Differences in Clinical Outcomes and Survival Among Primary, Secondary, and Concomitant Carcinoma In Situ of the Bladder.

PURPOSE: Carcinoma in situ (CIS) is a flat, high-grade, and aggressive form of urothelial carcinoma with a high risk of progression to muscle-invasive disease and metastasis. This study aimed to investigate differences in clinical outcomes and survival among patients with primary, secondary, and concomitant CIS of the bladder. METHODS: A total of 209 patients diagnosed with CIS between 2010 and 2022 in our department with a minimum follow-up of 12 months were retrospectively analyzed. Patients with muscle-invasive cancer at diagnosis, those with recurrence within one month after diagnosis, and those with primary malignant melanoma were excluded. The recurrence, progression, and cancer-specific mortality rates of patients receiving Bacillus Calmette-Guérin therapy for CIS were analyzed. RESULTS: A total of 96 patients with primary (n = 18), secondary (n = 29), and concomitant CIS (n = 49) were included in the analysis. The median follow-up was 52.2 months. Patients with secondary CIS had a significantly higher recurrence rate than those with concomitant CIS (58.6% vs. 32.7%, p = 0.016). However, no significant difference in progression rates was observed among the three groups. Furthermore, no significant association was observed between CIS subtypes and recurrence-free survival (RFS) (HR = 1.45, 95% CI 0.96-2.46, p = 0.16) or progression-free survival (PFS) (HR = 2.20, 95% CI 0.99-4.87, p = 0.054). CONCLUSION: Secondary CIS had a significantly higher recurrence rate than concomitant CIS. However, no statistically significant association was observed between CIS subtypes and RFS or PFS.

Unusual Presentation of Bladder Cancer in a Young Male With Significant Tattoo Exposure: A Case Report.

Recent studies have shown that polycyclic aromatic hydrocarbons (PAHs) can be found in commercial black tattoo inks raising suspicion of tattoo-related PAHs exposure to cancer risk. We present a case of a 27-year-old Hispanic nonsmoker male with bladder cancer (BC) following extensive tattoo sessions totaling over 100 hours. The patient was treated with transurethral resection of the bladder tumor (TURBT) and adjuvant intravesical Bacillus Calmette-Guerin (BCG) therapy. Although the oncogenesis of urothelial tumors in young patients is unclear, multiple environmental and genetic factors may contribute to the etiology. This case report underscores the importance of conducting toxicological and epidemiological studies on PAHs and emphasizes the need for increased documentation of tattoos in patients diagnosed with BC.

Strategies to Improve Clinical Outcomes and Patient Experience Undergoing Transurethral Resection of Bladder Tumor.

PURPOSE OF REVIEW: To describe patient experiences of transurethral resection of bladder tumor (TURBT) and review recent advances in enhancing clinical outcomes. RECENT FINDINGS: High rates of recurrence and progression of non-muscle invasive bladder tumors expose patients to multiple TURBT procedures throughout their disease process. Understanding the impact of TURBT on quality of life and patient experiences is crucial for shared decision-making, thus enhanced recovery protocol trials are being explored to improve patient outcomes. The variability in TURBT practices worldwide contributes to differing bladder tumor recurrence rates, prompting efforts to standardize practices by evaluating the impact of patient, hospital, and surgeon factors. For select cases, less intensive surveillance regimens have reduced toxicities and costs without compromising oncologic outcomes. New innovative approaches such as en bloc- and stratified resection techniques may reduce perioperative complications and improve clinical outcomes. Finally, neoadjuvant and ablative treatments have shown to be promising alternatives to TURBT, necessitating further investigation in this setting. TURBT is essential for diagnosing and treating bladder cancer. Reducing associated morbidities and improving surgical outcomes involve multifaceted approaches, including standardizing surgical practices, exploring innovative techniques, and optimizing surveillance regimens, all while promoting patient quality of life. Neoadjuvant therapies as alternative treatments are on the horizon and may ultimately change the landscape of bladder cancer care.

VI-RADS followed by Photodynamic Transurethral Resection of Non-Muscle-Invasive Bladder Cancer vs White-Light Conventional and Second-resection: the 'CUT-less' Randomised Trial Protocol.

