BERKELEY, CA (UroToday.com) - The endoscopic treatment of non-muscle invasive bladder cancer (NMIBC) patients in general, and in cases of patients with large bladder tumors, in particular, is still marked by the potential hazards of bladder wall perforation, intra- and postoperative bleeding (eventually requiring blood transfusions or re-intervention), urinary retention by blood clots and obturator nerve stimulation, mostly specific to the lateral wall location.
While according to the EAU Guidelines, monopolar transurethral resection of bladder tumors (TURBT) continues to represent the gold-standard in NMIBC treatment, the bipolar transurethral resection in saline (TURis) proved to achieve basically similar results - while providing maximum safety and no increased incidence of urethral strictures.
Once bipolar plasma vaporization was introduced as a safe and effective treatment option for the treatment of benign prostatic hyperplasia, both in the literature  as well as in our daily clinical practice, we realized the potential benefits of tumoral tissue plasma vaporization and started applying this technique for papillary bladder tumors.
Our present study aimed to perform a prospective, randomized, comparison of the bipolar plasma vaporization of bladder tumors (BPV-BT) versus the standard TURBT from the surgical efficacy and safety as well as short-term follow-up points of view. In total, 120 patients with at least one bladder tumor larger than 3 cm were enrolled and randomized by means of sealed envelopes.
In view of an accurate pathological analysis, the first step of BPV-BT consisted of tumor biopsy, performed with a thin resection loop, aiming to obtain a pathological specimen that would include tumoral tissue and the underlying muscle layer.
The main stage of the procedure was represented by the actual plasma vaporization, during which the hemispherical shaped electrode displaying a plasma corona on its surface was gradually moved in direct contact with the tumoral tissue (the “hovering” technique), thus producing a virtually blood-less vaporization. Tumor vaporization was applied until the muscular layer of the bladder wall was clearly exposed. The coagulation of any hemorrhagic sources was practically concomitant, eventually followed by larger vessels’ hemostasis. Subsequently, the bipolar resection of the center and margins of the tumoral bed was performed for pathological confirmation of the complete tumor removal. The vaporization area emphasized a remarkably smooth surface and sharp margins, with no irregularities or debris.
In the monopolar TURBT arm, the standard operative steps specific to the endoscopic resection were followed. The mean operative time was significantly shorter for BPV-BT by comparison to the standard resection (21.4 versus 32.7 minutes). The rate of obturator nerve stimulation was significantly higher in the TURBT group (18.3% versus 3.3%). Consequently, the bladder wall perforation rate was significantly lower for BPV-BT (0% versus 6.7%). On the other hand, the mean postoperative hemoglobin decrease was significantly greater in the TURBT series (0.3 versus 0.9 g/dl). Also, the mean catheterization period and hospital stay were significantly reduced in the BPV-BT series (2.5 days versus 3.5 days and 3.5 days versus 4.5 days, respectively).
According to the pathology results, in all NMIBC cases of both series (54 in the BPV-BT arm and 53 in the TURBT arm), none of the specimens resected from the center and margins of the tumoral bed area contained malignant tissue or cauterization artifacts. Similar tumor stage, grade and multiplicity distribution was determined for the two groups.
Standard monopolar Re-TURBT was performed 4 weeks after the initial procedure in all NMIBC patients. The overall as well as the primary site residual tumors rates were significantly reduced in the BPV-BT group (9.3% versus 20.8% and 7.4% versus 17%, respectively). Moreover, in cases of initial multiple tumors, significantly more residual lesions were found in the TURBT series (25% versus 9.7%).
Based on these results, we may conclude that BPV-BT seems to represent a promising endoscopic treatment alternative for NMIBC patients, with good surgical efficacy, reduced perioperative morbidity, fast postoperative recovery and significantly decreased residual tumors rate by comparison to standard monopolar TURBT. More over, the remarkably efficient tumoral tissue vaporization, excellent visibility, reduced intra- and postoperative bleeding, short period of catheterization and hospital stay, lack of complications and good oncological results may represent reliable arguments in favor of this new procedure.
- Babjuk M, Oosterlinck W, Sylvester R et al. - Guidelines on TaT1 (Non-muscle invasive) Bladder Cancer. European Association of Urology Guidelines, 2009 edition: 1-20.
- Puppo P, Bertolotto F, Introini C et al. Bipolar transurethral resection in saline (TURis): outcome and complication rates after the first 1000 cases. J Endourol 2009; 23(7):1145-9.
- Reich O, Schlenker B, Gratzke C et al. Plasma Vaporization of the Prostate: Initial Clinical Results. Eur Urol 2010; 57(4):693-8.
- Geavlete B, Multescu R, Dragutescu M et al. Transurethral resection (TUR) in saline plasma vaporization of the prostate vs standard TUR of the prostate: 'the better choice' in benign prostatic hyperplasia? BJU Int. 2010;106(11):1695-9.
- Geavlete P, Jecu M, Geavlete B. TURis Plasma Vaporisation - A new approach in non-muscle invasive bladder tumours. Eur Urol Today 2010; 21(6):36.
Bogdan Geavlete, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.