOSE

The advantages of en bloc resection of bladder tumors (ERBT) over transurethral resection of bladder tumors (TURBT) in terms of patient prognosis are not yet clear, and there are some technical limitations. We aimed to compare the tumor recurrence in non-muscle invasive bladder cancer (NMIBC) patients with tumor diameter ≥ 3 cm undergoing either TURBT or thulium laser ERBT.

METHODS

The patients included were those diagnosed with NMIBC based on pathological confirmation and underwent TURBT or modified thulium laser ERBT in the Department of Urology at Tongji Hospital from 2019 to 2024. The patients' medical records were meticulously collected and postoperative follow-up was diligently conducted by trained personnel. Recurrence-free survival curves were generated utilizing the Kaplan-Meier method, and group comparisons were performed using the log-rank trend test. To minimize biases, we employed stratified survival analysis, alongside univariate and multivariate Cox regression analysis.

RESULTS

This study included a total of 396 patients with NMIBC, with 214 undergoing TURBT and 182 undergoing ERBT. For all patients, there was no significant difference (P = 0.180) in RFS between the TURBT and ERBT groups. For patients with tumor diameter ≥ 3 cm, stratified analysis revealed that the RFS of the ERBT group was significantly better than that of the TURBT group (P = 0.033). However, in patients with tumor diameter < 3 cm, there was no significant difference (P = 0.150) between the two groups. Univariate (HR: 0.52, 95% CI 0.28-0.96, P = 0.036) and multivariate (HR: 0.49, 95% CI 0.25-0.93, P = 0.031) Cox analyses revealed that ERBT was an independent protective factor for recurrence in NMIBC patients with tumor diameter ≥3cm.

CONCLUSION

This study found that thulium laser ERBT may offer advantages in managing NMIBC patients with tumor diameters ≥ 3 cm. This could potentially drive the clinical application of thulium laser ERBT.

TRIAL REGISTRATION

Protocol was registered at Chinese Clinical Trial Register (ChiCTR) with number ChiCTR2000035407 on 12 August 2020.

A novel laser resection approach: efficacy of rotatable bi-channel en bloc resection of bladder tumor in a pilot in-vivo study

En bloc resection of bladder tumor (ERBT) involves removing bladder tumors and their base. Laser resection has been used to reduce complications including bleeding and obturator nerve reflex (ONR). We developed a novel approach (rotatable bi-channel en bloc resection of bladder tumor (RBC-ERBT)) and assessed its efficacy in a pilot in-vivo study to enhance laser ERBT's applicability in challenging bladder regions. In the laser RBC-ERBT procedure, lesions were excised by inserting a holmium laser through the rotating external working channel, while forceps were inserted through the internal working channel provided traction on the tissue. Fifteen laser RBC-ERBT procedures were performed in five different bladder areas of three live pigs. The technical success rate (TSR), procedure time, lesion size, occurrence of complications (bleeding, perforation, ONR), and detrusor muscle (DM) presence rate and DM thickness were evaluated. All 15 procedures were performed with a 100% TSR. The resections were successful in all bladder regions (posterior, left, right and anterior walls and dome). Median procedure time was 20 min. The resected specimen size was 10 mm × 7 mm to 17 mm × 13 mm. Mild bleeding occurred in two procedures (13.3%) but was effectively managed. No incidents of ONR or perforation were observed. Histological examination confirmed presence of DM in all specimens with a median DM thickness of 1.26 mm. Our pilot in-vivo study suggested the feasibility and effectiveness of laser RBC-ERBT for bladder tumors in various locations. This technique offers effective traction, improved visualization, and enhanced laser accessibility. Further studies are required to validate its effectiveness in humans.

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.

Prospective learning curve analysis of en bloc resection of bladder tumor using an ex vivo porcine model

BACKGROUND

As a relatively new surgical technique, the learning curve of en bloc resection of bladder tumor (ERBT) in ex vivo models remains unaddressed. This study aimed to explore the learning curve of ERBT in an ex vivo porcine model.