BACKGROUND: A second transurethral resection of bladder tumour (Re-TURBT) is recommended by European Association of Urology (EAU) Guidelines on non-muscle-invasive bladder cancers (NMIBCs) due to the risk of understaging and/or persistent disease following the primary resection. However, in many cases this may be unnecessary, potentially harmful, and significantly expensive constituting overtreatment. The CUT-less trial aims to combine the preoperative staging accuracy of Vesical Imaging-Reporting and Data System (VI-RADS) and the intraoperative enhanced ability of photodynamic diagnosis (PDD) to overcome the primary TURBT pitfalls thus potentially re-defining criteria for Re-TURBT indications. STUDY DESIGN: Single-centre, non-inferiority, phase IV, open-label, randomised controlled trial with 1:1 ratio. ENDPOINTS: The primary endpoint is short-term BC recurrence between the study arms to assess whether patients preoperatively categorised as VI-RADS Score 1 and/or Score 2 (i.e., very-low and low likelihood of MIBC) could safely avoid Re-TURBT by undergoing primary PDD-TURBT. Secondary endpoints include mid- and long-term BC recurrences and progression (i-ii). Also, health-related quality of life (HRQoL) outcomes (iii) and health-economic cost-benefit analysis (iv) will be performed. PATIENTS AND METHODS: All patients will undergo preoperative Multiparametric Magnetic Resonance Imaging of the bladder with VI-RADS score determination. A total of 327 patients with intermediate-/high-risk NMIBCs, candidate for Re-TURBT according to EAU Guidelines, will be enrolled over a 3-year period. Participants will be randomised (1:1 ratio) to either standard of care (SoC), comprising primary white-light (WL) TURBT followed by second WL Re-TURBT; or the Experimental arm, comprising primary PDD-TURBT and omitting Re-TURBT. Both groups will receive adjuvant intravesical therapy and surveillance according to risk-adjusted schedules. Measure of the primary outcome will be the relative proportion of BC recurrences between the SoC and Experimental arms within 4.5 months (i.e., any 'early' recurrence detected at first follow-up cystoscopy). Secondary outcomes measures will be the relative proportion of late BC recurrences and/or BC progression detected after 4.5 months follow-up. Additionally, we will compute the HRQoL variation from NMIBC questionnaires modelled over a patient lifetime horizon and the health-economic analyses including a short-term cost-benefit assessment of incremental costs per Re-TURBT avoided and a longer-term cost-utility per quality-adjusted life year gained using 2-year clinical outcomes to drive a lifetime model across the two arms of treatment. TRIAL REGISTRATION: ClinicalTrial.gov identifier (ID): NCT05962541; European Union Drug Regulating Authorities Clinical Trials Database (EudraCT) ID: 2023-507307-64-00.

Effect of Prior Transurethral Prostate Resection (TURP) or Laser Enucleation (ThuLEP) on Radiotherapy-Induced Toxicity and Quality of Life in Prostate Cancer Patients Undergoing Definitive Radiotherapy.

In our study, the post-radiotherapy quality of life of prostate cancer patients who previously underwent transurethral resection of the prostate (TURP) is compared to those who had thulium laser enucleation of the prostate (ThuLEP) and those who had no prior surgery. It also aims to identify and assess risk factors affecting therapy tolerance in this patient group. We analyzed 132 patients with localized prostate cancer treated with definitive radiotherapy (RT), including 23 who had prior TURP and 19 who previously underwent ThuLEP. A total of 62% of patients underwent irradiation within 12 months after surgery. We included only patients treated with radiotherapy using the IMRT technique. Changes in patient-reported urinary toxicity were evaluated using the International Prostate Syndrome Score (IPSS) and the quality of life index of the World Health Organization (QoL/WHO-PSS) over a three-year post-radiotherapy period. Patients with prior TURP experienced significant deterioration in QoL and IPSS immediately after irradiation (p < 0.001), whereas those without previous surgery showed both less significant differences in IPSS and QoL scores. In conclusion, patients with previous TURP/ThuLEP differ from those without previous surgery in urinary quality of life and acute and chronic urinary symptom profiles after RT. The surgical technique (ThuLEP vs. TURP) and the time interval to irradiation are crucial factors affecting RT tolerance in acute and late settings. The previously operated patient group reported a significantly longer period of increased symptom burden.

Treatment and survival of non-metastatic small cell carcinoma of the bladder from multiple centers in China.

Small cell carcinoma of the bladder (SCCB) is a rare, highly malignant neuroendocrine tumor. This study attempted to analyze tumor characteristics, treatments and clinical outcomes in China. We conducted a retrospective analysis of patients diagnosed with non-metastatic SCCB at multi-institutions between January 2007 and January 2022. The Kaplan-Meier method was used to calculate survival. A total of 20 patients were included. 10 had localized disease (T1-2N0), and 10 had locally advanced disease (≥ T3 or N+). 13 received local treatment (partial cystectomy or transurethral resection of the bladder tumor) and 7 received radical treatment (radical cystectomy or radiotherapy). A total of 18 patients (90%) received chemotherapy (CT), either neoadjuvant CT (n = 5) or adjuvant CT (n = 13). The median OS for the receiving local treatment was 65.3 months (95% CI 0 to 138 months) and the corresponding 1-year, 2-year, and 3-year OS was 77%, 54%, and 54%, respectively. The median OS for the receiving radical treatment was not reached and the corresponding 1-year, 2-year, and 3-year OS was 100%, 100%, and 75%, respectively. The median PFS for receiving local treatment was 13.8 months (95% CI 9.3 to 18.3 months) and the corresponding 1-year, 2-year, and 3-year PFS was 46%, 31%, and 31%, respectively. The median PFS for the receiving radical treatment was not reached and the corresponding 1-year, 2-year, and 3-year PFS was 83%, 56%, and 56%, respectively. This study reported the largest cohort of non-metastatic SCCB among Chinese population. Given its metastatic potential, CT remained an essential part of the treatment. The survival outcomes of radical cystectomy and RT in non-metastatic SCCB were encouraging.

