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.

Perioperative Outcomes and Trends in Transurethral Resection of Bladder Tumors with Photodynamic Diagnosis: Results from the GeRmAn Nationwide Inpatient Data Study.

Background: Photodynamic diagnosis (PDD) during transurethral resection of bladder tumor (TURBT) is guideline recommended, as it improves bladder cancer detection rates. However, the extent to which PDD is implemented in everyday clinical practice has not been thoroughly assessed. We aimed to evaluate the current trends and major perioperative outcomes of TURBT with PDD. Methods: The present study evaluated the GeRmAn Nationwide inpatient Data (GRAND) from 2010 (the year when PDD started to be coded separately in Germany) to 2021, which were made available from the Research Data Center of the German Bureau of Statistics. We undertook numerous patient-level and multivariable logistic regression analyses. Results: Overall, 972,208 TURBTs [228,207 (23%) with PDD and 744,001 (77%) with white light] were performed. Patients offered PDD during TURBT were younger (p < 0.001), presented fewer comorbidities (p < 0.001) and were discharged earlier from hospital (p < 0.001). PDD was associated with additional costs of about EUR 500 compared to white-light TURBT (p < 0.001). The yearly TURBT cases remained relatively stable from 2010 to 2021, whereas utilization of PDD underwent a 2-fold increase. After adjusting for major risk factors in the multivariate regression analysis, PDD was related to lower rates of transfusion (1.4% vs. 5.6%, OR: 0.29, 95% CI: 0.28 to 0.31, p < 0.001), intensive care unit admission (0.7% vs. 1.4%, OR: 0.56, 95% CI: 0.53 to 0.59, p < 0.001) and 30-day in-hospital mortality (0.1% vs. 0.7%, OR: 0.24, 95% CI: 0.22 to 0.27, p < 0.001) compared to white-light TURBT. On the contrary, PDD was related to clinically insignificant higher rates of bladder perforation (0.6% versus 0.5%, OR: 1.3, 95% CI: 1.2 to 1.4, p < 0.001), and reoperation (2.6% versus 2.3%, OR: 1.2, 95% CI: 1.1 to 1.2, p < 0.001). Conclusions: The utilization of PDD with TURBT is steadily increasing. Nevertheless, the road toward the establishment of PDD as the standard of care for TURBT is still long, despite of the advantages of PDD.

Bladder perforation as a complication of transurethral resection of bladder tumors: the predictors, management, and its impact in a series of 1570 at a tertiary urology institute.

OBJECTIVES: To report the incidence, predictors, the impact of bladder perforation (BP), and our protocol of management in patients who underwent trans-urethral resection of bladder tumor (TURBT). METHODS: This is a retrospective study, between 2006 and 2020, on patients who underwent TURBT for non-muscle-invasive bladder cancer (NMIBC). Bladder perforation was defined as any full thickness resection of the bladder wall. Bladder perforations were managed based on their severity and type. Small BP with no or mild symptoms were managed with prolongation of urethral catheters. Those with significant extraperitoneal extravasations were managed by insertion of a tube drain (TD). Abdominal exploration was done for extensive BP and all intraperitoneal extravasations. RESULTS: Our study included 1,570 patients, the mean age was 58 ± 11 years and 86% were males. Bladder perforation was recorded in 10% (n = 158) of the patients. The perforation was extraperitoneal in 95%, and in 86%, the perforation was associated with no symptoms, mild symptoms, or mild fluid extravasation that required only prolongation of the urethral catheter. On the other hand, active intervention was required for the 21 remaining patients (14%) with TD being the most frequent management. History of previous TURBT (p = 0.001) and obturator jerk (p = 0.0001) were the only predictors for BP. CONCLUSIONS: The overall incidence of bladder perforation is 10%; however, 86% required only prolongation of urethral catheter. Bladder perforation did not affect the probability for tumor recurrence, tumor progression nor radical cystectomy.

Thulium laser en bloc resection versus conventional transurethral resection of urinary bladder tumor: A comparative prospective study.

