PURPOSE: To comprehensively evaluate the efficacy of different energy sources used for en-bloc transurethral resection of bladder tumors (ERBT) on perioperative outcomes. METHODS: This sub-analysis derived from a prospective randomized study that enrolled patients undergoing ERBT vs conventional transurethral resection of the bladder (cTURB) from January 2019 to January 2022 (NCT03718754). Endpoints were pathological specimen quality and perioperative outcomes after either monopolar (m-ERBT) or bipolar (b-ERBT) or laser (l-ERBT) ERBT. RESULTS: 237 bladder tumors resected in 188 patients included in the analyses: 29 (12.2%) m-ERBT, 136 (57.4%) b-ERBT and 72 (30.4%) l-ERBT. Detrusor muscle (DM) was detected in 191 (80.6%) specimens. Per-tumor analysis revealed comparable rate of DM in the specimens obtained via different energy modalities (p = 0.7). Operative time was longer in the l-ERBT cohort compared to m-ERBT and b-ERBT (p = 0.02) and no obturator nerve reflex (ONR) onset was reported. On logistic regression analysis, b-ERBT was associated with negative lateral resection margins (OR 2.81; 95% CI 1.02-7.70; p = 0.04). There was no significant association of the resection technique with perforation and conversion rates (all p > 0.05). Within a median follow up of 22mo (IQR 11-29), a total of 35 (18.6%) patients had a local recurrence. On Cox regression analysis, patients resected with b-ERBT were less likely to have a recurrence (HR 0.34; 95% CI 0.15-0.78; p = 0.01); When adjusting for established confounders, this association was confirmed (HR 0.24; 95% CI 0.10-0.60; p = 0.002). CONCLUSIONS: Different energy sources might achieve comparable perioperative outcomes. Further perspectives involve the assessment of long-term differential oncological outcomes associated with various energy modalities.

Department of Biomedical Sciences Humanitas University Milan Italy

Department of Pathology Medical University of Vienna Vienna Austria

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

Department of Urology and Andrology Paracelsius Medical University Salzburg Austria

Department of Urology AOU Città della Salute e della Scienza Torino School of Medicine Turin Italy

Department of Urology Bichat Claude Bernard Hospital Paris Cité University Paris France

Department of Urology Comprehensive Cancer Center Medical University of Vienna Währinger Gürtel 18 20 1090 Vienna Austria

Department of Urology IRCCS Humanitas Research Hospital Milan Italy

Department of Urology Semmelweis University Budapest Hungary

Department of Urology University of Cologne Cologne Germany

Department of Urology University of Texas Southwestern Dallas TX USA

Department of Urology Weill Cornell Medical College New York NY USA

Division of Urology Department of Special Surgery The University of Jordan Amman Jordan

Faculty of Medicine Tel Aviv University Tel Aviv Israel

Karl Landsteiner Institute of Urology and Andrology Vienna Austria

Rabin Medical Center Petah Tikva Israel

Urology Department Research Center for Evidence Medicine Tabriz University of Medical Sciences Tabriz Iran

See more in PubMed

Babjuk M et al (2022) European Association of Urology guidelines on non-muscle-invasive bladder cancer (Ta, T1, and carcinoma in situ). Eur Urol 81(1):75–94. 10.1016/j.eururo.2021.08.010. (Epub 2021 Sep 10) PubMed

Svatek RS et al (2014) The economics of bladder cancer: costs and considerations of caring for this disease. Eur Urol. 10.1016/j.eururo.2014.01.006 PubMed

Mariappan P, Zachou A, Grigor KM (2010) Detrusor muscle in the first, apparently complete transurethral resection of bladder tumour specimen is a surrogate marker of resection quality, predicts risk of early recurrence, and is dependent on operator experience. Eur Urol 57(5):843–849. 10.1016/j.eururo.2009.05.047 PubMed

Cumberbatch MGK, Foerster B, Catto JWF, Kamat AM, Kassouf W, Jubber I, Shariat SF, Sylvester RJ, Gontero P (2018) Repeat transurethral resection in non-muscle-invasive bladder cancer: a systematic review. Eur Urol 73(6):925–933. 10.1016/j.eururo.2018.02.014. (Epub 2018 Mar 6) PubMed