En Bloc Versus Conventional Transurethral Resection of Bladder Tumors: A Systematic Review and Meta-analysis of Oncological, Histopathological, and Surgical Outcomes.

BACKGROUND AND OBJECTIVE: En bloc resection of bladder tumor (ERBT) has been introduced to enhance the quality of resection of bladder cancer. This review aims to compare the perioperative and oncological outcomes of ERBT and conventional transurethral resection of bladder tumor (cTURBT). METHODS: A literature search was conducted using the PubMed/Medline, Embase, and Web of Science databases to identify randomized controlled trials published until May 2024. The primary outcomes were the risk of recurrence and progression. The secondary outcomes were detrusor muscle (DM) presence, muscularis mucosae (MM) detectability, bladder perforation and obturator nerve reflex rates, operative time, length of catheterization and hospitalization, and residual tumor at repeat transurethral resection of bladder tumor (reTURBT). KEY FINDINGS AND LIMITATIONS: Seventeen studies met our inclusion criteria. No statistically significant difference was observed in 12-mo recurrence (risk ratio [RR] 0.81, 95% confidence interval [CI]: 0.65-1.02; p = 0.08), 24-mo recurrence (RR 1.02, 95% CI: 0.85-1.22; p = 0.8), and 12-mo progression (RR 0.68, 95% CI: 0.05-10.14; p = 0.8) rates. ERBT was significantly associated with a higher DM presence (RR 1.10, 95% CI: 1.01-1.20; p = 0.02), while no statistically significant difference emerged in the residual tumor at reTURBT and MM detectability (all p > 0.05). ERBT was significantly associated with a lower risk of bladder perforation (p = 0.002) and obturator nerve reflex (p < 0.001). Finally, ERBT was significantly associated with longer operative time, lower catheterization time, and lower length of hospital stay. The main limitation was heterogeneity among the included studies. CONCLUSIONS AND CLINICAL IMPLICATIONS: ERBT is safer due to fewer intraoperative events, but there was no significant difference in oncological outcomes compared with cTURBT. Higher DM detection with ERBT enhances initial disease stratification, potentially improving clinical decision-making and care delivery. PATIENT SUMMARY: En bloc resection of bladder tumors is associated with lower intraoperative complications than and superior histopathological information to the conventional resection technique. However, the absence of a difference in oncological outcomes underscores the influence of factors such as tumor characteristics, surgeon expertise, and postoperative care on subsequent events.

Streamlined surgical approach for coexistent urethral stricture and benign prostatic enlargement: feasibility, safety and patency results.

PURPOSE: To evaluate the technical feasibility, safety, and patency results of a simultaneous surgical approach to repair urethral stricture and treat benign prostatic enlargement endoscopically in a highly selected group of patients at a tertiary referral center. We hypothesize that this is technically feasible, safe, and does not affect urethroplasty outcomes. METHODS: A retrospective review of adult men who underwent simultaneous urethroplasty and endoscopic prostatic surgery between May 2017 and May 2024 at our institution was conducted. Patients with strictures < 15 French and prostates with adverse prognostic features of response to medical treatment were included. The primary outcome was technical feasibility and safety. The secondary outcome was stricture-free survival. RESULTS: Twenty men were treated during the study period. The median length of the urethral stricture was 3.0 cm (IQR 2.0-5.0), and the median size of the prostate was 95.0 cc (IQR 63.3-128.3). All patients were treated successfully with a median operative time of 194.5 min (IQR 180.0-246.8), and no procedures required conversion to a staged procedure or open prostatectomy. There were seven Clavien-Dindo I-II complications and one Clavien-Dindo IIIb complication (hematuria requiring endoscopic clot evacuation). At 22 months follow-up, two cases of urethral re-stricture were diagnosed, with one case requiring redo urethroplasty, though none had previous major complications. CONCLUSION: The combination of urethroplasty and endoscopic surgery for benign prostatic enlargement at the same stage appears to be technically viable and safe, and it does not compromise medium-term urethral patency results in a carefully selected group of patients.

An international multicentre randomised controlled trial of en bloc resection of bladder tumour vs conventional transurethral resection of bladder tumour: first results of the en bloc resection of urothelium carcinoma of the bladder (EBRUC) II trial.

