부산대학교 도서관

Background. Transurethral resection of bladder tumor (TURBT) represents a crucial step in the clinical care pathway of non-muscle-invasive bladder cancer (NMIBC). Conventional TURBT (cTURBT) may lead to suboptimal pathological characterization and incomplete tumor resection due to the limitations of the surgical technique. En-bloc resection of bladder tumor (ERBT) might provide more precise and controlled resection with a better detrusor muscle sampling, and reduced risk of tumor cell scattering. The aim of this study was to provide highest level of evidence over the role of ERBT in the treatment of NMIBC in terms of pathological, surgical and oncological outcomes, stratifying by energy source. Materials and Methods. After performing a systematic review of the current literature, we designed a prospective randomized controlled trial comparing cTURBT to ERBT. We enrolled patients with a maximum of three bladder lesions each smaller than three centimeters, that were randomly allocated to the ERBT or cTURBT group in a 3:2 ratio. The primary endpoint of the study was the feasibility of pathological staging of bladder cancer. Subsequently, we divided the patients in accordance with the energy source used (i.e., monopolar-ERBT [ERBT-m], bipolar-ERBT [ERBT-b] and thulium laser-ERBT [ERBT-l]) and compared pathological, surgical, and postoperative outcomes between the groups. Finally, we developed a classification of the depth of endoscopic bladder perforation (i.e., DEEP scale) during ERBT/cTURBT: “0” visible muscular layer with no perivesical fat; “1” visible muscle fibers with spotted perivesical fat; “2” exposition of perivesical fat; “3” intraperitoneal perforation. We investigated the predictors of high-grade perforations (DEEP 2–3) and assessing whether the DEEP scale independently predicted patients’ postoperative outcomes. Results. Our systematic review of the literature found that ERBT represents a considerable advancement in the surgical management of NMIBC. A total of 300 consecutive patients were enrolled in the study between April 2018 and June 2021. Similar rates of detrusor muscle presence (95% vs 94%, p=0.9) were found in the ERBT and cTURBT groups. T1 substaging feasibility rate was significantly superior for ERBT (100% vs 84%, p=0.02). The two groups did not differ both in term of intra-operative and post-operative outcomes. ERBT was converted to cTURBT in 6 cases (4.3%). With a median follow-up duration of 15 months (IQR 7-28 months), early oncological outcomes did not show any difference between the two arms in terms of recurrence. Five (10.2%), 10 (22.2%) and 0 cases of obturator nerve reflex (ONR) were recorded in ERBT-m, ERBT-b, and ERBT-l groups, respectively (p=0.001). Conversion to cTURBT was higher for lesions located in the anterior wall/dome/neck (p<0.001), irrespective from the energy used. A total of 146/248 (58.9%), 56/248 (22.6%), 41/248 (16.5%), 5/248 (2.0%) patients presented DEEP grade 0, 1, 2, and 3, respectively. Female gender [B coeff. 0.255 (95% CI 0.001–0.513); p=0.05], tumor location [B coeff. 0.188 (0.026–0.339); p=0.015], and obturator-nerve reflex [B coeff. 0.503 (0.148–0.857); p=0.006] were independent predictors of DEEP. The scale predicted independently major complications [Odd Ratio (OR) 2.221 (1.098–4.495); p=0.026], no post-operative chemotherapy intravesical instillation [OR 9.387 (2.434–36.200); p=0.001], longer irrigation time [B coeff. 0.299 (0.166–0.441); p<0.001] and hospital stay [B coeff. 0.315 (0.111–0.519); p=0.003]. Conclusions. ERBT is non-inferior to cTURBT in the rate of detrusor muscle sampling at final pathology. The T1 substaging feasibility was higher in ERBT group. Laser energy might be beneficial in lateral wall lesions to avoid ONR. Electrocautery might be preferred for lesions of the anterior wall/dome, since there is an increased risk of ERBT conversion to cTURBT (25%). The DEEP scale proved to be a visual tool for grading bladder perforation during TURBT, which can help physicians standardize complication reporting and plan postoperative management accordingly.
Universitat Autònoma de Barcelona. Programa de Doctorat en Cirurgia i Ciències Morfològiques