D’Andrea D et al (2023) En bloc versus conventional resection of primary bladder tumor (eBLOC): a prospective, multicenter, open-label, phase 3 randomized controlled trial. Eur Urol Oncol. 10.1016/j.euo.2023.07.010 PubMed

Gallioli A et al (2022) En bloc versus conventional transurethral resection of bladder tumors: a single-center prospective randomized noninferiority trial. Eur Urol Oncol 5(4):440–448. 10.1016/J.EUO.2022.05.001 PubMed

Kramer MW et al (2011) Current evidence for transurethral laser therapy of non-muscle invasive bladder cancer. World J Urol 29(4):433–442. 10.1007/s00345-011-0680-5 PubMed

Teoh JYC et al (2020) 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. 10.1016/j.eururo.2020.04.059 PubMed

Territo A, Bevilacqua G, Meneghetti I, Mercadé A, Breda A (2020) En bloc resection of bladder tumors: indications, techniques, and future directions. Curr Opin Urol. 10.1097/MOU.0000000000000737 PubMed

Kramer MW et al (2015) 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 33(12):1937–1943. 10.1007/s00345-015-1568-6 PubMed

Gontero P et al (2016) The impact of re-transurethral resection on clinical outcomes in a large multicentre cohort of patients with T1 high-grade/grade 3 bladder cancer treated with bacille Calmette–Guérin. BJU Int. 10.1111/bju.13354 PubMed PMC

Mariappan P et al (2020) Enhanced quality and effectiveness of transurethral resection of bladder tumour in non-muscle-invasive bladder cancer: a multicentre real-world experience from Scotland’s Quality Performance Indicators Programme [formula presented]. Eur Urol 78(4):520–530. 10.1016/j.eururo.2020.06.051 PubMed

Suarez-Ibarrola R, Soria F et al (2019) Surgical checklist impact on recurrence-free survival of patients with non-muscle-invasive bladder cancer undergoing transurethral resection of bladder tumour. BJU Int 123(4):646–650. 10.1111/bju.14557. (Epub 2018 Oct 23) PubMed

Hurle R et al (2016) ‘En Bloc’ resection of nonmuscle invasive bladder cancer: a prospective single-center study. Urology. 10.1016/j.urology.2016.01.004 PubMed

Diana P et al (2022) Energy source comparison in en-bloc resection of bladder tumors: subanalysis of a single-center prospective randomized study. World J Urol. 10.1007/s00345-022-04042-y PubMed PMC

Nicoletti R, Gauhar V, Castellani D, Enikeev D, Herrmann TRW, Teoh JYC (2023) Current techniques for en bloc transurethral resection of bladder tumor: a hands-on guide through the energy landscape. Eur Urol Focus. 10.1016/j.euf.2023.04.007 PubMed

Croghan SM, Compton N, Manecksha RP, Cullen IM, Daly PJ (2022) En bloc transurethral resection of bladder tumors: a review of current techniques. Can Urol Assoc J 16(5):E287–E293. 10.5489/cuaj.7539 PubMed PMC

Hashem A, Mosbah A, El-Tabey NA, Laymon M, Ibrahiem EH, Elhamid MA, Elshal AM (2021) Holmium laser en-bloc resection versus conventional transurethral resection of bladder tumors for treatment of non-muscle-invasive bladder cancer: a randomized clinical trial. Eur Urol Focus 7(5):1035–1043. 10.1016/j.euf.2020.12.003. (Epub 2020 Dec 30) PubMed

Traxer O, Pasqui F, Gattegno B, Pearle MS (2004) Technique and complications of transurethral surgery for bladder tumours. BJU Int 94(4):492–496. 10.1111/j.1464-410X.2004.04990.x PubMed

Yanagisawa T et al (2022) En bloc resection for bladder tumors: an updated systematic review and meta-analysis of its differential effect on safety, recurrence and histopathology. J Urol. 10.1097/JU.0000000000002444 PubMed

Oswald D et al (2022) Safety and efficacy of en bloc vs. conventional transurethral resection of bladder tumors: a meta-analysis and systematic review. Urologe. 10.1007/s00120-022-01765-z