Lateral Tumors Research Articles

Postoperative complications in endoscopic frontal transcortical surgery of lateral and third ventricle tumours

Neurosurgical approaches to lesions of the lateral and the third ventricles are divided into two fundamentally different groups: transcortical neurosurgical approaches, including - endoscopic and interhemispheric transcallosal microneurosurgical approaches. Complications in surgery of lateral and third ventricle tumours are often associated with the specific approach technique and could be transient. We analyzed postoperative neurological complications and the approach criteria on MRI or CT scans in postoperative period such as localization of corticotomy, distance from corticotomy to coronal suture, “angle of attack” after the frontal transcortical approach to the lateral and third ventricle based on 54 cases and presume transient nature of specific to approach complications and approaches’ factors that have role in postoperative mutism.

Partial nephrectomy through retroperitoneal approach with a new surgical robot system, KD-SR-01.

To present our experiences with partial nephrectomy (PN) through retroperitoneal approach (RP) with the Kangduo robotic system. From December 2020 to February 2021, the perioperative data of 11 patients underwent PN through RP with the Kangduo robotic system were collected prospectively. For the R.E.N.A.L. nephrometry score, 72.7% of patients had a low score (4-6) and 27.3% of patients had a medium score (7-9). Seven tumours were posterior (P), four tumours were on the midline (X). All procedures were completed successfully. The median warm ischemia time was 18.5 (IQR, 13.7-21.0) min. None of the patients had positive surgical margins at definitive histology (all pT1a). No high-grade perioperative complications or device-related adverse events occurred. At a mean follow-up of 8±0.8 months, no complications occurred in all patients. RPPN using the novel Kangduo robotic system is a safe and effective option for managing posterior and lateral renal tumours with R.E.N.A.L. nephrometry scores ≤9.

Classification and reconstruction of complex defects after lateral facial tumor surgery

Objective: To explore the classification and reconstruction strategy of defects in lateral face region after operation of malignant tumors. Methods: Eighteen cases with the reconstruction of complicated defects after resection of tumors in the region of lateral face from January 2015 to January 2018 in Hunan Cancer Hospital were retrospectively reviewed. There were 14 males and 4 females, aged from 32 to 68 years. According to the presence or absence of bony scaffold, complicated defects were divided into two main categories: soft tissue perforating defects and soft tissue defects combined with bony scaffold defects. All soft tissue perforating defects in 5 cases were repaired with free anterolateral femoral flaps. Among 13 cases with soft tissue plus bony scaffold defects, 3 were repaired with free fibular flaps, 6 with free fibular flaps combined with free anterolateral femoral flaps, and 4 with chimeric deep circumflex iliac artery perforator flaps combined with anterolateral femoral flaps. Results: All flaps survived well. Two patients complicated with fistula in floor of mouth, but the wound healed after dressing change. Transoral feeding was resumed within 2 weeks after surgery in all patients. One year follow-up evaluation showed that 14 cases had symmetrical face and 10 cases had mouth opening more than 3 transverse fingers. After 36-50 months of follow-up, 6 patients died, with an overall 3-year survival rate of 66.7%. Conclusion: The classification of defects with or without bony stent loss is conducive to the overall repair design, the recovery of facial contour stent, the effective fill of dead space and the maintain of residual occlusal relationship. Good reconstruction results require a multi flap combination of osteocutaneous and soft tissue flaps.

Neuroendoscopy in the Surgical Management of Lateral and Third Ventricular Tumors: Looking Beyond Microneurosurgery.