OBJECTIVES: To determine the safety and oncological advantages of en bloc resection of bladder tumour (ERBT) vs conventional transurethral resection of bladder tumour (cTURBT) in terms of resection quality, staging quality, and safety. PATIENTS AND METHODS: We conducted a single-blinded randomised controlled trial at seven European hospitals with the following inclusion criteria: first diagnosis of non-muscle-invasive bladder cancer, no singular carcinoma in situ, and tumour size >4.3 mm. Patients were randomised intraoperatively in a 1:1 ratio to either the ERBT or cTURBT group. Outcome analysis was performed using the chi-square test, t-test, and multivariate regression analysis. RESULTS: A total of 97 patients were randomised into the study (cTURBT = 40, ERBT = 57). A switch to cTURBT was necessary in two patients (3.5%) and 11.5% of the screened patients were preoperatively excluded for ERBT. There was no difference in the specimen presence of detrusor muscle with 73.7% in cTURBT and 67.3% in ERBT specimens (P = 0.69). There were no significant differences in mean operative time (ERBT 27.6 vs cTURBT 25.4 min, P = 0.450) or mean resection time (ERBT 16.3 vs cTURBT 15.5 min, P = 0.732). Overall the complication rate did not differ significantly (ERBT 18.2% vs cTURBT 7.5%, P = 0.142). Bladder perforations occurred significantly more often in the ERBT group (ERBT seven vs cTURBT none, P = 0.020). R0 status was reported more often after ERBT, whilst a second resection was significantly less frequent after ERBT (P = 0.018). Recurrence rates were comparable for both techniques after 6 months of follow-up. CONCLUSION: The feasibility of ERBT is higher than previously reported. Whereas other perioperative and safety parameters are comparable to cTURBT, bladder perforations occurred significantly more often in the ERBT group and raised safety concerns. This is why this trial was terminated.

Azoospermia Due to Functional and Partial Ejaculatory Duct Obstruction: A Rare Case Report and Literature Review.

Ejaculatory duct obstruction (EDO) is a rare but treatable cause of male infertility. This case report describes a 28-year-old male with obstructive azoospermia. The patient came to our hospital after a fertility check-up revealed azoospermia. A subsequent semen analysis confirmed azoospermia. Transrectal ultrasonography (TRUS) and magnetic resonance imaging (MRI) revealed bilaterally enlarged seminal vesicles and thickened, calcified ejaculatory duct walls. The patient underwent transurethral seminal vesiculoscopy and transurethral resection of the ejaculatory ducts (TURED) for presumed partial EDO. Despite two transurethral seminal vesiculoscopy and TURED procedures, postoperative semen analysis still showed azoospermia. TRUS indicated non-contractile seminal vesicles and an unobstructed ejaculatory duct. The patient ultimately underwent percutaneous epididymal sperm aspiration for assisted reproductive technology and his spouse got pregnant. We identified a case of azoospermia caused by a rare combination of partial and functional ejaculatory duct obstruction. There are currently no reports of similar cases. This case report aims to provide valuable insights for diagnosing and treating EDO.

Safety and efficacy of transurethral holmium laser enucleation of the prostate versus bipolar transurethral resection of the prostate in the treatment of benign prostatic hyperplasia: a prospective randomized controlled trial.

PURPOSE: To evaluate the safety and efficacy of transurethral holmium laser enucleation of the prostate (HoLEP) compared to bipolar transurethral resection of the prostate (bTUR-P) in the treatment of benign prostatic hyperplasia (BPH). METHODS: A total of 220 BPH patients hospitalized from January 2022 to September 2023 were included in this study. These patients were randomly assigned to HoLEP and bTUR-P groups, with 110 participants in each group. We collected preoperative general information, perioperative data, complications, and postoperative follow-up indicators from both groups of patients. RESULTS: The baseline characteristics of patients in both groups were similar, with no statistical significance (P > 0.05). Compared to the bTUR-P group, the HoLEP group exhibited significantly less intraoperative bleeding (P < 0.001), shorter bladder irrigation time (P = 0.002), shorter catheter retention time (P < 0.001), and reduced postoperative hospitalization (P = 0.002). Additionally, the pain score during urination after catheter removal was significantly lower in the HoLEP group (P < 0.001). Postoperative complications occurred in both groups; however, they were less frequent in the HoLEP group (4 cases), primarily consisting of urinary retention and postoperative bleeding. The bTUR-P group experienced more complications (9 cases). Significant reductions in postoperative residual urine volume (RUV) were observed in both groups (P < 0.001). Both groups also showed significant improvements in Quality of Life (QoL) scores and International Prostate Symptom Scores (IPSS), with the HoLEP group demonstrating a more significant decrease in IPSS (P < 0.001). CONCLUSION: After comprehensive evaluation, HoLEP was superior to bTUR-P in terms of safety and efficacy. Therefore, HoLEP may be a preferable choice for the treatment of BPH.

Dual treatment approach for leiomyomas of urinary bladder: Experience from tertiary hospital.