Background: Transurethral resection of bladder tumors (TURBT) is the standard management for urinary bladder tumors; however, new techniques as Thulium laser en bloc resection of bladder tumors (TmLRBT) have been introduced as a substitute to TURBT. Objectives: In this study safety, efficacy, and tumor recurrence after TmLRBT and TURBT were prospectively compared in patients with primary (<4 cm) bladder tumors. Patients and Methods: Between August 2019 and May 2021, patients with primary (<4 cm) bladder tumors were enrolled. Patients were randomized between the two procedures. All perioperative data were collected prospectively. Pathological specimen findings and recurrence rates were reported during follow-up visits. Results: Sixty patients underwent TURBT, and another 60 had TmLRBT. No significant differences were detected in patient demographics or preoperative tumor characteristics between the two groups. Operation time was less (28.2 vs. 38.9 min, P < 0.001), and rate of bladder perforation was lower with TmLRBT compared to TURBT (3.3% vs. 15.0%, P = 0.027). In the TmLRBT group, higher rate of muscle detection (95.0% vs. 78.3%, P < 0.001) in the pathological specimen, and lower rate of tissue destruction (0.0% vs. 21.6%, P < 0.001) were obtained compared to TURBT. Recurrence rate in cases of nonmuscle invasive bladder cancer was lower with TmLRBT (6.7% vs. 33.0%, P < 0.001). Conclusion: In this study, TmLRBT showed reduced operative time with lower perforation rates. Higher detection of detrusor muscle and less tissue destruction in the pathological specimen were obtained with TmLRBT, as well as lower rates of tumor recurrence. These findings suggest that TmLRBT is a safe and efficacious substitute to TURBT in tumors <4 cm.

Does repeat transurethral resection of bladder tumor influence the diagnosis and prognosis of T1 bladder cancer? A systematic review and meta-analysis.

BACKGROUND: To reduce recurrence or progression of tumor, NCCN guidelines recommend repeat transurethral resection of bladder tumors (reTURB) for non-muscle-invasive bladder cancer (NMIBC). The study aims to compare the impact of initial TURB and reTURB on the rate of residual or upstaging tumors and short-term and long-term survival outcomes of T1 bladder cancer (BC). MATERIALS AND METHODS: We searched through several public database, including PubMed, Embase, Ovid Medline and Ovid EBM Reviews - Cochrane Central Register of Controlled Trials. The latest search time was October 2021. RESULTS: In general, 68 articles were involved. Short-term RFS (1-year and 3-year) of reTURB group was better compared with TURB group in T1 patients. The pooled RR were 1.10 (95%CI: 1.01-1.19) and 1.15 (95%CI: 1.03-1.28), respectively. While reTURB did not improve long-term RFS (5-year, 10-year, 15-year) in T1 patients. The pooled RR were 1.12 (95%CI: 0.97-1.30), 1.11 (95%CI: 0.82-1.50) and 1.37 (95%CI: 0.50-3.74), respectively. Analysis of PFS, OS and CSS demonstrated similar outcomes with RFS. We found that about two-thirds of samples contained detrusor. The residual tumor rate in stage T1 was 0.48 (95%CI: 0.42-0.53). While the rate of upstaging in stage T1 was 0.10 (95%CI: 0.07-0.13). CONCLUSIONS: In conclusion, reTURB might provide short-term survival benefits for T1 BC, but it was not the same for long-term outcomes. The residual and upstaging rates of T1 BC in reTURB were around 50% and 10%, respectively. Our study might be conducive to clinically informed consents when patients expressed their concerns about the necessity of reTURB and its impact on diagnosis, treatment and prognosis.

La dosis única de instilación intravesical postoperatoria inmediata de quimioterapia no es superior al lavado continuo con suero / Immediate post-operative intravesical instillation of a single dose chemotherapy is not superior to continuous saline irrigation

Introducción y objetivos: Evaluar si existe alguna diferencia entre el efecto de la instilación intravesical de quimioterapia postoperatoria inmediata (IQPI) y el del lavado vesical continuo con suero salino (LVCS) en la recidiva del cáncer de vejiga (CV) en pacientes con CV primario de riesgo bajo o intermedio sin invasión muscular (CVSIM).Materiales y métodos: Se revisaron retrospectivamente las historias clínicas de 1.482 pacientes sometidos a resección transuretral de tumor de vejiga entre marzo de 1994 y agosto de 2020. Los pacientes se dividieron en 2 grupos según el tratamiento administrado de IQPI y/o LVCS (Grupo 1: solo LVCS; Grupo 2: LVCS tras IQPI). Los pacientes con CVSIM de riesgo bajo e intermedio también se dividieron en subgrupos según el tipo de tratamiento administrado: IQPI y/o LVCS.Resultados: Se incluyeron 594 pacientes con CVSIM primario. De los pacientes, 86 (14,5%) eran mujeres y 508 (85,5%) eran varones, con una edad media de 69 (60-78) años. La frecuencia de pacientes en el grupo 1 y el grupo 2 fue de 361 (60,8%) y 233 (39,2%), respectivamente. Se observó enfermedad recurrente en 213 (35,9%) pacientes. No hubo diferencias entre los grupos al comprar la frecuencia de la enfermedad recurrente, la mediana de tiempo hasta la primera recidiva y la frecuencia de la recidiva en los primeros 12 meses (p=0,064; p=0,671 y p=0,145, respectivamente). Las tasas de recidiva en los pacientes con CVSIM de bajo riesgo fueron menores cuando recibieron tratamiento con «LVCS tras IQPI” en comparación con «solo LVCS» (p=0,042). Sin embargo, no se observaron diferencias en los subgrupos de CVSIM de bajo riesgo al comparar las características patológicas de los tumores recurrentes como el número, el tamaño, el grado, el estadio y la presencia de carcinoma in situ (p>0,05, para cada una. (AU)