Intraventricular tumors pose a surgical challenge because of the difficulty in reaching their deep location through safe corridors and their adherence or proximity to vital neurovascular structures. Although microneurosurgery is the mainstay of surgical management, neuroendoscopy aided by adjuncts, namely, navigation and ultrasonic aspirators, has made a great contribution to improving surgical results. This article reviews the experience of a neurosurgical unit with endoscopic procedures for intraventricular tumors. The current indications, benefits, and complications of neuroendoscopy are described. This is a retrospective, observational study of lateral and third ventricular tumors tackled either purely with an endoscope or with its assistance over 19 years in a single unit at Bombay Hospital Institute of Medical Sciences, Mumbai. Of a total of 247 operated patients with intraventricular tumors, 85 cases operated using an endoscope were included. The majority of the patients had a tumor in the third ventricle (n = 62), whereas 23 patients had tumor in the lateral ventricle. The most common pathologies were colloid cyst and arachnoid cyst (n = 18). An endoscope was used for microsurgical assisted excision of tumors in 31 cases, biopsy in 24, cyst fenestration in 23, and pure endoscopic excision in seven cases. Microsurgery remains the gold standard for the removal of giant, vascular intraventricular tumors. However, endoscopic fenestration or excision of cysts and biopsy have become better alternatives in many cases. Endoscope-assisted microsurgery affords safety and helps in achieving a more complete excision.

Microsurgical anatomy of the lateral posterior choroidal artery: implications for intraventricular surgery involving the choroid plexus.

The lateral posterior choroidal artery (LPChA) should be a major surgical consideration in the microsurgical management of lateral ventricular tumors. Here the authors aim to delineate the microsurgical anatomy of the LPChA by using anatomical microdissections. They describe the trajectory, segments, and variations of the LPChA and discuss the surgical implications when approaching the choroid plexus using different routes. Twelve colored silicone-injected, lightly fixed, postmortem human head specimens were prepared for dissection. The origin, diameter, trunk, course, segment, length, spatial relationships, and anastomosis of the LPChA were investigated. The surgical landmarks of 4 different approaches to the LPChA were also examined thoroughly. The LPChA was present in 23 hemispheres (96%), and in 14 (61%) it originated from the posterior segment of the P2 (i.e., P2P); most commonly (61%) the LPChA had 2 trunks, and in 17 hemispheres (74%) it had a C-shaped trajectory. According to its course, the authors divided the LPChA into 3 segments: 1) cisternal, from PCA to choroidal fissure (length 10.6 ± 2.5 mm); 2) forniceal, starting at the choroidal fissure, 8.2 ± 5.7 mm posterior to the inferior choroidal point, and terminating at the posterior level of the choroidal fissure (length 28.7 ± 6.8 mm); and 3) pulvinar, starting at the posterior choroidal fissure and terminating in the pulvinar (length 5.9 ± 2.2 mm). The LPChA was divided into 3 patterns according to its entrance into the choroidal fissure: A (anterior) 78%; B (posterior) 13%; and C (mixed) 9%. The transsylvian trans-limen insulae approach provided the best exposure for cisternal and proximal forniceal segments; the lateral transtemporal approach facilitated a more direct approach to the forniceal segment, including cases with posterior entrance; the transparietal transcortical and contralateral posterior interhemispheric transfalcine transprecuneus approaches provided direct access to the pulvinar segment of the LPChA and to the posterior forniceal segment, including cases with posterior choroidal entrance. The LPChA typically runs in the medial border of the choroid plexus, which may facilitate its recognition during surgery. The distance between the AChA at the inferior choroidal point and the LPChA is a valuable reference during surgery, but there are cases of posterior choroidal entrance. Most frequently, there are 2 or more LPChA trunks, which makes possible the sacrifice of one trunk feeding the tumor while preserving the other that provides supply to relevant structures. The intraventricular approaches can be selected based on the tumor location and the LPChA anatomy.

Intraventricular meningiomas: A case series and literature review.

