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

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

INTRODUCTION

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

Outcomes and Complications of Bipolar vs. Monopolar Energy for Transurethral Resection of Bladder Tumors: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Bipolar and monopolar transurethral resections have a stable status for non-muscle invasive bladder cancer (NMIBC). We conducted a meta-analysis to analyze the outcomes and complications of bipolar vs. monopolar energy for transurethral resection of bladder tumors (TURB).

Methods: The Preferred Reporting Items for Systematic Reviews and Meta-analyses was followed. Based on the Population, Intervention, Comparator, Outcomes, and Study Designs (PICOS) strategy, randomized controlled trials were searched in MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. The reference lists of the associated articles were also retrieved. The data were calculated by Rev Man v5.3.0.

Results: Eleven publications containing an amount of 2, 099 patients were involved in the study. Two groups did not show a significant difference in the mean age and the number of bladder tumors. The results showed that m-TURB had a greater decrease in postoperative hemoglobin level [mean difference (MD) −0.26, 95% confidence interval (CI) −0.48 to −0.04, P = 0.02] and sodium level (MD −0.36, 95% CI −0.62 to −0.10, P = 0.007) compared with b-TURB. B-TURB spent relatively little in hospitalization time (MD −0.52, 95% CI −0.88 to −0.15, P = 0.005) than m-TURB with the exception of operation time (P = 0.47) and catheterization time (P = 0.19). B-TURB did not show a significant difference in the incidence rate of obturator reflex (P = 0.10), bladder perforation (P = 0.32), postoperative blood transfusion (P = 0.28), and clot retention (P = 0.21) compared with the b-TURB group. Besides, there were no significant difference in terms of muscle tissue sampling (P = 0.43), recurrence-free survival at 6 months (P = 0.68) and 12 months (P = 0.78).

Conclusions: B-TURB was more effective than m-TURB in minimizing intraoperative or postoperative bleeding with the smaller loss of hemoglobin and the shorter hospitalization time for patients with NMIBC.

Surgical challenges and considerations in Tri-modal therapy for muscle invasive bladder cancer

Trimodal therapy (TMT) for muscle invasive bladder cancer has become an accepted alternative to radical cystectomy and has become integrated into national guidelines as standard a treatment option. The urologist plays a critical role in proper patient selection, thorough transurethral resection, ongoing cystoscopic surveillance and management of local recurrences. There exists multiple patient related and tumor related factors, which contribute to the selection of TMT vs. radical cystectomy for a patient with muscle invasive bladder cancer. Although the ideal patient for TMT has a tumor which can undergo a visibly complete resection, has no associated hydronephrosis, does not invade the prostatic urethra and is not associated with diffuse carcinoma in situ throughout the bladder, select patients who do not meet all these criteria can still be successfully treated with this approach. A multidisciplinary approach including urology, radiation oncology and medical oncology is paramount with clear communication of tumor location, timing of chemoradiation and repeat cystoscopic resection followed by surveillance. Nonmuscle invasive bladder cancer recurrences can occur in up to 26% of patients after completion of TMT, with many being treated by routine and standard therapy for non-muscle invasive bladder cancer. However, in this population after TMT, early salvage cystectomy should be considered in those with adverse features, including T1 disease, tumor greater than 3 cm, CIS, or lymphovascular invasion. Salvage cystectomy can be performed for local recurrences with acceptable oncologic control and no clear evidence of any greater risk of early complications; however, there may be a slightly increased risk for late complications, namely small bowel obstruction, ureteral stricture, and parastomal hernia. An understanding of these surgical considerations is of utmost importance to the treating urologist in selecting and managing a patient through TMT.

Best Practices to Optimise Quality and Outcomes of Transurethral Resection of Bladder Tumours

CONTEXT

Transurethral resection of bladder tumour (TURBT) for bladder cancer (BC) is an underappreciated common urological procedure. TURBT outcomes are highly variable, and results are dependent on judgement and surgical skill.

OBJECTIVE

To perform a narrative review and identify optimal best practice in TURBT including preparation, choice of equipment, procedural steps, surgical technique, and management of difficult scenarios and complications.

EVIDENCE ACQUISITION

Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched. Important studies were identified and reviewed by an international panel of urologists representing major urological societies and guideline panels with a record of academic publication in this field. In areas where the group identified a lack of evidence or agreement, discussions took place until a consensus was reached.

EVIDENCE SYNTHESIS

A total of 814 studies were identified and 43 were included. The majority were retrospective (level of evidence 3), with only two prospective randomised trials. Four broad themes were identified, which formed the basis for the review: (1) the role of TURBT within the overall management of BC, (2) TURBT techniques, (3) measurement of outcomes including quality control and checklists, and (4) postoperative management. Familiarity with all aspects of the procedure is necessary to minimise morbidity and improve oncological outcomes. Development of new instruments and techniques, and prospective audit of TURBT outcomes are important future goals.

CONCLUSIONS

TURBT is a common and challenging operation with known variable outcomes. To reduce these variations and optimise outcomes, best practice based on evidence and expert opinion is recommended.

PATIENT SUMMARY

Transurethral resection of bladder tumour (TURBT) is a common but deceptively difficult urological operation. Optimal outcomes depend on experience and surgical skill. An international group of experienced TURBT surgeons review critical aspects of the procedure and share best practice to stimulate further discussion.

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.

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

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

Safety and efficacy of bipolar versus monopolar transurethral resection of bladder tumor: a systematic review and meta-analysis

PURPOSE

Transurethral resection of bladder tumor is the standard of care for the management of patients with bladder mass. Primary objective of this study was to compare safety and efficacy of the two energy modalities used for TURBT (monopolar and bipolar).

MATERIALS AND METHODS

Systematic literature search of various electronic databases was conducted to include all the randomized studies comparing two groups. Standard PRISMA (Preferred reporting Items for Systematic reviews and Meta-analysis) guidelines were pursued for this review and study protocol was registered with PROSPERO (CRD42019139987).

RESULTS

In the present review, eight RCTs including 1147 patients were included. Resection time, hospital stay and catheter duration were significantly shorter with bipolar group. There was no significant difference in incidence of obturator reflex (OR 0.65, CI [0.35, 1.2], p = 0.17), whereas incidence of bladder perforation was significantly higher in the monopolar group (6.4% versus 3.3%, p = 0.01. However, sensitivity analysis including 3 high quality studies revealed equal incidence of bladder perforations. Need for blood transfusion was similar in the two groups but fall in hemoglobin was significantly lower in bipolar group (MD - 0.45 CI [- 0.72, - 0.18], p = 0.0009). Bipolar group was found to have significantly lower incidence of tissue artifacts due to thermal energy on pathological examination (OR 0.27 CI [0.15, 0.47], p < 0.00001).

CONCLUSIONS

Bipolar and monopolar devices are equally safe in terms of obturator jerk and bladder perforation. Bipolar group was significantly better as compared to monopolar for hospital stay, catheter duration and fall in hemoglobin; however, the clinical relevance of most of these parameters is little.