METHODS

In this prospective study, eight endoscopists without prior experience in ERBT were divided into two groups: junior endoscopists, with less than 100 transurethral resection of bladder tumor (TURBT) procedure experience, and senior endoscopists, with at least 100 TURBT procedure experience. Each endoscopist performed 30 ERBT procedures on artificial lesions in an ex vivo porcine bladder model. The procedure time, perforation, en bloc resection status, and absence of detrusor muscle (DM) were recorded. The inflection points were identified using cumulative sum (CUSUM) analysis. Procedure results were compared between the two phases and two groups.

RESULTS

In all, 240 artificial lesions were successfully resected using ERBT. The CUSUM regression line indicated the inflection point at the 16th procedure for the junior endoscopists and at the 13th procedure for the senior endoscopists. In both groups, the procedure time, perforation, piecemeal resection, and DM absence rates were significantly lower in the consolidation phase than in the initial phase. The procedure time for the senior endoscopists was lower than for the junior endoscopists in both phases.

CONCLUSIONS

ERBT performance improved significantly after reaching the inflection point of the learning curve in the ex vivo model. We recommend a minimum of 16 ERBT procedures in ex vivo models for urologists with less than 100 TURBT experience and a minimum of 13 procedures for those with at least 100 TURBT experience before advancing to live animal training or supervised clinical practice.

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

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

Repeat Transurethral Resection for Non-muscle-invasive Bladder Cancer: An Updated Systematic Review and Meta-analysis in the Contemporary Era

CONTEXT

Repeat transurethral resection (reTUR) is a guideline-recommended treatment strategy in high-risk non-muscle-invasive bladder cancer (NMIBC) patients treated with transurethral resection of bladder tumor (TURBT); however, the impact of recent procedural/technological developments on reTUR outcomes has not been assessed yet.

OBJECTIVE

To assess the outcomes of reTUR for NMIBC in the contemporary era, focusing on whether temporal differences and technical advancement, specifically, photodynamic diagnosis and en bloc resection of bladder tumor (ERBT), affect the outcomes.

EVIDENCE ACQUISITION

Multiple databases were queried in February 2023 for studies investigating reTUR outcomes, such as residual tumor and/or upstaging rates, its predictive factors, and oncologic outcomes, including recurrence-free (RFS), progression-free (PFS), cancer-specific (CSS), and overall (OS) survival. We synthesized comparative outcomes adjusting for the effect of possible confounders.

EVIDENCE SYNTHESIS

Overall, 81 studies were eligible for the meta-analysis. In T1 patients initially treated with conventional TURBT (cTURBT) in the 2010s, the pooled rates of any residual tumors and upstaging on reTUR were 31.4% (95% confidence interval [CI]: 26.0-37.2%) and 2.8% (95% CI: 2.0-3.8%), respectively. Despite a potential publication bias, these rates were significantly lower than those in patients treated in the 1990-2000s (both p < 0.001). ERBT and visual enhancement-guided cTURBT significantly improved any residual tumor rates on reTUR compared with cTURBT based on both matched-cohort and multivariable analyses. Among studies adjusting for the effect of possible confounders, patients who underwent reTUR had better RFS (hazard ratio [HR]: 0.78, 95% CI: 0.62-0.97) and OS (HR: 0.86, 95% CI: 0.81-0.93) than those who did not, while it did not lead to superior PFS (HR: 0.74, 95% CI: 0.47-1.15) and CSS (HR: 0.94, 95% CI: 0.86-1.03).

CONCLUSIONS

reTUR is currently recommended for high-risk NMIBC based on the persistent high rates of residual tumors after primary resection. Improvement of resection quality based on checklist applications and recent technical/procedural advancements hold the promise to omit reTUR.

