PURPOSE: To learn about the history and development of en bloc resection of bladder tumour (ERBT), and to discuss its future directions in managing bladder cancer. METHODS: In this narrative review, we summarised the history and early development of ERBT, previous attempts in overcoming the tumour size limitation, consolidative effort in standardising the ERBT procedure, emerging evidence in ERBT, evolving concepts in treating large bladder tumours, and the future directions of ERBT. RESULTS: Since the first report on ERBT in 1980, there has been tremendous advancement in terms of its technique, energy modalities and tumour retrieval methods. In 2020, the international consensus statement on ERBT has been developed and it serves as a standard reference for urologists to practise ERBT. Recently, high-quality evidence on ERBT has been emerging. Of note, the EB-StaR study showed that ERBT led to a reduction in 1-year recurrence rate from 38.1 to 28.5%. An individual patient data meta-analysis is currently underway, and it will be instrumental in defining the true value of ERBT in treating non-muscle-invasive bladder cancer. For large bladder tumours, modified approaches of ERBT should be accepted, as the quality of resection is more important than a mere removal of tumour in one piece. The global ERBT registry has been launched to study the value of ERBT in a real-world setting. CONCLUSION: ERBT is a promising surgical technique in treating bladder cancer and it has gained increasing interest globally. It is about time for us to embrace this technique in our clinical practice.

Academic Urology Unit University of Aberdeen Aberdeen UK

Department of Biomedical Sciences Humanitas University Milan Italy

Department of Surgery S H Ho Urology Centre The Chinese University of Hong Kong Hong Kong SAR China

Department of Urology 2nd Faculty of Medicine Hospital Motol Charles University Prague Czech Republic

Department of Urology and Andrology Salzburg University Hospital Paracelsus Medical University 5020 Salzburg Austria

Department of Urology Città Della Salute e Della Scienza University of Torino School of Medicine Turin Italy

Department of Urology Comprehensive Cancer Center Medical University of Vienna Vienna Austria

Department of Urology Fundació Puigvert Autonoma University of Barcelona Barcelona Spain

Department of Urology IRCCS Humanitas Research Hospital Rozzano Italy

Department of Urology Kantonsspital Frauenfeld Frauenfeld Switzerland

Department of Urology The Jikei University School of Medicine Tokyo Japan

Department of Urology The Stokes Centre for Urology Royal Surrey Hospital Guildford UK

Department of Urology University College London Hospital NHS Foundation Trust London UK

Department of Urology University Hospital Schleswig Holstein Lübeck Germany

Department of Urology University of Texas Southwestern Dallas TX USA

Department of Urology Weill Cornell Medical College New York NY USA

Hourani Center for Applied Scientific Research Al Ahliyya Amman University Amman Jordan

Institut Universitaire du Cancer Toulouse Oncopôle Toulouse France

Institute for Urology and Reproductive Health Sechenov University Moscow Russia

Unit of Urological Robotic Surgery and Renal Transplantation Careggi Hospital University of Florence Florence Italy

Urothelial Cancer Working Group European Association of Urology Young Academic Urologists (EAU YAU Amsterdam Netherlands

Zobrazit více v PubMed

Engel RM. Philipp Bozzini–the father of endoscopy. J Endourol. 2003;17(10):859–862. doi: 10.1089/089277903772036145. PubMed DOI

Reuter MA, Reuter HJ. The development of the cystoscope. J Urol. 1998;159(3):638–640. doi: 10.1016/S0022-5347(01)63691-7. PubMed DOI

Beer E. Landmark article May 28, 1910: removal of neoplasms of the urinary bladder. By Edwin Beer JAMA. 1983;250(10):1324–1325. PubMed

Herr HW. Early history of endoscopic treatment of bladder tumors from Grunfeld’s polypenkneipe to the Stern-McCarthy resectoscope. J Endourol. 2006;20(2):85–91. doi: 10.1089/end.2006.20.85. PubMed DOI

Babjuk M, Burger M, Capoun O, Cohen D, Comperat EM, Dominguez Escrig JL, Gontero P, Liedberg F, Masson-Lecomte A, Mostafid AH, Palou J, van Rhijn BWG, Roupret M, Shariat SF, Seisen T, Soukup V, Sylvester RJ. European association of urology guidelines on non-muscle-invasive bladder cancer (Ta, T1, and Carcinoma in Situ) Eur Urol. 2022;81(1):75–94. doi: 10.1016/j.eururo.2021.08.010. PubMed DOI