Objective: Intraventricular meningiomas (IVMs) are rare type of meningiomas. Majority of IVMs are located in lateral ventricles. Study Design: Case Series. Setting: Civil Hospital Karachi. Period: January 2013 to January 2018. Material & Methods: 15 patients were assessed with histologically verified IVMs, clinical features, radiological findings, surgical approaches, outcome and literature review. Results: The most common presentations included raised intracranial pressure (66.7%), visual deficits (40%), cognitive changes and dysphasia. All lesions arose in the lateral ventricles. Preoperative diagnosis was confirmed on MRI. Excision was performed using the posterior parietal and parieto-temporal approach for lateral ventricle tumors. Total excision was done in 13 out of 15 patients and two patients with residual tumor underwent stereotactic radiosurgery. Biopsy report showed WHO grade-I lesion in all cases. Postoperative complications included CSF leakage, transient hemiparesis and dysphasia. Glasgow Outcome Score of 5 was found in majority of cases (87%) on follow-up. Conclusion: These results depict that IVMs can be excised completely with minimum postoperative morbidity. However, resection requires planning to avoid eloquent cortical damage.

Indication and results of endoscopic submucosal dissection for right located lateral spreading tumors

Indication and results of endoscopic submucosal dissection for right located lateral spreading tumors

Evaluation of Pure Endoscopic Endonasal Approach in Management of Giant Pituitary Adenoma

Abstract Background Giant pituitary adenoma represents one of the challenging tumor for neurosurgeons. Many microsurgical approaches in the past were used for its management. Recently and with evolution of the endoscopic equipment and instruments, extended endoscopic transsphenoidal approach become one of the preferable approaches for its surgical excision. Methods We prospectively document the clinical , surgical and follow up data for all patients presented with giant pituitary adenoma to Ain-Shams university hospital and Weill Cornell Medical College, Presbyterian hospital and were surgically treated with extended transsphenoidal approach from 2015 till 2019. Results Our group study formed of 44 patients with mean age 53.03 (range 14.7-82.4) and a male predominance (59%). The main presentation was visual problems in 75% followed by partial hypopituitarism in 31.81% while headache was in 13.64%. Only 4 patients had functioning adenoma (3 prolactinoma and 1 acromegaly). Average tumor volume was 26.95 ± 17.25 cm3, while the mean maximum tumor diameter was 4.73 cm (range 4.0-8.0 cm). Radiographic invasion was found in 97.73% to suprasellar cistern, 61.36% to the cavernous sinus and in 34% to the sphenoid sinus. GTR was achieved in 45.45% with Knosp score is the only significant predictor factor for resection rate (p = 0.04). Visual improvement achieved in 75.76%. 50% (2 patient) of the patients with functioning adenoma were cured. Complications included CSF leak in 3 patients, permanent DI in 4 patients and postoperative hematoma in 2 patients. Recurrence and progression rates without upfront radiation therapy were 5.00 % and 31.81% respectively after mean follow up period 57.90 months. Conclusions Extended endoscopic approaches for achieving maximum resection with minimal morbidity for giant pituitary adenoma are very effective. Lateral tumor extension with cavernous sinus invasion represents the limiting point in achieving gross total resection. Upfront radiation therapy for patients with residual adenoma can be avoided but regular follow up should be warranted.

Endoscopic submucosal dissection of a lateral spreading tumor involving the appendiceal orifice using a multi-traction device.

Endoscopic submucosal dissection of a lateral spreading tumor involving the appendiceal orifice using a multi-traction device.

Surgical Approaches to Tumors of the Occipito-Cervical, Subaxial Cervical, and Cervicothoracic Spine: An Algorithm for Standard versus Extended Anterior Cervical Access

