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Commentary on ESOU19 webcast "Is en-bloc TUR the best staging tool?"

Watch the ESOU19 webcast “Is en-bloc TUR the best staging tool?”

Transurethral resection of the bladder (TURBT) represents the most important step in the treatment of non-muscle invasive bladder cancer (NMIBC), with the aim to provide an accurate diagnosis and staging, allowing a correct risk-stratification of the patient and, consequently, improving clinical decision-making. However, despite being one of the most frequently performed urological surgical procedure, conventional TURBT is associated with multiple drawbacks such as the tumor cell scattering through fragmentation, the risk of seeding and reimplantation as well as the incomplete resection and the high rate of missing detrusor muscle, with detrimental impacts on oncological outcomes. The presence of detrusor muscle in the resection specimen can be considered a proxy of the quality of TURBT, representing a surrogate marker for the completeness of the resection.

En bloc resection of the bladder (ERBT) has been developed with the aim to improve the quality of the resection by overcoming the limitations of conventional TURBT. As shown in this webcast, ERBT could probably be considered the best endoscopic staging tool for bladder cancer. Actually, compared to conventional TURBT, ERBT has shown to be able to improve the rate of detrusor muscle in the specimen (97-100% vs 60-90% for ERBT vs TURBT, respectively), regardless of the energy source (monopolar, bipolar, laser). Moreover, ERBT preserves the anatomy of the tumor and bladder layers, thus diminishing the risk of confusing the muscularis mucosae with the muscolaris propria and allowing for pathologic evaluation of the resection margins. The impact of ERBT on oncological outcomes remains mostly unknown. The results of the first randomized controlled trial of ERBT vs conventional TURB were recently reported at the last meeting of the American Urological Association (AUA 2018, San Francisco). A substantially lower recurrence rate was found in the en-bloc group during the 1 and 2 years’ follow-up (3.9% versus 13.5% and 6.5% versus 18.8%) due to the substantially fewer other site recurrent lesions. No data on progression was reported.

To date, no definitive conclusions can be drawn regarding the impact of ERBT on oncological outcomes, and more level I evidence is needed in this field. However, the improvements in tumor staging, mainly related to the quality of the specimens sent to the pathologist, should be underlined and, therefore, the performance of ERBT (or at least the resection of the tumor in fractions) advised.

Kramer MW, Altieri V, Hurle R, Lusuardi L, Merseburger AS, Rassweiler J, et al. Current Evidence of Transurethral En-bloc Resection of Nonmuscle Invasive Bladder Cancer. Eur Urol Focus 2017;3:567–76.