Bryan RT, Collins SI, Daykin MC, Zeegers MP, Cheng KK, Wallace DM, Sole GM. Mechanisms of recurrence of Ta/T1 bladder cancer. Ann R Coll Surg Engl. 2010;92(6):519–524. doi: 10.1308/003588410X12664192076935. PubMed DOI PMC

Teoh JY, Kamat AM, Black PC, Grivas P, Shariat SF, Babjuk M. Recurrence mechanisms of non-muscle-invasive bladder cancer - a clinical perspective. Nat Rev Urol. 2022;19(5):280–294. doi: 10.1038/s41585-022-00578-1. PubMed DOI

Kitamura K, Kataoka K, Fujioka H, Kashiwai K. Transurethral resection of a bladder tumor by the use of a polypectomy snare. J Urol. 1980;124(6):808–809. doi: 10.1016/S0022-5347(17)55675-X. PubMed DOI

Kawada T, Ebihara K, Suzuki T, Imai K, Yamanaka H. A new technique for transurethral resection of bladder tumors: rotational tumor resection using a new arched electrode. J Urol. 1997;157(6):2225–2226. doi: 10.1016/S0022-5347(01)64724-4. PubMed DOI

Ukai R, Kawashita E, Ikeda H. A new technique for transurethral resection of superficial bladder tumor in 1 piece. J Urol. 2000;163(3):878–879. doi: 10.1016/S0022-5347(05)67824-X. PubMed DOI

Saito S. Transurethral en bloc resection of bladder tumors. J Urol. 2001;166(6):2148–2150. doi: 10.1016/S0022-5347(05)65523-1. PubMed DOI

Yanagisawa T, Yorozu T, Miki J, Iwatani K, Obayashi K, Sato S, Kimura T, Takahashi H, Egawa S. Feasibility and accuracy of pathological diagnosis in en-bloc transurethral resection specimens versus conventional transurethral resection specimens of bladder tumour: evaluation with pT1 substaging by 10 pathologists. Histopathology. 2021;78(7):943–950. doi: 10.1111/his.14307. PubMed DOI

Yanagisawa T, Miki J, Yorozu T, Iwatani K, Obayashi K, Sato S, Kimura T, Takahashi H, Egawa S. Vertical lamina propria invasion diagnosed by en bloc transurethral resection is a significant predictor of progression for pT1 bladder cancer. J Urol. 2021;205(6):1622–1628. doi: 10.1097/JU.0000000000001630. PubMed DOI

Fried NM, Murray KE. High-power thulium fiber laser ablation of urinary tissues at 1.94 microm. J Endourol. 2005;19(1):25–31. doi: 10.1089/end.2005.19.25. PubMed DOI

Zhong C, Guo S, Tang Y, Xia S. Clinical observation on 2 micron laser for non-muscle-invasive bladder tumor treatment: single-center experience. World J Urol. 2010;28(2):157–161. doi: 10.1007/s00345-010-0532-8. PubMed DOI

Tamegai Y, Saito Y, Masaki N, Hinohara C, Oshima T, Kogure E, Liu Y, Uemura N, Saito K. Endoscopic submucosal dissection: a safe technique for colorectal tumors. Endoscopy. 2007;39(5):418–422. doi: 10.1055/s-2007-966427. PubMed DOI

Nagele U, Kugler M, Nicklas A, Merseburger AS, Walcher U, Mikuz G, Herrmann TR. Waterjet hydrodissection: first experiences and short-term outcomes of a novel approach to bladder tumor resection. World J Urol. 2011;29(4):423–427. doi: 10.1007/s00345-011-0653-8. PubMed DOI

He D, Fan J, Wu K, Wang X, Wu D, Li L, Li X, Liu L, Cao P, Cao J, Chang LS. Novel green-light KTP laser en bloc enucleation for nonmuscle-invasive bladder cancer: technique and initial clinical experience. J Endourol. 2014;28(8):975–979. doi: 10.1089/end.2013.0740. PubMed DOI

