Resection Of Non-muscle Invasive Bladder Cancer Research Articles

ASO Author Reflections: Changes in the Urinary Microbiome After Transurethral Resection of Nonmuscle-Invasive Bladder Cancer: Insights from a Prospective Observational Study.

ASO Author Reflections: Changes in the Urinary Microbiome After Transurethral Resection of Nonmuscle-Invasive Bladder Cancer: Insights from a Prospective Observational Study.

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

BackgroundEn 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). ObjectiveTo evaluate whether eTURB is superior to cTURB in resection of NMIBC and specimen retrieval. Design, setting, and participantsThis 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. InterventionParticipants were randomized 1:1 to undergo eTURB (n = 192) or cTURB (n = 192). Outcome measurements and statistical analysisThe 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 limitationsA 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). ConclusionsIn 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 summaryWe 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.

A commentary on 'systematic review and meta-analysis of randomized controlled trials of perioperative outcomes and prognosis of transurethral en-bloc resection versus conventional transurethral resection for nonmuscle-invasive bladder cancer' (Int J Surg 2022; 104:106777).

A commentary on 'systematic review and meta-analysis of randomized controlled trials of perioperative outcomes and prognosis of transurethral en-bloc resection versus conventional transurethral resection for nonmuscle-invasive bladder cancer' (Int J Surg 2022; 104:106777).

A pilot study to assess the safety and usefulness of combined transurethral endoscopic mucosal resection and en-bloc resection for non-muscle invasive bladder cancer

BackgroundTransurethral resection (TUR) is the standard operation used for non-muscle invasive bladder cancer (NMIBC). Although most solid tumors are principally removed via single block resection without incising the mass, disruption of the lesion is unavoidable in traditional TUR. Furthermore, pathological diagnosis is often difficult due to heat-related denaturation of tissues in TUR. Although transurethral en-bloc resection is useful for judging tumor invasion, it is associated with a prolonged operative duration. We attempted to show the safety and usefulness of combined endoscopic mucosal resection (EMR) and en-bloc resection in NMIBC patients.MethodsWe investigated 39 patients with clinical NMIBC who were treated using our original EMR + en-bloc resection technique, which involved removal of the tumor mass that protruded from the mucosa, using a polypectomy snare similar to that used for EMR. The residual lesion was removed using en-bloc resection. The operative period, duration of hospitalization, and recurrence rates were compared with those of conventional TUR (n = 31).ResultsThe mean (standard deviation, range) time interval for EMR and total operative duration were 1.6 (1.1, 1–5) min and 18.3 (10.5, 3–48) min, respectively. The total operative duration was comparable to that of TUR (17.3 min, p = 0.691). The mean duration of catheterization in the EMR + en-bloc resection group (4.2 days) was also similar to that in the TUR group (3.7 days; p = 0.285). No severe complications were observed with EMR + en-bloc resection. The pathologists were able to determine tumor invasiveness with considerable certainty in all specimens obtained via the EMR + en-bloc procedure than via TUR, and the difference in the ease of diagnosis was statistically significant (p = 0.016). Recurrence rates were comparable (p = 0.662) between the EMR + en-bloc (15.4%) and TUR groups (19.4%).ConclusionsOur results demonstrated that the EMR + en-bloc resection technique is feasible, safe, and useful for treating patients with NMIBC. Furthermore, this technique helps provide a more accurate pathological diagnosis.

The prognostic impact of hexaminolevulinate-based bladder tumor resection in patients with primary non-muscle invasive bladder cancer treated with radical cystectomy.