PATIENT SUMMARY

Recent endoscopic/procedural developments improve the outcomes of repeat resection for high-risk non-muscle-invasive bladder cancer. Further investigations are urgently needed to clarify the potential impact of the use of these techniques on the need for repeat transurethral resection in the contemporary era.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

En Bloc Resection of Bladder Tumors (ERBT) using different lasers - Hybrid and Holmium Laser

INTRODUCTION

The En-bloc Resection of Bladder Tumors (ERBT) is a method that offers more benefits compared to the traditional Transurethral Resection of Bladder Tumor (TURBT) (1, 2). Recent studies have shown that ERBT offers better pathological analysis and oncological outcomes (3-6). Thulium and holmium are the most frequently used lasers for this procedure, with the hybrid laser being a new addition that combines thulium and diode to improve hemostatic properties (5, 7-9).

OBJECTIVE

This report aims to discuss the use of two types of lasers, hybrid and holmium, for ERBT.

MATERIAL AND METHODS

Two case studies were conducted. The first case featured a 68-year-old male with two tumors measuring 1.5cm and 2cm. The hybrid laser was used for the procedure. The second case involved a 70-year-old female with a 5cm tumor on the posterior bladder wall, and holmium laser was used with morcellation of the tumor. The quality of histopathological analysis was evaluated. The perioperative data and the entire procedure of the two cases were documented in a step-by-step video.

RESULTS

Both lasers demonstrated excellent results without technical difficulties. There was no bleeding, and both patients were discharged with one day of hospitalization. The detrusor muscle was present without artifacts, and the morcellation did not affect the analysis. The first case showed a pT1G3, and the second case showed a pT2 urothelial carcinoma. The hybrid laser exhibited superior hemostatic capacity compared to the holmium laser.

CONCLUSION

ERBT can use hybrid or holmium lasers without affecting histopathological analysis, even with morcellation.

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.

En Bloc Versus Conventional Resection of Primary Bladder Tumor (eBLOC): A Prospective, Multicenter, Open-label, Phase 3 Randomized Controlled Trial

BACKGROUND

En bloc transurethral resection of the bladder (eTURB) might improve the surgical management of non-muscle-invasive bladder cancer (NMIBC) in comparison to conventional TURB (cTURB).

OBJECTIVE

To evaluate whether eTURB is superior to cTURB in resection of NMIBC and specimen retrieval.

DESIGN, SETTING, AND PARTICIPANTS

This was a randomized, multicenter trial in patients with up to three cTa-T1 NMIBC tumors of 1-3 cm in size, who were enrolled from January 2019 to January 2022.

INTERVENTION

Participants were randomized 1:1 to undergo eTURB (n = 192) or cTURB (n = 192).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was the prevalence of detrusor muscle (DM) in the specimen retrieved. Secondary endpoints included bladder perforation, persistent disease at second-look TURB, positive lateral resection margin, positive deep resection margin, operation time, perforation rate, obturator reflex, conversion from eTURB to cTURB, recurrence-free survival, and disease recurrence at 3 mo.

RESULTS AND LIMITATIONS

A total of 384 patients were randomized to undergo eTURB or cTURB. A total of 452 tumors were resected and analyzed for the primary outcome. eTURB was superior to cTURB in retrieval of DM (80.7% vs 71.1%; mixed-model p = 0.01). Bladder perforation (5.6% vs 12%; difference -6.4%; 95% confidence interval [CI] -12.2% to -0.6%) and obturator reflex (8.4% vs 16%; difference -7.6%; 95% CI -14.3% to -0.9%) were less frequent in the eTURB arm than in the cTURB arm. Operation time did not differ between the two techniques (26 min, interquartile range [IQR] 20-38 for eTURB vs 25 min, IQR 17-35 for cTURB; difference 1 min, 95% CI -25.9 to 4.99). Second-look TURB was performed in 24 patients in the eTURB arm and 34 in the cTURB arm, with no difference in the rate of residual papillary disease (pTa/pT1: 56% vs 55.9%; difference 0.1%, 95% CI -25.5% to 25.7%). At median follow-up of 13 mo (IQR 7-20), 18.4% of the patients in the eTURB arm and 16.7% in the cTURB arm had experienced bladder cancer recurrence (Cox hazard ratio 0.87, 95% CI 0.49-1.52; p = 0.6).