INTRODUCTION AND IMPORTANCE: Leiomyomas are rare, benign mesenchymal tumors. They represent 1 to 5 % of all urinary bladder tumors. 20 % are asymptomatic, but most presentations are voiding and storage, followed by hematuria. Surgery has been reported to be a standard treatment, depending on the size of the tumor and its location in the bladder. The following case report, we discuss the case of a bladder leiomyoma presenting with storage and voiding symptoms and managed with dual approach of Transurethral resection of bladder tumor (TURBT) and open urethrotomy. CASE PRESENTATION: A 39-year-old female who presented with a one-year history of total hematuria and a blood clot that was ovoid in shape presented with urge incontinence, nocturia, strain during urination, and incomplete bladder emptying. She was mildly anemic, afebrile, with no palpable peripheral lymph node and no palpable mass. PVE revealed an anteriorly located cervix. The patient's Labs revealed to have moderate anemia of 8 g/dl, blood chemistry was uneventful, and ultrasound (USS) revealed that both kidneys were normal. The urinary bladder was well distended, with a mass located at the base, measuring 4.13 cm × 4.14 cm. MRI revealed a well-circumscribed intramural tumor on the left side measuring 4.3 cm × 4.2 cm, close to the bladder neck. A cystoscopy was used to visualize the tumor from the left lateral wall at 3 o'clock, extending to 5 o'clock, and part of the bladder neck. The tumor was solid, easily bled, and had an irregular margin, and the bladder mucosa was normal. The 1st TURBT was used for diagnosis; although she still persistent storage and voiding symptoms, she subsequently underwent 2nd TURBT, which was resected to completion with the aid of ventral urethrotomy. After the TURBT, tumor protruded into the urethra, complete excision was performed through the urethra due to extension of the tumor to the urethra. The patient's postoperative events were uneventful, and the patient was discharged with catheter care for 10 days. On follow-up, hematuria resolved, and there were no lower urinary tract symptoms. CLINICAL DISCUSSION: Leiomyoma of the urinary bladder is a rare, benign mesenchymal tumor. They are the most common type of tumor of the urinary bladder. The most common presentations are storage and voiding symptoms, and hematuria. The initial USS can be used, and CT IVU or MRI is necessary for surveillance of the upper tract, possibly with respect to the tumor location in relation to the ureteric orifice. Tumors can be endovesical, intramural or extravesical, resulting in different presentations. Some tumors are pedunculated and can move close to the bladder neck or even at the urethra and present with urinary retention. Leiomyomas are surgically excised, and sometimes via a dual approach, transurethral resection of bladder tumors is important. These patients have a very low recurrence rate and are symptom free, and they have a good prognosis. CONCLUSION: Leiomyomas are surgically excised, and sometimes via a dual approach, transurethral resection of bladder tumors is important. These patients have a very low recurrence rate and are symptom free, and they have a good prognosis.

Quality and Educational Value of YouTube Surgical Videos of Transurethral Resection of the Prostate: A Descriptive Cross-Sectional Study.

Introduction The aim of the study is to evaluate the quality and educational value of surgical videos on YouTube (Alphabet Inc., Mountain View, CA) demonstrating transurethral resection of the prostate (TURP). Methods A thorough YouTube search for "TURP" or "transurethral resection of the prostate" was performed. Each video's uploader, content, duration, date of upload, time since upload, views, comments, likes, and dislikes, and Video Power Index (VPI) scores were recorded and evaluated. Video analysis and rating followed the LAParoscopic Surgery Video Educational Guidelines (LAP-VEGaS) recommendations, which constitute nine items with values from 0 (absence) to 2 (complete presence). The guidelines' overall score can be 0 to 18. A higher score is indicative of a better level of educational value. Results There were a total of 43 videos included, 10 (23.3%) of which were academic publications. The average LAP-VEGaS score was 6.58, with 22 (51.2%), 18 (41.8%), and three (7%) videos classified as having low, medium, and high educational quality, respectively. None of the videos satisfied all the requirements outlined in the checklist. There was no statistically significant positive correlation observed between the educational score and the number of views. Conclusion A significant proportion of transurethral resection of the prostate (TURP) videos available on the YouTube platform exhibit limited educational value. Videos frequently lack comprehensive and in-depth descriptions of surgical operations. Those seeking information on TURP should carefully choose which videos to view. It is recommended that academic institutions establish comprehensive criteria aimed at enhancing the educational value of surgical videos on the YouTube platform.

Evaluating the Quality of Primary Transurethral Resection of Bladder Tumor: A Nine-Year Review at a Tertiary Healthcare Center.

OBJECTIVE: This study aimed to assess the quality of primary transurethral resection of bladder tumor (TURBT) procedures performed at Aga Khan University Hospital (AKUH) over nine years, focusing on proper documentation, completeness of tumor resection, quality of histopathology reports, complication rates, and adherence to European Association of Urology (EAU) guidelines. MATERIALS AND METHODS: A retrospective analysis of patients aged 25-75 who underwent primary TURBT at AKUH between 2010 and 2019 was done. Patients with incomplete records, concomitant procedures, or those who underwent emergency TURBT were excluded. Data was collected on patient demographics, clinical presentation, intraoperative details, and histopathology reports. Statistical analysis was performed using SPSS Version 27.0. RESULTS: 300 patients were initially identified, with 265 meeting the inclusion criteria. The mean age was 61.5 years, with 83% being male. Complete tumor resection was achieved in 35% (n=92) of cases, while deep biopsy was taken in 85% (n=226). Detrusor muscle (DM), a marker of resection quality, was noted in 75% (n=200) of histopathology reports. However, documentation quality varied, with 54% (n=143) of cases lacking clear information on resection completeness. The administration of a single instillation of a chemotherapeutic agent (SICA) was recorded in 79% (n=210) of patients, and the 30-day postoperative complication rate was monitored. CONCLUSION: The study highlights areas for improvement in the quality of TURBT procedures at AKUH, particularly in the documentation of resection completeness and adherence to established guidelines. Ensuring thorough resection and proper documentation is critical to optimizing patient outcomes and future management plans.