To propose a surgical approach algorithm for the tumors of the cervicothoracic spine. All patients operated for vertebral column tumors involving the occipito-cervicothoracic spine were reviewed. Oncologic characteristics and surgical approach were gathered. Approach was classified by the use of staging and trajectory (posterior, transnasal, transoral, transmandibular, transcervical, transsternal). Angle of attack was defined for the occipitocervical junction tumor as the angle inscribed by the inferior mandibular plane and line connecting the superior tumor pole and mandibular angle. For lesions extending below the thoracic inlet, angle of attack was that inscribed by the plane of the thoracic inlet and the line connecting the jugular notch and inferior tumor pole. In total, 115 patients were included (mean age 56.7 years, 64 [56%] male, average size 26.5 cm3, 39 [34%] primary tumors). Sixty-nine (60%) of patients had single-stage procedures (57 [49.6%] posterior-only, 12 [10.4%] anterior-only), 35 (30.4%) had 2-stage procedures, and 11 (9.6%) had 3- or 4-stage approaches. Lesions requiring a combined transmandibular-transcervical approach all involved the C2 and C3 levels and had a significantly steeper angle of attack (42.5 ± 9.5 vs. 6.1 ± 13.3°; P= 0.01) and greater superior tumor extent above the inferior plane of the mandible (3.69±2.18 vs. 0.33±0.78;P= 0.002). Lateral tumor extent, tumor size, nor inferior angle of attack differed significantly between approach groups. Here, we present a preliminary decision-making algorithm for the management of vertebral column tumors of the cervicothoracic spine. Based on this single-center experience, we suggest which patients, assessed via a combination of tumor histology and regional anatomy, may benefit from extended anterior surgical access.

Lateral ventricular stenting as a method of preventing trapped temporal horn following resection of lateral ventricular trigone tumor. Case report and review of literature

Resection of lateral ventricular trigone tumor can lead the development of specific complication like a trapped temporal horn. Secretion of cerebrospinal fluid from the choroid plexus in closed space leads to progressive enlargement of the temporal horn. The enlargement of the temporal horn leads to lateral transtentorial herniation with brain steam compression, which manifested by disorders of consciousness, hemiparesis, memory impairment and loss of visual fields. The proposed stenting technique allows to prevent the development of extended temporal horn and excludes the requirement its treatment in the long-term period. Over the past year, intraoperative stenting have been performed in five cases. In the long-term period none of the patients have had trapped temporal horn. There was no case of stent dysfunction.The article presents a clinical case of ventricular stenting following resection of lateral ventricular trigone tumor.

Location, morphology and invasiveness of lateral spreading tumors in the colorectum differ between two large cohorts from an eastern and western country

Background and study aimsData from Japanese series show that surface morphology of laterally spreading tumors (LST) in the colon identifies lesions with different incidence and pattern of submucosal invasion. Such data from western countries are scarce. We compared clinical and histological features of LST in a western country and an eastern country, with special interest on mucosal invasiveness of LST, and investigated the effect of clinical factors on invasiveness in both countries. Patients and methodsPatients with LST lesions ≥20mm were included from a multicenter prospective registry in Spain and from a retrospective registry from the National Cancer Center Hospital East, Japan. The primary outcome was the presence of submucosal invasion in LST. The secondary outcome was the presence of high-risk histology, defined as high-grade dysplasia or submucosal invasion. ResultsWe evaluated 1102 patients in Spain and 663 in Japan. Morphological and histological characteristics differed. The prevalence of submucosal invasion in Japan was six-fold the prevalence in Spain (Prevalence Ratio PR=5.66; 95%CI: 3.96, 8.08), and the prevalence of high-risk histology was 1.5 higher (PR=1.44; 95%CI: 1.31, 1.58). Compared to the granular homogeneous type and adjusted by clinical features, granular mixed, flat elevated, and pseudo-depressed types were associated with higher odds of submucosal invasion in Japan, whereas only the pseudo-depressed type showed higher risk in Spain. Regarding high-risk histology, both granular mixed and pseudo-depressed were associated with higher odds in Japan, compared with only the granular mixed type in Spain. ConclusionThis study reveals differences in location, morphology and invasiveness of LST in an eastern and a western cohort.

Colorectal Endoscopic Submucosal Dissection: An Update on Best Practice.

