Current Techniques for En Bloc Transurethral Resection of Bladder Tumor: A Hands-on Guide Through the Energy Landscape

Transurethral resection of bladder tumor (TURBT) is considered the cornerstone of treatment for non–muscle-invasive bladder cancer (NMIBC) owing to its diagnostic and therapeutic roles. There is increasing interest in en bloc resection of bladder tumor (ERBT) as a potential alternative to TURBT in NMIBC because of three potential benefits: (1) it provides an intact tumor specimen for proper histological assessment; (2) it avoids fragmentation and minimizes the number of floating tumor cells, reducing the chance of tumor reimplantation; and (3) it reduces the risk of complications such as bladder perforation because of a more controlled resection procedure [1]. In comparison to conventional TURBT, ERBT has advantages in reducing irrigation time and avoiding bladder perforation, although it may require a longer operating time; no benefit in terms of recurrence rates has been demonstrated [2].

In terms of oncological outcomes, according to a meta-analysis comparing 29 studies that included 4484 patients, while the pooled 12-mo and 24-mo risk ratios (RRs) for recurrence did not significantly differ between TURBT and EBRT (12 mo: RR 0.96, 95% confidence interval [CI] 0.74–1.23; 24 mo: RR 0.83, 95% CI 0.55–1.23), the rates of detrusor muscle presence (pooled RR 1.31, 95% CI 1.19–1.43) and of detectable muscularis mucosae (pooled RR 2.69, 95% CI 1.81–3.97) favored EBRT [3]. Moreover, the rate of residual tumor at repeat TURBT was lower after EBRT than after conventional TURBT in one randomized controlled trial and three observational studies (pooled RR 0.47, 95% CI 0.31–0.71). In terms of postoperative complications, the RR for bladder perforation was 0.13 (95% CI 0.05–0.34) in favor EBRT [3].

Different ERBT techniques have been described, with bipolar electrocautery and laser the more favored energy modalities. This mini-review summarizes the current technique for ERBT and highlights the pros and cons of each energy modality as a guide for energy selection according to the clinical case and, most importantly, the operating surgeon’s experience and preference.

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