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

Thulium laser en bloc resection is a safe and efficacious alternative to conventional bipolar transurethral resection of bladder tumors

Introduction

Bipolar transurethral resection of bladder tumors (bTURBT) is the standard of care technique for the management of bladder tumors; however, new techniques such as thulium laser en bloc resection of bladder tumors (TmLRBT) have been introduced as alternatives to bTURBT. In this study, detrusor muscle acquisition, perioperative outcomes and survival outcomes after TmLRBT and bTURBT were prospectively compared in patients with primary bladder tumors (1-5 cm).

Material and methods

This prospective interventional study, conducted over ten years, involved 542 patients under a single surgeon. Inclusion criteria were a single tumor of 1-5 cm. The primary endpoint was the presence or absence of detrusor muscle. Perioperative criteria included operative time, hospital stay length, catheterization duration, bladder perforations, readmissions, and complication incidence. Recurrence-free survival (RFS) and cancer-specific survival (CSS) were analyzed using the Kaplan-Meier method with subgroup comparisons by the log-rank test.

Results

Of 449 patients, 211 underwent TmLRBT and 238 underwent bTURBT. Detrusor muscle was present in 201 (95.2%) TmLRBT patients vs 154 (64.7%) bTURBT patients (p <0.001). Complications were less frequent in the TmLRBT group (p <0.05). Hemoglobin drop (p <0.001), hospital stay (p <0.001), catheterization duration (p <0.001), and operative time (p <0.001) were all significantly lower in the TmLRBT group. Kaplan-Meier analysis showed no significant differences in RFS (p = 0.255) and CSS (p = 0.258) between the groups.

Conclusions

TmLRBT demonstrated significantly better detrusor muscle inclusion and perioperative outcomes compared to bTURBT.

Efficacy and safety of office-based diode laser ablation for recurrent low-grade non-muscle-invasive bladder cancer under local anaesthesia: A pilot study

Introduction

Low-grade tumors account for approximately 50% of non-muscle invasive bladder cancer (NMIBC) with recurrence rates between 46% and 62%. Management of NMIBC recurrence typically involves transurethral resection of bladder tumor (TURBT) under general or regional anesthesia, which carries perioperative risks and considerable healthcare costs due to repeated procedures. Therefore, less invasive treatments such as office-based laser ablation, which aim to manage recurrences and reduce inpatient procedures without compromising oncological control, are needed.

Objectives

This study aims to assess the efficacy and safety of office-based diode laser ablation for treating recurrent NMIBC under local anesthesia and to evaluate the influence of tumor size on treatment outcomes.

Methods

A retrospective analysis was conducted on patients with recurrent low-grade NMIBC who underwent office-based diode transurethral laser ablation (TULA) under local anesthesia between 2021 and 2022.

Results

A total of 30 patients were included, with a mean age of 55 (±12) years. The mean original tumor size was 2.82 (±2.59) cm The mean recurrent tumor size was 1.15 (±0.88) cm, with a median of two recurrent tumors (range 1-20). The recurrence rate post-ablation for the entire cohort was 70%, with a median post-ablation recurrence duration of 5 months. The recurrence rate post-TULA was significantly higher in patients with an ablated tumor size of more than 1 cm compared to those with a tumor size of less than 1 cm (86.6% vs. 53.3%, p = 0.046). None of the patients experienced tumor progression, with a median follow-up duration of 12 months. Patients tolerated the procedure well, reporting only mild pain, and there were no complications greater than grade 1 on the Clavien-Dindo classification.

Conclusion

Office-based diode laser ablation is a safe, effective, and well-tolerated alternative for treating recurrent low-grade NMIBC with a low volume, less than 1 cm, under local anesthesia.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Partial and radical cystectomy provides equivalent oncologic outcomes in bladder cancer when combined with adequate lymph node dissection: A population-based study

PURPOSE

To compare the oncologic outcomes of bladder cancer (BCa) patients after partial cystectomy (PC) or radical cystectomy (RC) combined with lymph node dissection (LND).

METHODS

Relevant data from BCa patients who had >3 lymph nodes (LNs) removed were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. Different thresholds of LN count in LND were tested to eliminate potential selection bias, and the optimal threshold was applied to screen patients who underwent adequate LND. After propensity score matching, the oncologic outcomes after PC or RC were compared in patients who underwent adequate LND.

RESULTS

After preliminary screening, 6,785 BCa cases diagnosed between 2004 and 2015 with removal of > 3 LNs were enrolled in the analysis, including 633 (9.3%) PC cases and 6,152 (90.7%) RC cases. The PC and RC groups presented entirely different profiles in clinical parameters such as sex, T stage, number of lymph nodes (LNs) removed, and adjuvant therapy. In particular, the LN-positive rate and count were higher in the RC group, even after adjusting for other confounding factors. After comparison using different thresholds, the LN positive rate and count were similar when the LN count in LND was restricted to > 12. In patients who had > 12 LNs removed, after propensity score matching, PC and RC presented similar oncologic outcomes. Further exploration found that the prognosis of patients was associated with age, T stage, and the number of positive LNs.

CONCLUSION

PC and RC could provide equivalent oncologic outcomes in BCa when combined with adequate LND. The conclusion needs further validation in future studies.

The 980 nm diode laser treatment for non-muscle-invasive bladder tumor with en bloc technique: single-center experience

Background

Transurethral resection of the bladder tumor (TURBT) is one of the most established urological procedures for the treatment of the primary non-muscle-invasive bladder cancer (NMIBC). The aim of the study is to evaluate the efficacy and safety of 980 nm diode laser as a treatment for primary NMIBC.

Methods

Eighty-eight patients with NMIBC were treated by en bloc transurethral resection with 980 nm diode laser, and 76 patients were treated by plasmakinetic transurethral resection from May 2016 to July 2019 at the Department of Urology, Tangdu Hospital, Air Force Medical University. The clinical data were collected and compared between the two groups.

Results

The bladder irrigation time was shortened in 980 nm diode laser group compared to that of plasmakinetic transurethral resection group (4.1 ± 0.6 vs 13.1 ± 3.1 h, p < 0.001). A total of 13.2% (10/76) patients experienced obturator nerve reflex, and 5.3% (4/76) experienced delayed bleeding in plasmakinetic transurethral resection group, while no obturator nerve reflex and delayed bleeding cases were observed in 980 nm diode laser group (p < 0.05). The postoperative catheterization and hospitalization time showed no significant difference between the two groups. The median follow-up time was 27 months (13–38 months). No significant difference in the recurrence rate was observed between the two groups.

Conclusions

The 980 nm diode laser is an effective and safe tool in transurethral resection of NMIBC using en bloc technique. It has less perioperative complications and shortened bladder irrigation time.