Endoscopic submucosal dissection (ESD) is a method of en-bloc resection of neoplastic colorectal lesions which is less invasive compared to surgical resection. Lesion stratification, architecture recognition and estimation of depth of invasion are crucial for patient selection. Expert endoscopists have integrated a variety of classification systems including Paris, lateral spreading tumor (LST), narrow band imaging (NBI), international colorectal endoscopic (NICE) and Japanese NBI expert team (JNET) in their day-to-day practice to enhance lesion detection accuracy. Major societies recommend ESD for LST-non granular (NG), Kudo-VI type, large depressed and protruded colonic lesions with shallow submucosal invasion. Chance of submucosal invasion enhances with increased depth as well as tumor location and size. In comparison to endoscopic mucosal resection (EMR), ESD has a lowerl recurrence rate and higher curative resection rate, making it superior for larger colonic lesions management. Major complications such as bleeding and perforation could be seen in up to 11% and 16% of patients, respectively. In major Western countries, performing ESD is challenging due to limited number of expert providers, lack of insurance coverage, and unique patient characteristics such as higher BMI and higher percentage of previously manipulated lesions.

Endoscopic Endonasal and Supraorbital Removal of Tuberculum Sellae Meningiomas: Anatomic Guides and Operative Nuances for Keyhole Approach Selection.

With growing worldwide endoscopy experience, endonasal and supraorbital removal of tuberculum sellae meningiomas (TSM) has increased. To describe anatomic factors for guiding approach selection and outcomes. Retrospective analysis of patients undergoing endonasal or supraorbital TSM resection: approach criteria, clinical outcomes, acute magnetic resonance imaging (MRI) fluid-attenuated inversion-recovery (FLAIR)/T2 changes. From 2008 to 2020, 33 patients (mean age 55±11 yr) were identified: 20 (61%) had endonasal and 13 (39%) supraorbital removal. Comparing endonasal and supraorbital approaches, mean tumor volume (3.7±3.5 cm3 vs 7.7±8.5 cm3, P=.07); percent tumor above planum (42% vs 65%, P=.02), and lateral tumor beyond supraclinoid internal carotid arteries (1.4±2.0 mm vs 4.0±3.2 mm, P=.006) were greater for supraorbital route. Sellar depth was greater for endonasal route tumors (12.2±2.6 mm vs 9.3±2.4 mm, P=.003). Endoscopy, used in 10/13(77%) supraorbital cases, was helpful in additional tumor removal in 4/10(40%). Gross total removal and mean volumetric tumor resection were 16/20(80%) and 97.5% by endonasal, and 5/13(39%) and 96% by supraorbital route. Vision improved in 12/17 (71%) endonasal, 6/8 (75%) supraorbital operations, and worsened in 1 (3%) supraorbital case. Endonasal approach with optic canal decompression increased over study period: 15/20 (75%) endonasal patients vs 1/13(8%) supraorbital (P<.001). Postoperative FLAIR/T2 MRI changes occurred in 2/12 supraorbital and 0/20 endonasal cases. In our experience, both endonasal and supraorbital routes are safe and effective for TSM removal. Greater tumor extension below planum and medial optic canal invasion favor endonasal route, while larger size and lateral extension favor supraorbital route. Given high frequency of TSM growth into optic canals and better access for medial optic canal tumor removal, endonasal route may be preferred for most TSMs.

How to trick artificial intelligence: rectal heterotopic gastric lateral spreading tumor.

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Epigenetic Reprogramming Mediated by Maternal Diet Rich in Omega-3 Fatty Acids Protects From Breast Cancer Development in F1 Offspring.

Diets rich in omega-3 fatty acids (FA) have been associated with lowered risks of developing certain types of cancers. We earlier reported that in transgenic mice prone to develop breast cancer (BCa), a diet supplemented with canola oil, rich in omega-3-rich FA (as opposed to an omega-6-rich diet containing corn oil), reduced the risk of developing BCa, and also significantly reduced the incidence of BCa in F1 offspring. To investigate the underlying mechanisms of the cancer protective effect of canola oil in the F1 generation, we designed and performed the present study with the same diets using BALB/c mice to remove any possible effect of the transgene. First, we observed epigenetic changes at the genome-wide scale in F1 offspring of mothers fed diets containing omega-3 FAs, including a significant increase in acetylation of H3K18 histone mark and a decrease in H3K4me2 mark on nucleosomes around transcription start sites. These epigenetic modifications contribute to differential gene expressions associated with various pathways and molecular mechanisms involved in preventing cancer development, including p53 pathway, G2M checkpoint, DNA repair, inflammatory response, and apoptosis. When offspring mice were exposed to 7,12-Dimethylbenz(a)anthracene (DMBA), the group of mice exposed to a canola oil (with omega 3 FAs)-rich maternal diet showed delayed mortality, increased survival, reduced lateral tumor growth, and smaller tumor size. Remarkably, various genes, including BRCA genes, appear to be epigenetically re-programmed to poise genes to be ready for a rapid transcriptional activation due to the canola oil-rich maternal diet. This ability to respond rapidly due to epigenetic potentiation appeared to contribute to and promote protection against breast cancer after carcinogen exposure.