Effect of Ropivacaine Combined with Nalbuphine on Pain during Anaesthesia Recovery in Patients with Prostatic Hyperplasia Undergoing Transurethral Resection of Prostate.

BACKGROUND: As a frequent disease, prostatic hyperplasia could be treated by transurethral resection of prostate (TURP). However, postoperative pain may affect the prognosis of patients to some extent, so exploring reasonable anaesthetic drugs is an important measure to reduce the recovery period of anaesthesia. This study used the combination of ropivacaine and nalbuphine for intraoperative anaesthesia in patients undergoing TURP to investigate its effect on pain during anaesthesia recovery. METHODS: A retrospective study was conducted on the clinical data of 205 patients with prostatic hyperplasia who underwent TURP in our hospital from June 2020 to December 2022. All patients experienced epidural anaesthesia, and 110 patients who used ropivacaine combined with nalbuphine were included in the study group, whereas 95 patients who used ropivacaine and lidocaine were classified as the control group. The Visual Analogue Scale was used to evaluate the pain conditions of patients. The levels of pain mediators, such as substance P (SP), bradykinin (BK) and histamine (HIS), the stress levels, including cortisol (Cort), adrenocorticotropic hormone (ACTH) and norepinephrine (NE), and the incidence of adverse reactions were compared between the two groups. RESULTS: At T0 (postoperative 30 min), T1 (postoperative 60 min), T2 (postoperative 2 h) and T3 (postoperative 4 h), the study group had significantly lower pain scores (p < 0.01), levels of SP, BK and HIS (p < 0.001), and levels of Cort, ACTH and NE (p < 0.05) than the control group. No statistical difference was observed in the incidences of adverse reactions between the two groups (p > 0.05). CONCLUSIONS: The combination of ropivacaine and nalbuphine has a notable analgesic effect during anaesthesia recovery in patients undergoing TURP. It inhibits the secretion of pain and physical stress indicators and relieves postoperative pain to a large extent.

Incidence and Pitfalls of Adipose Tissue Encountered in Urinary Bladder Biopsy/Transurethral Resection Specimens.

Despite the College of American Pathologists' recommendation against diagnosing "fat invasion" in urinary bladder biopsies and transurethral resection of bladder tumor specimens (TURBT), some pathologists still consider this scenario as pathologic stage T3. However, a formal evaluation of fat in biopsies/TURBT has not been performed. Material obtained from TURBT is considered as clinical staging (cT) and that obtained from cystectomy is true pathologic staging (pT). Herein, we analyze adipose tissue incidence/distribution, cancer involving fat, staging ramifications, and clinical outcomes in a large series of biopsies/TURBT. Among 366 biopsies/TURBT specimens, data on adipose tissue presence, location, and quantity were analyzed. An initial analysis of 200 consecutive biopsies/TURBT specimens (including benign/cancer), adipose tissue was identified in 37% of 200 specimens (22% biopsies, 78% TURBT), primarily in the lamina propria (57%) or both lamina propria/muscularis propria (32%). A subsequent analysis of 183 invasive cancer (cT1/cT2) biopsies/TURBT revealed adipose tissue in 40% of specimens, predominantly within both the lamina propria and muscularis propria. Among all cT1/cT2 specimens, 26% (23/88) had cancer involving fat. Clinical follow-up on these putative "cT3" specimens revealed 10 patients who underwent radical cystectomy of which only 1 of 10 remained pT3/pT4 (although 8 patients had neoadjuvant chemotherapy). Adipose tissue is commonly found in biopsies/TURBT, predominantly localized in the lamina propria and sometimes extending into the muscularis propria. Importantly, the presence of tumor "invading" fat on biopsies/TURBT does not necessarily indicate pT3 disease. This underscores the need for standardized reporting practices, emphasizing the importance of reserving pathologic staging for cystectomy specimens.

Image directed redesign of bladder cancer treatment pathways: the BladderPath RCT.