To investigate whether hexaminolevulinate-based (HAL) bladder tumor resection (TURBT) impacts on outcomes of patients with primary non-muscle-invasive bladder cancer (NMIBC) who were eventually treated with radical cystectomy (RC). A total of 131 consecutive patients exhibiting NMIBC at primary diagnosis were retrospectively investigated whether they had undergone any HAL-guided TURBT prior to RC. Uni- and multivariable analyses were used to evaluate the impact of HAL-TURBT on cancer-specific (CSS) and overall survival (OS). The median follow-up was 38months (IQR 13-56). Of the 131 patients, 69 (52.7%) were managed with HAL- and 62 (47.3%) with white light (WL)-TURBT only prior to RC. HAL-TURBT was associated with a higher number of TURBTs prior to RC (p = 0.002) and administration of intravesical chemotherapy (p = 0.043). A trend towards a higher rate of tumor-associated immune cell infiltrates in RC specimens (p = 0.07) and a lower utilization rate of post-operative systemic chemotherapy (p = 0.10) was noted for patients who were treated with HAL-TURBT. The 5-year CSS/OS was 90.9%/74.5% for the HAL-group and 73.8%/55.8% for the WL-group (p = 0.042/0.038). In multivariable analysis, lymph node tumor involvement (p = 0.007), positive surgical margins (p = 0.001) and performance of WL-TURBT only (p = 0.040) were independent predictors for cancer-specific death. The present data suggest that the resection of NMIBC under HAL exerts a beneficial impact on outcomes of patients who will need to undergo RC during their course of disease. This finding may be due to improved risk stratification as the resection under HAL may allow more patients to be treated timely and adequately.

Role of second transurethral resection in determining residual tumor in nonmuscle-invasive bladder cancer

Introduction: Presence of residual tumors is not an uncommon event after transurethral resection of bladder tumor, and no studies from Nepal so far has addressed this issue. We conducted this study to determine the rate of residual tumors after first transurethral resection of nonmuscle-invasive bladder cancer, and to determine the factors associated with the presence of residual tumors and upstaging of nonmuscle-invasive bladder cancer.
 Methods: This was a prospective observational study of 43 patients of bladder cancer who had a diagnosis of nonmuscle-invasive bladder cancer following an initial transurethral resection. Demographic data and data on tumor characteristics were obtained. Patients underwent a second transurethral resection within 2 to 8 weeks. Histopathological findings at first and second resection were compared.
 Results: There were 20 patients with Ta tumor and 23 patiens with T1 tumor at initial resection. Residual tumor was detected in 18 (41.86%) patients overall, 2 in patients with Ta tumor (10%) and 16 in patients with T1 tumor (69.5%). Tumors with T1 stage, high grade, size more than 3 centimeters and sessile growth pattern were seen to have significant association with the presence of residual tumors. Six patients with T1 disease upstaged to T2 disease after second resection (26%), while there were no upstaging with Ta tumors. Tumors with T1 stage, sessile configuration and size more than 3 centimeters were found to be significantly associated with upstaging.
 Conclusion: A second transurethral resection for nonmuscle-invasive bladder cancer should be considered if the initial tumor is T1 stage, high grade, more than 3 centimeters in size and has sessile growth pattern.

Cost‑effectiveness analysis of hexaminolevulinate (Hexvix®) guided cystoscopy in Non‑Muscle Invasive Bladder Cancer patients (NMIBC) in Italy

OBJECTIVE: To estimate the incremental cost‑effectiveness of hexaminolevulinate (Hexvix®) + Blue Light (H+BL) cystoscopy (compared to white light cystoscopy only) when used at initial transurethral resection of the bladder tumour (TURBT) for patients diagnosed with non‑muscle invasive bladder cancer (NMIBC) in Italy.METHODS: A cost‑effectiveness model has been developed to estimate the incremental cost‑effectiveness of introducing H+BL at initial TURBT for patients diagnosed with NMIBC in Italy. The model consists of two parts: 1) a short term decision tree which estimates the outcome of the initial diagnostic procedure, and 2) a Markov cohort model which is used to estimate long term outcomes through extrapolation based on data and assumptions about patient management, the natural history of the disease and the empirical efficacy of H+BL in improving diagnosis detection and reducing recurrence. Cost‑effectiveness results are expressed as incremental costs per QALY gained. Univariate and probabilistic sensitivity analyses are conducted to test the robustness of the model to changes in inputs and assumptions.RESULTS: Base case results suggest that Hexvix® is a dominant strategy when used in the resection of NMIBC. Hexvix® is expected to be associated with 0.070 incremental QALYs, with cost savings of € 435 per patient. Sensitivity analyses suggest that the cost of Hexvix® and the relative risk of recurrence in intermediate and low risk groups are key drivers in the model. Probabilistic analyses indicate that Hexvix® is expected to be cost‑effective in >99% of iterations, assuming a willingness to pay threshold of € 25,000 per QALY.CONCLUSION: In conclusion, Hexvix® is expected to be a cost‑effective strategy when used in the resection of NMIBC in Italy.