CONCLUSIONS

In patients with clinical NMIBC with up to three tumors of 1-3 cm in size, tumor removal via eTURB resulted in a higher rate of DM in the pathologic specimen in comparison to cTURB. Moreover, eTURB was associated with lower frequency of obturator reflex and bladder perforation than cTURB was. While improving on the quality indicators for NMIBC, the long-term differential oncologic benefits of eTURB remain uncertain.

PATIENT SUMMARY

We compared two techniques for removal of bladder tumors and found that tumor removal in a single piece, called en bloc resection, provides a better-quality specimen for pathology analysis and fewer complications in comparison to the conventional method. This trial is registered at ClinicalTrials.gov as NCT03718754.

How do endoscopic bladder tumor resection techniques affect pathology practice? EAU Section of Uro-Technology (ESUT) and Uropathology (ESUP) survey

PURPOSE

We aimed to examine how different endoscopic bladder tumor resection techniques affect pathologists' clinical practice patterns.

METHODS

An online survey including 28 questions clustered in four main sections was prepared by the ESUT ERBT Working Group and released to the pathologists working in the institutions of experts of the ESUT Board and the working groups and experts in the uropathology working group. A descriptive analysis was performed using the collected data.

RESULTS

Sixty-eight pathologists from 23 countries responded to the survey. 37.3% of the participants stated that they always report the T1 sub-staging. Of those who gave sub-staging, 61.3% used T1a, b. 85.2% think that en bloc samples provide spatial orientation faster than piecemeal samples, and 60% think en bloc samples are timesaving during an inspection. 55.7% stated that whether the tissue sample is en bloc or piecemeal is essential. 57.4% think en bloc sample reduces turnaround time and is cost-effective for 44.1%. A large number of pathologists find that the pathology examination of piecemeal samples has a longer learning curve.

CONCLUSION

The survey shows that pathologists think that they can diagnose faster, accurately, and cost-effectively with ERBT samples, but they do not often encounter them in practice. Moreover, en bloc samples may be a better choice in pathology resident training. Evidence from real-life observational pathology practice and clinical research can reveal the current situation more clearly and increase awareness on proper treatment in endoscopic management of bladder tumors.

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.

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.

Current Techniques for En Bloc Transurethral Resection of Bladder Tumor: A Hands-on Guide Through the Energy Landscape

En bloc resection of bladder tumor (ERBT) has attracted interest as a potentially superior technique to transurethral resection of bladder tumor (TURBT) to obtain detrusor muscle in the specimen. Different ERBT techniques have been described, with bipolar electrocautery and laser being the more favored energy modalities. Electrocautery EBRT has an advantage in terms of widespread availability in clinics and ease of conversion to piecemeal resection in case of large bladder tumors in different locations. Laser EBRT has an advantage in preventing obturator nerve reflex, which is particularly useful for lateral wall tumors. Further research is needed to assess the potential case-related advantages of the ERBT techniques over each other. PATIENT SUMMARY: Surgical removal of a bladder tumor as a whole single piece, called en bloc resection, is a safe procedure for the diagnosis and treatment of noninvasive bladder cancer. In this mini-review we summarize the evidence for current techniques for en bloc resection.

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.