Introduction and objectives: To evaluate whether there is any difference between immediate postoperative instillation of intravesical chemotherapy (IPOIC) and continuous saline bladder irrigation(CSBI) in terms of bladder cancer(BC) recurrence in patients with primary low- or intermediate-risk non-muscle-invasive BC (NMIBC).Materials and methods: Medical records of 1482 patients who underwent transurethral resection of bladder tumor between March 1994 and August 2020 were reviewed retrospectively. Patients were divided into two groups according to IPOIC and/or CSBI administration status (Group 1: CSBI alone; Group 2: CSBI following IPOIC). Low- and intermediate-risk NMIBC patients were also divided into subgroups according to IPOIC and/or CSBI administration status.Results: A total of 594 patients with primary NMIBC were included. Of the patients, 86 (14.5%) were female and 508 (85.5%) were male with a median age of 69 (60-78) years. The frequency of patients in group 1 and group 2 were 361 (60.8%) and 233 (39.2%), respectively. Recurrent disease was observed in 213 (35.9%) patients. There was no difference between the groups when they were compared for recurrent disease frequency, median time to first recurrence and frequency of recurrence within first 12 months (P=.064, P=.671, and P=.145, respectively). Disease recurrence rates in low-risk NMIBC patients was lower when they were treated with “CSBI following IPOIC” when compared to “CSBI alone” (P=.042). However, no difference was observed in low-risk NMIBC subgroups when they were compared for pathological features of recurrent tumors such as number, size, grade, stage, and presence of carcinoma in situ (P>.05, for each).Conclusions“CSBI following IPOIC” combination was not superior to “CSBI alone” for preventing adverse pathological outcomes in recurrent low- and intermediate-risk NMIBC. (AU)

Immediate post-operative intravesical instillation of a single dose chemotherapy is not superior to continuous saline irrigation.

INTRODUCTION AND OBJECTIVES: To evaluate whether there is any difference between immediate postoperative instillation of intravesical chemotherapy (IPOIC) and continuous saline bladder irrigation (CSBI) in terms of bladder cancer (BC) recurrence in patients with primary low- or intermediate-risk non-muscle-invasive BC (NMIBC). MATERIALS AND METHODS: Medical records of 1482 patients who underwent transurethral resection of bladder tumor between March 1994 and August 2020 were reviewed retrospectively. Patients were divided into two groups according to IPOIC and/or CSBI administration status [Group-1 = CSBI alone; Group-2 = CSBI following IPOIC]. Low- and intermediate-risk NMIBC patients were also divided into subgroups according to IPOIC and/or CSBI administration status. RESULTS: A total of 594 patients with primary NMIBC were included. Of the patients, 86 (14.5%) were female and 508 (85.5%) were male with a median age of 69 (60-78) years. The frequency of patients in Group-1 and Group-2 were 361 (60.8%) and 233 (39.2%), respectively. Recurrent disease was observed in 213 (35.9%) patients. There was no difference between the groups when they were compared for recurrent disease frequency, median time to first recurrence and frequency of recurrence within first 12 months (P = .064, P = .671, and P = .145, respectively). Disease recurrence rates in low-risk NMIBC patients was lower when they were treated with "CSBI following IPOIC" when compared to "CSBI alone" (P = .042). However, no difference was observed in low-risk NMIBC subgroups when they were compared for pathological features of recurrent tumors such as number, size, grade, stage, and presence of carcinoma in situ (P > .05, for each). CONCLUSIONS: "CSBI following IPOIC" combination was not superior to "CSBI alone" for preventing adverse pathological outcomes in recurrent low- and intermediate-risk NMIBC.

