Transurethral Resection of Bladder Tumour: The Neglected Procedure in the Technology Race in Bladder Cancer - Beyond the Abstract

Although bladder cancer (BC) is the 10th most common cancer worldwide, it has always had less attention and funding compared to other cancers.1 Whilst this has been recognised for some time, in this editorial we suggest that there is a danger that this inequality may now occur within BC itself: we contrast technological developments in robotic radical cystectomy (RARC) with transurethral resection of bladder tumor (TURBT), the standard of care for patients with non-muscle invasive bladder cancer (NMIBC).



TURBT was the first minimally invasive cancer operation in urology when described nearly 60 years ago2 but has become increasingly outdated in modern urologic oncology: urologists use a resectoscope which was never designed for this purpose and which cuts the tumor into pieces. For many years TURBT was thought to be an easy operation procedure to master but the consequences of a suboptimal operation are now well recognised3,4 and we now know that experience, surgical skill and judgment play a major role in achieving high-quality outcomes5 yet there is only one course at any of the major urology meetings that focuses on this technique (in contrast to a number of courses on RARC).

Although TURBT is now recognised as a challenging operation, the rate of technical innovation has lagged far behind other similar procedures such a transurethral resection of prostate (TURP)6 or gastrointestinal endoscopy.  New enhanced visualisation technologies such as high-definition cameras, photodynamic diagnosis, or narrow-band imaging are increasingly used along with bipolar energy. En-bloc resection (EBR) is a new promising technique7 but is currently limited by the difficulty of retrieving samples greater than 3 cm from the bladder. Despite the critical unmet need to develop a retrieval device manufacturers have shown little interest in developing instrumentation for EBR but in contrast, there has been enormous interest in developing intra-corporeal stapling devices to facilitate intra-corporeal urinary diversion during RARC.

There are further examples of this developing inequality between TURBT and RARC: A search of PubMed shows that over the last 10 years using the keywords ‘robotic cystectomy, technique’ and ‘TURBT, technique’ reveal 670 and 347 papers respectively.

The reasons for the apparent lack of interest amongst urologists in improving surgical techniques and outcomes for NMIBC are not clear particularly when compared with the great interest urologists have shown in RARC. One explanation may be that TURBT is carried out by urologists often without a focused interest in bladder cancer because it is familiar to all urologists from their training.  

There is a need to level the playing field in bladder cancer by focusing on the entire disease rather than a single operation and we conclude by issuing a call to arms: Urological Societies should place more emphasis on TURBT at their annual meetings with a fair balance between courses on RARC and TURBT. Instrument manufacturers need to invest in model development and promote new techniques such as EBR through sponsored courses and finally, urologists must ensure that trainees are taught TURBT and emerging techniques such as EBR properly and are supervised until they are able to demonstrate technical competence.

Written by: Nikhil Mayor,1 Hugh Mostafid,1 Ashish Kamat2

  1. The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
  2. Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
References: 

  1. Sloan FA, Yashkin AP, Akushevich I, Inman BA. The Cost to Medicare of Bladder Cancer Care. Eur Urol Oncol. 2019 PMID: 31412015
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  3. Role of Restaging Transurethral Resection for T1 Non-muscle invasive Bladder Cancer: A Systematic Review and Meta-analysis.
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Eur Urol Focus. 2018 Jul;4(4):558-567.
  4. Brausi M, Collette L, Kurth K et al. Variability in the recurrence rate at first follow-up cystoscopy after TUR in stage Ta T1 transitional cell carcinoma of the bladder: a combined analysis of seven EORTC studies. Eur Urol. 2002;41:523-531.
  5. Mariappan P, Finney SM, Head E et al. Good quality white-light transurethral resection of bladder tumours (GQ-WLTURBT) with experienced surgeons performing complete resections and obtaining detrusor muscle reduces early recurrence in new non-muscle-invasive bladder cancer: validation across time and place and recommendation for benchmarking. BJU Int. 2012;109:1666-1673.
  6. Huang SW, Tsai CY, Tseng CS et al. Comparative efficacy and safety of new surgical treatments for benign prostatic hyperplasia: systematic review and network meta-analysis. BMJ. 2019;367:l5919.
  7. Mori K, D’Andrea D, Enikeev DV, Egawa S, Shariat SF. En bloc resection for nonmuscle invasive bladder cancer: review of the recent literature. Curr Opin Urol. 2020;30:41-47.
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