The American Urologic Association and European Urologic Association guidelines both recommend a transurethral resection of the bladder tumor (TURBT) to resect the tumor to the fullest extent safely possible as the initial step in the treatment and diagnosis of bladder cancer [1,2]. For purposes of this discussion, I will define standard TURBT as a cystoscopic resection of a tumor using either monopolar or bipolar electrocautery. The mandate for my argument is that the current best and safest approach is standard TURBT. While no surgical approach is perfect, the question at hand is whether there are better approaches for resecting bladder tumors. I will highlight the strengths and weaknesses of TURBT recognizing that for a technique to replace TURBT it will need to match the strengths and overcome the weaknesses of the current standard. While others might claim superior approaches, lacking randomized trials the current standard will remain the dominant approach.
The current strengths of TURBT are numerous. The equipment is readily available and training is widespread. While there is clearly a learning curve to any approach, there are many practitioners who are facile with this technique and it is taught to all urologists as part of their complete armamentarium. Changing an approach to another technique could require retraining of most urologists and many would not adopt a new technique. There is also a risk of harm to many patients as has occurred during the adoption phase of many other technologies including robotic/laparoscopic approaches . TURBT is a common procedure utilized by most urologists in the community. It is not reserved to tertiary centers so the approach has to be accessible to most urologists or risk lack of access to many patients.
Currently TURBT is a safe procedure. A study of over 10 000 procedures performed in more than 200 institutions through-out the United States found an overall complication rate of 5.7% and rate of UTIs around 3% . A study including 21 515 TURBTs prospectively registered in the National Surgical Quality Improvement Program found that postoperative complication rates were 4.3% and only 1% of study patients developed more than one complication; the most common complications were urinary tract infection (3.0%) and hematuria (2.1%) .
Perhaps the greatest criticism of TURBT is the issue related to adequate staging of bladder cancer. The issue of understaging bladder cancer is significant with up to 40% of patients getting understaged from TURBT to cystectomy despite the addition of cross-sectional imaging and exam under anesthesia . Some of these patients are found to have lymph node involvement which cannot be improved upon by TURBT techniques. Identification of invasion into the perivesical fat or other organs would likely only be determined if there is planned resection into fat and this could result in perforation and is often avoided for safety reasons. However, it is important to determine if the cancer is involving the muscle since this differentiates nonmuscle invasive bladder cancer and muscle invasive bladder cancer with consequential differences in treatment and prognosis.
Residual cancer is seen at time of repeat resection of up to 50% of patients with high-grade Ta tumors and 50–70% of patients with T1 tumors [1,2]. Based on this, repeat TURBT is recommended to confirm the stage and presence of residual disease especially if muscle is not present on initial resection. To assist pathologists with their diagnosis, it can be helpful to send the exophytic portion of the specimen separately from the base so the muscle layer is better defined [1,2,7].
The question remains whether a new technique can reliable obtain muscle in a safe manner in a consistent basis. Can it reduce residual disease which may be a consequence of a field effect rather than inadequate first resection especially if blue light cystoscopy is used? Would an en-bloc resection which finds high-grade T1 allow one to be confident enough with this finding to avoid a second resection and proceed with intravesical therapy? While there is clearly a benefit to avoid a second anesthetic in bladder cancer patients who are frequently older and have concomitant comorbidities, the level of evidence to support this change in management would have to be high. There is also a need to recognize that for many patients with low-grade or noninvasive cancers, the current standard is more than adequate and there is no need to reinvent the wheel.
There certainly have been efforts to address these questions regarding the efficacy of en-bloc TURBT. A review of studies of en-bloc resection found that most studies were single arm trials with relatively small patient cohorts . While the rate of muscle in specimens was over 90%, the impact on recurrence and the ability to avoid a 2nd resection was unclear. There were other limitations to the approach. Certain patients are not good candidates for the approach such as larger tumors (>3 cm) and when tumors are located at the anterior and posterior bladder wall, and at the bladder neck. If certain patients are not good candidates for en-bloc resection then urologists will have to be competent with TURBT and en-bloc resection. This will require more learning and a diffusion of experience across techniques. It does not seem that it would be good to only use TURBT for the harder tumors in terms of location and size if the surgeon does not gain experience with TURBT for medium sized tumors. The safety of en-bloc resection seems similar to TURBT but most studies do not use standardized system to collect data on complications and any superiority to standard TURBT is lacking evidence from randomized trials. Finally, the approach for most en-bloc resection utilizes laser technology. The cost and availability of these lasers especially thulium : yttrium aluminum garnet laser is not well established and as noted above, the limiting of access to TURBT would be harmful to many patients.
As a community, urologists are quick to embrace technologies that advance our field and improve the care of patients. The burden of proof, however, lies with the new technique to demonstrate superiority prior to replacing a proven approach.
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Conflicts of interest
Abbott: Scientific study or trial; Cepheid: consultant/advisor; Pacific Edge: scientific study or trial; FKD: scientific study or trial; MDxHealth: consultant/advisor, scientific study or trial; Anchiano: scientific study or trial; GenomeDx Biosciences, Inc.: scientific study or trial; Photocure: consultant/advisor, scientific study or trial; UroGen: Data Safety Monitoring Committee; AstraZeneca: consultant/advisor; Merck: consultant/advisor; Vessi Medical: leadership position; Nucleix: consultant; Radera: consultant; Cleveland Diagnostics: consultant; Standard TURBT remains the standard – Y.L.
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