Hurle R, Casale P, Lazzeri M, Paciotti M, Saita A, Colombo P, Morenghi E, Oswald D, Colleselli D, Mitterberger M, Kunit T, Hager M, Herrmann TRW, Lusuardi L. En bloc re-resection of high-risk NMIBC after en bloc resection: results of a multicenter observational study. World J Urol. 2020;38(3):703–708. doi: 10.1007/s00345-019-02805-8. PubMed DOI

Teoh JY, Mayor N, Li KM, Lo KL, Ng CF, Mostafid H. En-bloc resection of bladder tumour as primary treatment for patients with non-muscle-invasive bladder cancer: routine implementation in a multi-centre setting. World J Urol. 2021;39(9):3353–3358. doi: 10.1007/s00345-021-03675-9. PubMed DOI

Naselli A, Introini C, Germinale F, Spina B, Puppo P. En bloc transurethral resection of bladder lesions: a trick to retrieve specimens up to 4.5 cm. BJU Int. 2012;109(6):960–963. doi: 10.1111/j.1464-410X.2012.10982.x. PubMed DOI

Rapoport L, Vinarov A, Enikeev D, Sorokin N, Dymov A, Sukhanov R, Kislyakov D, Proskura A, Damiev A, Gololobov G, Lekarev V. V05–01 technical aspects of transurethral thulium laser en bloc resection of bladder cancer. J Urol. 2018;199(4S):e573–e573. doi: 10.1016/j.juro.2018.02.1388. DOI

Enikeev D, Taratkin M, Margulis V, Sorokin N, Severgina L, Paramonova N, Kislyakov D, Kozlov V, Rapoport L, Shariat SF, Glybochko P. Safety and short-term oncological outcomes of thulium fiber laser en bloc resection of non-muscle-invasive bladder cancer: a prospective non-randomized phase II trial. Bladder Cancer. 2020;6:201–210. doi: 10.3233/BLC-200275. DOI

Kramer MW, Rassweiler JJ, Klein J, Martov A, Baykov N, Lusuardi L, Janetschek G, Hurle R, Wolters M, Abbas M, von Klot CA, Leitenberger A, Riedl M, Nagele U, Merseburger AS, Kuczyk MA, Babjuk M, Herrmann TR. En bloc resection of urothelium carcinoma of the bladder (EBRUC): a European multicenter study to compare safety, efficacy, and outcome of laser and electrical en bloc transurethral resection of bladder tumor. World J Urol. 2015;33(12):1937–1943. doi: 10.1007/s00345-015-1568-6. PubMed DOI

Teoh JY, MacLennan S, Chan VW, Miki J, Lee HY, Chiong E, Lee LS, Wei Y, Yuan Y, Yu CP, Chow WK, Poon DM, Chan R, Lai F, Ng CF, Breda A, Kramer MW, Malavaud B, Mostafid H, Herrmann T, Babjuk M. An International collaborative consensus statement on en bloc resection of bladder tumour incorporating two systematic reviews, a two-round Delphi survey, and a consensus meeting. Eur Urol. 2020;78(4):546–569. doi: 10.1016/j.eururo.2020.04.059. PubMed DOI

Waldbillig F, Hein S, Grune B, Suarez-Ibarrola R, Liatsikos E, Salomon G, Reiterer A, Gratzke C, Miernik A, Kriegmair MC, Ritter M. Current European trends in endoscopic imaging and transurethral resection of bladder tumors. J Endourol. 2020;34(3):312–321. doi: 10.1089/end.2019.0651. PubMed DOI

Bonfante G, Puliatti S, Sighinolfi MC, Eissa A, Ciarlariello S, Ferrari R, Ticonosco M, Goezen AS, Guven S, Rassweiler J, Bianchi G, Rocco B, Micali S, Italian Endourological Association EAUEGE-YG. A survey-based study on the spread of en-bloc resection of bladder tumors among IEA and ESUT members. Minerva Urol Nephrol. 2021;73(4):413–416. doi: 10.23736/S2724-6051.21.04627-9. PubMed DOI

Yanagisawa T, Mori K, Motlagh RS, Kawada T, Mostafaei H, Quhal F, Laukhtina E, Rajwa P, Aydh A, Konig F, Pallauf M, Pradere B, D'Andrea D, Comperat E, Miki J, Kimura T, Egawa S, Shariat SF. En bloc resection for bladder tumors: an updated systematic review and meta-analysis of its differential effect on safety. Recur Histopathol J Urol. 2022;207(4):754–768. doi: 10.1097/JU.0000000000002444. PubMed DOI