Comparison of Thulium Laser Resection of Bladder Tumors and Conventional Transurethral Resection of Bladder Tumors for Non-Muscle-Invasive Bladder Cancer.

INTRODUCTION: The thulium laser resection of bladder tumors (TmLRBT) was increasingly used in the treatment of non-muscle-invasive bladder cancer (NMIBC) recently, and here we report the relevant outcomes of our institution to evaluate its efficacy and safety. METHODS: We retrospectively collected the data of NMIBC patients who underwent either TmLRBT or transurethral resection of bladder tumor (TURBT). The baseline characteristics and perioperative outcomes were compared in these 2 groups. RESULTS: The TmLRBT had a higher rate of detrusor identification than TURBT (97.4 vs. 87.6%, p = 0.001). After screening, 134 patients who underwent TmLRBT and 152 patients who received TURBT were enrolled in the analysis, and their baseline characteristics were similar. During the TURBT, 24 (15.8%) obturator nerve reflexes and 9 (5.9%) bladder perforations occurred, while none happened during the TmLRBT. After surgery, TmLRBT patients had fewer postoperative gross hematuria (38.1 vs. 96.7%, p < 0.001) and postoperative irrigation (27.6 vs. 92.7%, p < 0.001), and its irrigation duration was significantly shorter (2.3 vs. 3.3 day, p < 0.001). During the follow-up, no significant difference in the recurrence rate was detected (p = 0.315). CONCLUSIONS: TmLRBT is a safer technique than conventional TURBT in the treatment of NMIBC, and it could offer better specimens for pathologic assessment while the cancer control was not compromised.

Validation of a Novel Assessment Tool Identifying Proficiency in Transurethral Bladder Tumor Resection: The OSATURBS Assessment Tool.

Background: Competence in transurethral resection of bladder tumors (TURB) is critical in bladder cancer management and should be ensured before independent practice. Objective: To develop an assessment tool for TURB and explore validity evidence in a clinical context. Design, Setting, and Participants: From July 2019 to March 2021, a total of 33 volunteer doctors from three hospitals were included after exemption from the regional ethics committee (REG-008-2018). Participants performed two TURB procedures on patients with bladder tumors. A newly developed assessment tool (Objective Structured Assessment for Transurethral Resection of Bladder Tumors Skills, OSATURBS) was used for direct observation assessment (DOA), self-assessment (SA), and blinded video assessment (VA). Outcome Measurements and Statistical Analysis: Cronbach's alpha and Pearson's r were calculated for across items internal consistency reliability, inter-rater reliability, and test-retest reliability. Correlation between OSATURBS scores and the operative experience was calculated with Pearson's r and a pass/fail score was established. Differences in assessment scores were explored with paired t-test and independent samples t-test. Results and Limitations: The internal consistency reliability across items Cronbach's alpha was 0.94 (n = 260, p < 0.001). Inter-rater reliability was 0.80 (n = 64, p < 0.001). Test-retest correlation was high, r = 0.71 (n = 32, p < 0.001). Relationship with TURB experience was high, r = 0.71 (n = 32, p < 0.001). Pass/fail score was 19 points. DOAs were strongly correlated with video ratings (r = 0.85, p < 0.001) but with a significant social bias with lower scores for inexperienced and higher scores for experienced participants. Participants tended to overestimate their own performances. Conclusions: OSATURBS tool for TURB can be used for assessment of surgical proficiency in the clinical setting. DOA and SA are biased, and blinded VA of TURB performances is advised. Clinical Trials NCT03864302.

Thulium Laser Resection of Bladder Tumors vs. Conventional Transurethral Resection of Bladder Tumors for Intermediate and High Risk Non-Muscle-Invasive Bladder Cancer Followed by Intravesical BCG Immunotherapy.

