Morcellation is a well-established technique in endoscopic enucleation of the prostate (EEP). It allows for fast and safe removal of large tissue volume through the urethra. Prostate tissue after morcellation is suitable for pathological assessment, namely for the detection of incidental prostate cancer. This data suggests that morcellation may be successfully adapted to evacuate the bladder tumor.
Enbloc resection of bladder tumor (ERBT) has emerged as an alternative method to standard transurethral resection of bladder tumor (TURBT) for the treatment and diagnosis of non-muscle-invasive bladder cancer (NMIBC). ERBT offers several advantages, including a higher rate of detrusor muscle presence in histological specimens and improved orientation of the specimen for pathological assessment. Initially, ERBT was used only for small tumors, but there is a growing recognition that it is also suitable for larger lesions. While small tumors easily pass through the endoscope channel, in large ones, the issue of lesion extraction arises. And morcellation seems to be an optimal solution for this task.
Challenges in Tumor Extraction
The extraction of large tumors is one of the present challenges of ERBT, which is easy to overcome with a closer look. In the article, we discuss all of the tools and techniques: endobags and laparoscopic grasps, vaporization, and morcellation of exophytic part, etc.
A two-step technique for lesions larger than 3 cm might be used. The first step includes resection of the larger exophytic part in one piece and its morcellation. The second step - en bloc resection of the tumor base, which is then removed in one piece through the resectoscope. Despite initial skepticism, studies have demonstrated that morcellated tissue remains suitable for pathological examination, allowing for accurate histological staging and grading. This challenges the traditional belief that en bloc resection is impractical for large tumors and supports its broader adoption in clinical practice.
Enhanced Pathological Assessment
Unlike conventional TURBT, EBRT allows to preserve the orientation of the muscle layer in the specimen, providing accurate grading and staging. Pathologists also find the tissue after en bloc resection more convenient for examination. A higher rate of detrusor muscle detection allows to reduce the rate of early re-TURBT and also opens up new opportunities for wider implementation of trimodal bladder-sparing strategy in selected patients even with muscle-invasive bladder cancer.
Minimizing Floating Tumor Cells
One of the major concerns in bladder cancer surgery is the release of circulating tumor cells (CTCs), which may contribute to disease progression and recurrence. Studies suggest that EBRT significantly reduces the risk of CTC dissemination compared to conventional TURBT, potentially improving long-term oncological outcomes.
Is it A New Standard?
Upcoming large-scale studies are needed to establish long-term benefits of ERBT for large bladder tumors definitively. Our currently published comprehensive review goes deeper into the latest evidence and future directions of EBRT for large bladder tumors, providing an additional step toward its widespread adoption.
Written by: Diana Babaevskaya,1 Andrey Morozov,1 Eddie Fridman,2,3 Larisa Tsoy,4 Shahrokh F. Shariat,1,5-8 Yossef Molchanov,2 Maxim Yakimov,9 Eva Compérat,10 Thomas R. W. Herrmann,11-13 Dmitry Enikeev1,5,14,15
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.
- Department of Diagnostic Pathology, Sheba Medical Center, Ramat Gan.
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Institute for Clinical Morphology and Digital Pathology, Sechenov University, Moscow, Russia.
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.
- Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan.
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas.
- Department of Urology, Weill Cornell Medical College, New York, New York, USA.
- Pathology Department, Rabin Medical Center, Petah Tikva, Israel.
- Department of Pathology, Hôpital Tenon, Sorbonne Université, Paris, France.
- Department of Urology, Spital Thurgau AG, Kantonspital Frauenfeld, Frauenfeld, Switzerland.
- Division of Urology, Department of Surgical Sciences, Stellenbosch University, Western Cape, Stellenbosch, South Africa.
- Hannover Medical School, Hannover, Germany.
- Department of Urology, Rabin Medical Center, Petah Tikva.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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