Standard Transurethral Resection vs Transurethral Laser Surgery for Bladder Cancer: A Systematic Review and Meta-Analysis Comparing Clinical Outcomes and Complications

Introduction: Transurethral resection of bladder tumor (TURBT) remains the gold standard method of diagnosing and treating nonmuscle invasive bladder cancer. Laser resection has been demonstrated as a safe and efficacious alternative; however, its mainstream use remains limited. The aim of this review is to comparatively evaluate clinical outcomes of TURBT and laser resection of bladder tumor (LRBT) for bladder cancer. Methods: A systematic review of the literature was performed for studies comparing TURBT and LRBT for bladder cancer. Outcome measurements were recurrence rates, complication rates, patient demographics, operative duration, and inpatient stay. Meta-analysis was performed using Review Manager 5. Results: Twenty studies on 2621 patients (n = 1364 for TURBT and n = 1257 for LRBT) met inclusion criteria. Demographics, including age and gender ratio and follow-up period, were similar in both groups. Recurrence rates were similar between TURBT and LRBT (29.1% vs 28.2%, p = 0.12). TURBT had a significantly greater obturator kick rate (11.5% vs 0.4%, p < 0.0001) and perforation rate (3.7% vs 0.009%, p = < 0.0001). In the six studies which reported on presence of detrusor muscle in the specimen, it was significantly greater in the LRBT group (96.6% vs 88.1%, p = 0.01). There was no significant difference in operative time between the two groups. TURBT was associated with a significantly longer catheter duration (mean difference [MD] 0.98 days shorter in LBRT group; 95% confidence interval [95% CI] -1.45 to -0.5, p = < 0.00001), and length of stay (MD 1.12 days shorter in LRBT group, 95% CI -1.7 to -0.54, p = 0.0001). Conclusions: LRBT for bladder cancer has the benefit of reduced catheter duration, length of stay, and perforation without impacting negatively on operation duration, recurrence rates, or specimen quality.

En-bloc resection of non-muscle invasive bladder cancer: does it really make a difference?

PURPOSE OF REVIEW

Transurethral resection of bladder tumour (TURBT) followed by pathology investigation of the obtained specimens is the initial step in the management of urinary bladder cancer (UBC). By following the basic principles of oncological surgery, en-bloc resection of bladder tumour (ERBT) aims to overcome the limitations associated with conventional transurethral resection, and to improve the quality of pathological specimens for a better decision making. The current bulk of evidence provides controversial results regarding the superiority of one technique over the other. The aim of this article is to summarize the recent data and provide evidence on this unanswered question.

RECENT FINDINGS

Despite heterogeneous and controversial data, ERBT seems to have a better safety profile and deliver higher quality pathologic specimens. However, the recent evidence failed to support the hypothesized oncological potential benefits of ERBT in the initial surgical treatment of patients with UBC.

SUMMARY

ERBT has gained increasing interest globally in the past decade. It continues to represent a promising strategy with a variety of features intended to solve the inherent limitations of TURBT. However, the current quality of evidence does not allow solid conclusions to be drawn about its presumed superiority compared with the conventional technique.

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

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

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.

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

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

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.

Endoscopic laser en bloc removal of bladder tumor. Surgical radicality and improvement of the pathological diagnostic accuracy

INTRODUCTION

Bladder cancer is one of the most common tumors among the general population. The first surgical approach to the tumor is often the transurethral resection with monopolar or bipolar loop. Recently, laser energy has become an alternative for resection of small bladder tumor, because it allows to obtain high quality samples with the "en bloc" technique. Our study aims to show the results of endoscopic diode laser treatment of bladder tumor up to three centimeters in maximum diameter.

MATERIALS AND METHODS

189 patients underwent "en bloc" resection with diode dual length laser (980 nm-1470 nm). Follow up was over 12 months. Patients age range was from 45 to 75 years. Maximum diameter of the lesions was 3.0 cm. For each patient, a cold forceps biopsy sample was performed.

RESULTS

All samples collected presented detrusorial layer. Pathological exam showed: 28 (14.8%) Ta, G1-G2; 7 (3.7%) T3, G2-G3; 14 (7.4%) T1, G2-G3 and 140 ( 74.1%) Ta, G2-G3. No complications occurred during or after surgery. At a median follow-up period of 6 months, we had no recurrence in the previous site of tumor. In the follow up at 3/6/12 months in 4 cases we had recurrence in different sites of bladder wall.