Background: Transurethral resection of bladder tumour has been the mainstay of bladder cancer staging for > 60 years. Staging inaccuracies are commonplace, leading to delayed treatment of muscle-invasive bladder cancer. Multiparametric magnetic resonance imaging offers rapid, accurate and non-invasive staging of muscle-invasive bladder cancer, potentially reducing delays to radical treatment. Objectives: To assess the feasibility and efficacy of the introducing multiparametric magnetic resonance imaging ahead of transurethral resection of bladder tumour in the staging of suspected muscle-invasive bladder cancer. Design: Open-label, multistage randomised controlled study in three parts: feasibility, intermediate and final clinical stages. The COVID pandemic prevented completion of the final stage. Setting: Fifteen UK hospitals. Participants: Newly diagnosed bladder cancer patients of age ≥ 18 years. Interventions: Participants were randomised to Pathway 1 or 2 following visual assessment of the suspicion of non-muscle-invasive bladder cancer or muscle-invasive bladder cancer at the time of outpatient cystoscopy, based upon a 5-point Likert scale: Likert 1-2 tumours considered probable non-muscle-invasive bladder cancer; Likert 3-5 possible muscle-invasive bladder cancer. In Pathway 1, all participants underwent transurethral resection of bladder tumour. In Pathway 2, probable non-muscle-invasive bladder cancer participants underwent transurethral resection of bladder tumour, and possible muscle-invasive bladder cancer participants underwent initial multiparametric magnetic resonance imaging. Subsequent therapy was determined by the treating team and could include transurethral resection of bladder tumour. Main outcome measures: Feasibility stage: proportion with possible muscle-invasive bladder cancer randomised to Pathway 2 which correctly followed the protocol. Intermediate stage: time to correct treatment for muscle-invasive bladder cancer. Results: Between 31 May 2018 and 31 December 2021, of 638 patients approached, 143 participants were randomised; 52.1% were deemed as possible muscle-invasive bladder cancer and 47.9% probable non-muscle-invasive bladder cancer. Feasibility stage: 36/39 [92% (95% confidence interval 79 to 98%)] muscle-invasive bladder cancer participants followed the correct treatment by pathway. Intermediate stage: median time to correct treatment was 98 (95% confidence interval 72 to 125) days for Pathway 1 versus 53 (95% confidence interval 20 to 89) days for Pathway 2 [hazard ratio 2.9 (95% confidence interval 1.0 to 8.1)], p = 0.040. Median time to correct treatment for all participants was 37 days for Pathway 1 and 25 days for Pathway 2 [hazard ratio 1.4 (95% confidence interval 0.9 to 2.0)]. Limitations: For participants who underwent chemotherapy, radiotherapy or palliation for multiparametric magnetic resonance imaging-diagnosed stage T2 or higher disease, it was impossible to conclusively know whether these were correct treatments due to the absence of histopathologically confirmed muscle invasion, this being confirmed radiologically in these cases. All patients had histological confirmation of their cancers. Due to the COVID-19 pandemic, we were unable to realise the final stage. Conclusion: The multiparametric magnetic resonance imaging-directed pathway led to a substantial 45-day reduction in time to correct treatment for muscle-invasive bladder cancer, without detriment to non-muscle-invasive bladder cancer participants. Consideration should be given to the incorporation of multiparametric magnetic resonance imaging ahead of transurethral resection of bladder tumour into the standard pathway for all patients with suspected muscle-invasive bladder cancer. The improved decision-making accelerated time to treatment, even though many patients subsequently needed transurethral resection of bladder tumour. A proportion of patients can avoid transurethral resection of bladder tumour completely, reducing costs and morbidity, given the much lower cost of magnetic resonance imaging and biopsy compared to transurethral resection of bladder tumour. Future work: Further work to cross-correlate with the recently developed Vesical Imaging-Reporting and Data System will improve accuracy and aid dissemination. Longer follow-up to examine the effect of the pathway on outcomes is also required. Incorporation of liquid deoxyribonucleic acid-based biomarkers may further improve the quality of decision-making and should also be investigated further. Study registration: This study is registered as ISRCTN 35296862. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR135775) and is published in full in Health Technology Assessment; Vol. 28, No. 42. See the NIHR Funding and Awards website for further award information.

The BladderPath trial explored how to accelerate diagnosis and avoid unnecessary surgery for patients with bladder cancer which had grown into the muscle wall of the bladder, referred to as muscle-invasive bladder cancer. Following initial outpatient diagnosis, bladder cancer patients currently undergo inpatient or day-case surgical tumour removal using a telescope (transurethral resection of bladder tumour). This surgery is fundamental to the treatment of early bladder cancer (non-muscle-invasive). However, for muscle-invasive disease, the main role of transurethral resection of bladder tumour is to confirm that the tumour has grown into the bladder muscle, and this is often inaccurate; the actual correct treatment for muscle-invasive bladder cancer patients should include chemotherapy, radiotherapy and/or bladder removal. For these patients, having transurethral resection of bladder tumour may delay this correct treatment and impact survival. Additionally, for patients determined to need palliative care due to advanced disease, the transurethral resection of bladder tumour may represent over-treatment. A magnetic resonance imaging scan with contrast agent (called multiparametric magnetic resonance imaging) gives a clearer picture of the bladder than normal scans, allowing distinction between invasive and non-invasive tumours. The BladderPath trial investigated adding multiparametric magnetic resonance imaging for patients with suspected muscle-invasive bladder cancer and the effect on treatment times. Subsequent therapy could include transurethral resection of bladder tumour if clinically determined as necessary by the treating team. Trial participants were randomly allocated either to the standard pathway (Pathway 1: all underwent transurethral resection of bladder tumour) or to a new pathway (Pathway 2). In Pathway 2, urologists conducting the initial outpatient diagnostic bladder inspections used a scale to assess whether tumours appeared to be either probably non-muscle-invasive or possibly muscle-invasive. Participants whose tumours appeared possibly muscle-invasive had initial multiparametric magnetic resonance imaging as their next investigation instead of transurethral resection of bladder tumour. We then compared the duration of time from initial diagnosis to receiving the correct treatment for participants in each pathway. Of the 143 participants, 75 (52.1%) were diagnosed as possibly muscle invasive. In Pathway 1, the duration for half of the participants in the group to have received their correct treatment for muscle-invasive bladder cancer was 98 days, which reduced to 53 days in Pathway 2. Furthermore, the duration for half of all the participants in the two groups to have received their correct treatment was 37 days for Pathway 1 and 31 days for Pathway 2. In summary, use of initial multiparametric magnetic resonance imaging in suspected muscle-invasive bladder cancer participants substantially reduced the time to correct treatment (surgery, radiotherapy, chemotherapy or instigation of palliative care) and avoided unnecessary surgery. There was no negative impact on participants with non-invasive disease. Adopting multiparametric magnetic resonance imaging into the pathway ahead of transurethral resection of bladder tumour for patients with suspected muscle-invasive bladder cancer is recommended.