Surgical techniques in the management of supratentorial pediatric brain tumors: 10 years' experience at a tertiary care center in the Middle East.

Background: The goal of this retrospective study is to present the first epidemiological data on pediatric supratentorial central nervous system (CNS) tumors in Lebanon and to review the various surgical management strategies used.Methods: We conducted a retrospective case series of all pediatric patients who presented with a supratentorial CNS tumor and underwent surgery at our institution between 2006 and 2016. We collected and analyzed demographic characteristics, tumor location, clinical manifestations, histopathology, and surgical management strategies and outcome, and discussed them after dividing the tumors as per location and in view of published literature.Results: Ninety-nine children were studied with a male-to-female ratio of 2.3:1 and a mean age of 8.5 years. The most common location was convexity (44%) and included low-grade and high-grade glial tumors, along with other miscellaneous lesions. The next location was sellar/diencephalic (34%), including craniopharyngiomas, hypothalamic/optic pathway/thalamic gliomas, hamartomas, and pituitary/Rathke’s cyst, where there was notable use of endoscopic techniques (21%). Tumors in the pineal region (13%) were tectal gliomas, germ cell tumors, and pineoblastomas and were mostly treated endoscopically. The last group was lateral intraventricular tumors (8%) and was mostly choroid plexus lesions and ependymomas. Overall, the surgical objective was achieved in 95% with mild/moderate complications in 17%.Conclusion: A variety of pathologies may affect the pediatric population in the supratentorial region. Different surgical strategies, including microsurgical and endoscopic techniques, may be employed to remove, debulk, or biopsy these tumors depending on their location, suspected diagnosis, prognosis, and the need for treatment of possible associated hydrocephalus.

Primary Dural Repair Using Titanium Microclips Following Lateral Skull Base Surgery

Objective Standard techniques for primary dural repair following lateral skull base surgery are both technically challenging and time consuming without the potential for primary dural repair. Inadequate closure may result in postoperative cerebrospinal fluid (CSF) leak infectious sequalae. Traditional methods of dural repair rely on secondary obliteration of the CSF fistula. We hypothesized that the use of nonpenetrating titanium microclips may serve as a useful adjunct in primary dural repair or the establishment of an immobile repair layer following lateral skull base surgery. Methods Here, we report a novel technique for primary dural repair using nonpenetrating titanium microclips as an adjunct to standard techniques in a series of six patients with lateral skull base pathologies. Results A total of six consecutive lateral skull base tumor patients with titanium microclip dural reconstruction were included in our case series. Lateral skull base pathologies represented in this group included two jugular foramen schwannomas, one vestibular schwannoma, one petroclival meningioma, one glomus jugulare paraganglioma, and one jugular foramen chordoid meningioma. Conclusion To our knowledge, this is the first report on the use of microclips in repairing dural defects following lateral skull base surgery. Surgical outcomes for this small case series suggest that dural repair of the later skull base with nonpenetrating titanium microclips is a useful adjunct in dural repair following lateral skull base surgery.