CONCLUSIONS

Laser "en bloc" resection is an effective, feasible, and safe treatment for bladder tumor. It could be a valid alternative to monopolar and bipolar resection in small bladder cancer treatment.

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 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.

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

INTRODUCTION

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

CASE PRESENTATION

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

CONCLUSION

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

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.

Comparison of various types of lasers and transurethral resection in the treatment of bladder tumors: a systematic review and meta-analysis

Bladder cancer is one of the most common cancers of the urinary tract. The two available treatments for this malignancy are laser and Transurethral Resection of the Bladder Tumor (TURBT). The aim of this study was to compare the different parameters of these two methods. A systematic search was performed on PubMed, Scopus and Google Scholar between 2000 and 2021. All articles related to non-muscle invasive bladder cancer (NMIBC) were extracted. All analyses were performed using R-studio statistical software version 1.0.136. In total, 11 studies that reported tumor recurrence in two methods were evaluated. A total of 626 and 742 patients were treated with laser and TURBT, respectively. Tumor recurrence, duration of operation, hospitalization and catheterization in laser therapy were significantly lower than TURBT. In addition, the incidence of complications was lower in patients treated with laser. The incidence of obturator nerve reflex, bladder perforation and postoperative bladder irrigation was significantly higher in patients treated with TURBT. Only in relation to postoperative urethral stricture, no significant difference was observed between the two treatment methods. Laser therapy compared to TURBT in patients with NMIBC has fewer complications and faster recovery. Also, the risk of tumor recurrence in laser therapy is less than TURBT.

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 Systematic Review of Thulium Fiber Laser: Applications and Advantages of Laser Technology in the Field of Urology

Laser technology is widely used in urological surgery, from lithotripsy, prostate surgery to en-bloc resection of tumours. While Holmium:YAG has been widely employed over the last two decades, in recent years, there has been a surge of interest in Thulium Fiber Laser (TFL), which offers theoretical advantages of better water absorption and lower stone ablation thresholds. A systematic review was conducted to assess the evidence from clinical research on TFL's application for lithotripsy and prostate surgery. It identified 357 articles and 8 (1506 patients) were selected, of which 4 clinical studies each investigated TFL enucleation of prostate (ThuFLEP) and TFL lithotripsy. For flexible ureteroscopic lithotripsy (FURSL), stone ablation settings ranged from 0.1-4 J, and 7-300 Hz, mean operative time ranged from 23.4-39.8 minutes and lasing time ranged from 1.2-10 minutes. For stone dusting in percutaneous nephrolithotomy (PCNL), settings of 0.2 J and 125-200 Hz were found to be optimal. For ThuFLEP, all studies showed a significant improvement in IPSS (International Prostate Symptom Score), urinary flow rate (Qmax), quality of life measures, and post-void residual volume, with mean operative time ranging from 67-104.5 minutes. Our review shows that there is limited evidence on the use and clinical outcomes of TFL. ThuFLEP might suggest equivalence to the widely used HoLEP in the available evidence so far. TFL lithotripsy shows promising results but further prospective, randomized trials are required to properly assess its usability, clinical effectiveness and standardisation of the settings for successful adoption of the technology.

En Bloc Resection of Bladder Tumor-Is It the Way Forward?

Transurethral resection of bladder tumors (TURBT) represents the cornerstone in diagnosis and treatment of bladder cancer but recurrence is observed in up to 80% and over- or understaging with TURBT is common. A more recent development to overcome these limitations represents en-bloc resection of bladder tumors (ERBT) which offers several advantages over TURBT. In this report, we briefly review studies assessing outcomes of bladder cancer patients undergoing ERBT. Most randomized and non-randomized trial demonstrate improvement in clinical outcomes for ERBT over TURBT, however more pathological and translational studies are warranted.