Does dutasteride reduce the bleeding in transurethral resection of the prostate in patients on antiplatelet drugs?

Background: The aim of this study was to assess the effect of a 4-week dutasteride treatment on reducing the intraoperative and postoperative bleeding, as well as the amount and duration of irrigation required to clear the urine after transurethral resection of the prostate (TURP) ≥50 g in men receiving the antiplatelet drug (APD). Materials and methods: This double-blind randomized clinical trial included patients with a prostate size ≥50 g who were indicated for TURP and were already receiving APD. The study was conducted in the Urology Department of Cairo University over a 12-month period. Routine preoperative laboratory investigations were performed in all patients. Moreover, baseline prostate size, serum prostate-specific antigen level, and International Prostate Symptom Score were estimated. The patients were randomly divided into 2 equal groups (groups A and B). Group A, the dutasteride group, received dutasteride (0.5 mg) once daily for 4 weeks. Group B, the placebo group, received a placebo capsule once daily for 4 weeks. Both groups underwent bipolar TURP. Fifteen patients were excluded from the study; 9 patients from group A and 6 patients from group B, either due to drug intolerability or loss follow-up. Results: The mean blood loss was insignificant between the 2 groups immediately after and 24 hours after surgery (Δ hemoglobin: 1.41 ± 0.63 g/dL vs. 1.48 ± 0.54 g/dL, 2.12 ± 0.70 g/dL vs. 2.31 ± 0.78 g/dL, respectively, p = 0.631, p = 0.333; Δ hematocrit: 2.97% ± 1.51% vs. 3.16% ± 1.36%, 4.96% ± 1.87% vs. 5.73% ± 4.39%, respectively, p = 0.610, p = 0.380). However, there were significant differences in duration of indwelling urethral catheter (5.10 ± 0.55 days vs. 5.80 ± 1.79 days, p = 0.048), duration of bladder irrigation (13.60 ± 2.85 hours vs. 16.33 ± 6.62 hours, p = 0.044), and the amount of saline used for bladder irrigation (11.03 ± 2.30 L vs. 13.87 ± 6.13 L, p = 0.046) between group A and group B. respectively. Conclusions: Treatment with dutasteride for 4 weeks before TURP in men receiving APD did not significantly reduce intraoperative or postoperative bleeding after TURP but could significantly reduce the duration of indwelling catheter placement, as well as the duration and amount of saline irrigation.

Efficacy and Safety of Obturator Nerve Block in Transurethral Resection of Bladder Tumors: A Comprehensive Review.

Transurethral resection of bladder tumors (TURBT) is a pivotal procedure in the management of bladder cancer, essential for both diagnosis and treatment. Effective anesthesia is crucial in TURBT to ensure a stable and pain-free operative field, facilitate precise tumor resection, and minimize complications such as the obturator reflex, which can lead to involuntary leg movement and bladder injury. The obturator nerve block (ONB) is a regional anesthesia technique designed to prevent the obturator reflex by blocking the obturator nerve, which innervates the adductor muscles of the thigh. This comprehensive review evaluates the efficacy and safety of ONB in TURBT. It begins by discussing the anatomical and physiological aspects of the obturator nerve, followed by a detailed examination of various ONB techniques, including ultrasound-guided and landmark-based methods. The review assesses the impact of ONB on pain management, reduction of adductor muscle spasms, and overall improvement in surgical conditions and patient satisfaction. Additionally, it explores the incidence and types of complications associated with ONB, such as hematoma, nerve injury, and local anesthetic systemic toxicity (LAST). It compares ONB with other anesthesia techniques used in TURBT, such as general, spinal, and epidural anesthesia. A critical analysis of key clinical studies and meta-analyses is presented to provide a comprehensive understanding of the current evidence on ONB efficacy and safety. Future directions and innovations in ONB techniques, including advances in imaging and nerve localization, are also discussed. Practical recommendations for implementing ONB in clinical practice, including guidelines for clinician training and patient selection criteria, are provided. This review aims to inform clinicians about the benefits and risks of ONB in TURBT, guide clinical practice, and identify areas for future research to optimize anesthesia management in bladder cancer surgery.