Bipolar Black Runner Spatula Loop for Precise En Bloc Resection of Bladder Tumors

Introduction: En bloc resection of bladder tumor (ERBT) aims to preserve the basic oncologic principles in bladder cancer resection, improve histopathologic evaluation, and provide high-quality samples.1–4 However, there is still a need to enhance versatile instrumentation for the safe and precise resection of bladder tumors, those shapeless, different-sized, and distorted in challenging locations of the bladder. The evidence is scarce in terms of how ERBT can be applied technically in the most practical way, and it seems that ERBT is still not sufficiently generalized in the clinical practice of urologists.5 Specifically, due to mass tissue accumulation in large tumors, it is not always possible to perform ERBT.6,7 The commonly used resecting loop for bipolar transurethral resection is set at a 90° angle and is designed for prostatic resection. This angle may be suitable for the trigon and bladder neck, but depth control is more difficult in posterior and lateral wall tumors. In this study, we report our favorable experience using a bipolar black runner spatula loop, which enabled us to perform precise ERBT. Methods: Bipolar black runner spatula loop, which was custom designed for transurethral prostate enucleation (Olympus® WA22558C), was used in this study in addition to standard TUR equipment (Olympus, The TURis bipolar system). The tumors were circumferentially confined to the normal urothelium, and resection was started at the base of the tumor under narrow band imaging guidance (Olympus Visera Video System). Results: The patients were 44–77 years with a mean of 62.33. Mean resection time was 15 minutes (3–30). The detrusor muscle was present in all samples, and T1 substaging and lateral margin assessments were provided in all cases. The spatula apparatus of the loop prevented the tumor from accumulating on the resectoscope. Thus, tumor base and detrusor fibers could be seen more clearly. The loop's 45° angle allowed for circumferential resection of the wall layers, making them smoother with the bladder tumor bed within the resection margins. Furthermore, the angled loop allowed for the use of en bloc resection in different anatomical regions of the bladder. Using a bipolar current provided a significant advantage, as switching to resection in fragments is attainable whenever necessary during resection without equipment change. Conclusions: Bipolar black runner spatula loop seems to be safe and effective for the ERBTs from our initial experience. During resection, the custom-designed spatula prevented tumor accumulation in the image area, and the 45° angle provided resecting the wall layers smoother within the resection margins circumferentially in different bladder locations. Less angled loop allowed the resectoscope tip to sweep up and down, making it possible to sweep in a shallow arc below the tumor. It may enhance the sample quality, allowing instant conversion to piecemeal resection if technical difficulties arise, which may also decrease the risk of complications. Equipment explicitly custom designed for ERBT can provide en bloc resection of distorted tumors, large tumors, and tumors in difficult places, following basic oncologic principles. No competing financial interests exist. Runtime of video: 9 mins 56 secs

Monopolar versus bipolar transurethral resection of lateral wall-located bladder cancer under obturator nerve block: a single center prospective randomized study.

ABSTRACTIntroduction:The aim of the present prospective-randomized study was to compare perioperative outcomes and complications of bipolar and monopolar TURBT for lateral wall-located non-muscle invasive bladder cancers (NMIBC) under obturator nerve block (ONB).Patients and Methods:80 patients who underwent TURBT for lateral wall-located primary bladder tumors under ONB from March, 2016 to November, 2019 were included in the present study. The patients were randomized equally into two groups; monopolar TUR (M-TURBT) and bipolar TUR (B-TURBT). The primary and secondary outcomes were safety (obturator jerk and bladder perforation) and efficacy (complete tumor resection and sampling of the deep muscle tissue).Results:Obturator jerk was detected in 2 patients (5%) in M-TURBT while obturator jerk was not observed during B-TURBT (p=0.494). Bladder perforation was not observed in both groups. All of the patients underwent complete tumor resection. There was no significant difference in muscle tissue sampling (67.5% vs. 72.5%, p=0.626) and thermal tissue damage rates (12.5% vs. 25%, p=0.201). The majority of complications were low-grade and the differences in Clavien grade 1-3 complications between groups were not statistically significant.Conclusion:In the treatment of lateral-wall located NMIBCs, either M-TURBT or B-TURBT can be safely and effectively performed by combining spinal anesthesia with ONB. Even so, it should be taken into consideration that low-grade postoperative hemorrhagic complications may occur in patients who undergo M-TURBT.