AUA 2018: Medium Size Bladder Tumors En-block Bipolar Resection on Put to the Test

San Francisco, CA ( The conventional transurethral resection of bladder tumor (TURBT) technique involves piecemeal resection of the tumor, which is contrary to the established oncological principles of cancer surgery. En-block TURBT has been championed as a superior technique since the tumor is left intact during resection which leads to improved pathological evaluation and improved recurrence rates.  Dr. Geavlete, from Bucharest Romania, presents a long-term, prospective, randomized-controlled trial aimed at comparing the clinical outcomes of patients with medium size papillary non-muscle invasive bladder tumors (NMIBT) treated with either standard or en-block bipolar resection TURBT. 

120 patients with non-invasive papillary bladder tumors between 1 and 3 cm in diameter were equally randomized between the surgical techniques. Patients with solid sessile tumors, lesions located in the bladder neck area and tumors involving the ureteral orifice were excluded from the study. En-bloc TURBT was performed with the bi-polar plasma-button for each individual tumor. The deep margin was obtained using a single swipe with the loop electrode. The control group was treated with the standard monopolar loop TURBT.  The follow-up protocol consisted of urinary cytology and cystoscopy, performed every 3 months for 1 year and every 6 months up to 4 years.

Tumor sizes between the techniques were comparable (1.8 cm versus 1.7 cm). Information regarding multifocality and tumor location was not shared in the presentation or in the poster. En-bloc TURBT was associated with a reduced rate of obturator reflex related bladder perforations (1.7% versus 8.3%), decreased mean operative time (9.4 versus 17.1 minutes), hemoglobin level drop (0.3 versus 0.8 g/dL), catheterization period (1.6 versus 2.7 days) and hospital stay (2.1 versus 3.4 days) compared to the standard TURBT. A significantly lower recurrence rate was noted in the en-block group during the first 2 years (3.9% versus 13.5% and 6.5% versus 18.75%). The recurrence benefit of en-bloc disappeared in years 3 and 4, where the recurrence rates become comparable. This phenomenon suggests that en-bloc TUR may decrease the risk of tumor cell seeding associated with conventional, which have been theorized in other reports. 

In conclusion, en-bloc plasma-button TURBT appears to provide a safer surgical procedure with decreased perioperative morbidity and faster recovery when compared to standard TURBT.  In addition, to the benefits associated with a more accurate pathological evaluation en-block, TURBT was found to be associated with improved oncologic outcomes in early follow-up consistent with the theory that en-bloc TUR may decrease tumor seeding associated with the standard TURBT procedure. 

Presenter: Bogdan Geavlete, MD, PhD ("Saint John" Emergency Clinical Hospital, Department of Urology in Bucharest, Romania)

Written by: Andres F. Correa, MD, Urologic Oncology Fellow, Fox Chase Cancer Center, Philadelphia, PA at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA

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