Gallioli A, Diana P, Fontana M, Territo A, Rodriguez-Faba O, Gaya JM, Sanguedolce F, Huguet J, Mercade A, Piana A, Aumatell J, Bravo-Balado A, Algaba F, Palou J, Breda A. En bloc versus conventional transurethral resection of bladder tumors: a single-center prospective randomized noninferiority trial. Eur Urol Oncol. 2022;5(4):440–448. doi: 10.1016/j.euo.2022.05.001. PubMed DOI

D’Andrea D, Soria F, Hurle R, Enikeev D, Kotov S, Xylinas E, Lusuardi L, Heidenreich A, Gu D, Frego N, Taraktin M, Ryabov M, Gontero P, Comperat E, Shariat SF. En-bloc vs. conventional resection of primary bladder tumor (eBLOC): a multicenter, open-label, phase 3 randomised controlled trial. Eur Urol Open Sci. 2022;45:S51. doi: 10.1016/S2666-1683(22)02454-5. PubMed DOI

Teoh YCJ, Chan T, Tsang C, Li K, Cheng KC, Cho C, Chan HC, Chiu Y, Ho B, Li T, Law M, Lee Y, Cheng C, Lo K, Lam K, Chan K, So HS, Leung C, Chan C, Yiu M, Ng C, Poon V, Leung C, Chi-Fai N. Transurethral en bloc resection versus standard resection of bladder tumour: a multi-center randomized trial (EB-StaR Study) Eur Urol. 2023;83:S997–S998. doi: 10.1016/S0302-2838(23)00751-0. DOI

Kirk PS, Lotan Y, Zargar H, Fairey AS, Dinney CP, Mir MC, Krabbe LM, Cookson MS, Jacobson NE, Montgomery JS, Vasdev N, Yu EY, Xylinas E, Kassouf W, Dall'Era MA, Sridhar SS, McGrath JS, Aning J, Shariat SF, Thorpe AC, Morgan TM, Holzbeierlein JM, Bivalacqua TJ, North S, Barocas DA, Grivas P, Garcia JA, Stephenson AJ, Shah JB, Daneshmand S, Spiess PE, van Rhijn BWG, Mertens L, Black P, Wright JL. Impact of maximal transurethral resection on pathological outcomes at cystectomy in a large. Multi-institut Cohort J Urol. 2023;209(5):882–889. doi: 10.1097/JU.0000000000003193. PubMed DOI

Giacalone NJ, Shipley WU, Clayman RH, Niemierko A, Drumm M, Heney NM, Michaelson MD, Lee RJ, Saylor PJ, Wszolek MF, Feldman AS, Dahl DM, Zietman AL, Efstathiou JA. Long-term outcomes after bladder-preserving tri-modality therapy for patients with muscle-invasive bladder cancer: an updated analysis of the Massachusetts general hospital experience. Eur Urol. 2017;71(6):952–960. doi: 10.1016/j.eururo.2016.12.020. PubMed DOI

Teoh JYC, Herrmann TRW, Babjuk M, et al. Re: valeria Panebianco, yoshifumi narumi, ersan altun, multiparametric magnetic resonance imaging for bladder cancer: development of VI-RADS (vesical imaging-reporting and data system) Eur Urol. 2018;75(2):e27–e28. doi: 10.1016/j.eururo.2018.09.007. PubMed DOI PMC

Teoh YCJ Transurethral Modified En Bloc Resection For Large Bladder Tumours. https://clinicaltrials.gov/ct2/show/NCT04081246 Accessed on 07/04/2023.

Teoh YCJ The Global En Bloc Resection of Bladder Tumour Registry. https://clinicaltrials.gov/ct2/show/NCT04934540 Accessed on 07/04/2023.

Teoh JY, Cho CL, Wei Y, Isotani S, Tiong HY, Ong TA, Kijvikai K, Chu PS, Chan ES, Ng CF, Asian Urological Surgery T, Education G. A newly developed porcine training model for transurethral piecemeal and en bloc resection of bladder tumour. World J Urol. 2019;37(9):1879–1887. doi: 10.1007/s00345-018-2602-2. PubMed DOI