Background: Thulium laser resection of bladder tumors (TmLRBT) is recently considered as a common treatment option for non-muscle-invasive bladder cancers (NMIBC), but whether it is superior to Transurethral resection of bladder tumors (TURBT) are still undetermined. Materials and Methods: We retrospectively screened our institution database to identify patients who were treated by conventional TURBT or TmLRBT for NMIBC and followed by intravesical bacillus Calmette-Guérin (BCG) immunotherapy. The preoperative characteristics, perioperative outcomes, and recurrence-free survival were compared to assess the safety and efficacy of the two procedures. Results: Eventually, 90 patients who underwent TmLRBT (n = 37) or TURBT (n = 53) followed by intravesical BCG immunotherapy were included. Two groups were similar in baseline characteristics except for the smaller tumor size of the TmLRBT group(1.7 cm vs. 2.2 cm; P = 0.036). Obturator nerve reflex occurred in eight patients in the TURBT group and 3 of them suffered from bladder perforation while none happened in the TmLRBT group. The TmLRBT also had a shorter irrigation duration. In the multivariate Cox regression, the TmLRBT was related to less recurrence risk (HR: 0.268; 95% CI, 0.095-0.759; P = 0.013). Conclusion: Our results suggested that TmLRBT is safer than conventional TURBT with fewer perioperative complications, and it offers better cancer control, therefore might be a superior option for NMIBC patients with intermediate and high recurrence risk.

Safety and efficacy of thulium laser resection of bladder tumors versus transurethral resection of bladder tumors: a systematic review and meta-analysis.

The thulium laser resection of bladder tumor (TmLRBT) is widely used in the treatment of non-muscle-invasive bladder cancer (NMIBC), and we conduct this study to compare the safety and efficacy of TmLRBT with transurethral resection of bladder tumor (TURBT). A comprehensive literature research was conducted using multiple databases, and comparative studies evaluating the safety and efficacy of TmLRBT and TURBT were included. For continuous outcomes, the weighted mean difference (WMD) was used to measure the difference, whereas the risk ratio (RR) with a 95% confidence interval (CI) was calculated for binary variables. Overall, ten studies with 1558 patients enrolled were included in the meta-analysis. The baseline characteristics of two groups were comparable. The operative time (p = 0.24) and catheterization time (p = 0.41) of two groups were similar but the TmLRBT group had a shorter length of hospital stay (p = 0.04). TmLRBT was related to fewer intraoperative complications including obturator nerve reflex (p < 0.001) and bladder perforation (p < 0.001). Although the rate of postoperative irrigation did not significantly differ in our analysis (p = 0.28), the TmLRBT was related to a significantly shorter duration of irrigation (p = 0.004). Besides, the TmLRBT group had a higher rate of identification of detrusor (p = 0.02). However, TmLRBT did not suggest significantly better cancer control than TURBT including the overall recurrence (p = 0.052), 1-year recurrence (p = 0.23), and 2-year recurrence (p = 0.40). Compared with conventional TURBT, the TmLRBT showed superior safety and non-inferior efficacy in cancer control. TmLRBT could also provide high-quality specimens for pathology diagnosis; therefore, it is an as effective option for NMIBC.

Significance of 5-Aminolevulinic Acid-mediated Photodynamic Diagnosis Following Standard Transurethral Resection in Non-muscle Invasive Bladder Cancer.

Background/Aim: Transurethral resection of bladder tumors (TURBT) guided by photodynamic diagnosis (PDD) with 5-aminolevulinic acid (5-ALA) has been shown to be superior to conventional white light (WL) cystoscopy with regard to diagnostic accuracy, for non-muscle invasive bladder cancer (NMIBC); however, PDD is usually performed prior to WL TURBT. The objective of this study was to investigate the diagnostic significance of 5-ALA-mediated PDD following TUR of NMIBC. Patients and Methods: In 83 NMIBC patients, all visible tumors were completely resected under the conventional WL guidance followed by additional resection if fluorescent lesions were observed under the blue light (BL) guidance, and random biopsy was further conducted. Results: With the BL source, 39 (47.0%) patients were judged to have fluorescent lesions. Twenty (51.3%) of the 39 patients with positive findings by PDD were diagnosed with residual cancer by additional resection, while random biopsy detected cancers in 2 (4.5%) of the 44 patients with negative findings by PDD. Accordingly, the sensitivity, specificity, positive predictive value and negative predictive value in diagnosing residual cancer by our PDD system were 90.9, 68.9, 51.3 and 95.5%, respectively. Univariate analysis showed that the presence of residual cancers shown by WL TURBT was significantly associated with the preoperative findings of urinary cytology, tumor multiplicity, pathological T stage and tumor grade, of which only the preoperative finding on urinary cytology was shown to have an independent impact on the diagnosis of residual cancer. Conclusion: 5-ALA-mediated PDD following standard WL TURBT could improve the diagnostic accuracy in NMIBC patients, particularly those who are positive for preoperative urinary cytology.

Current Standards in the Endoscopic Management of Bladder Cancer: A Survey Evaluation among Urologists in German-Speaking Countries.

INTRODUCTION: To assess the current diagnostic, treatment, and documentation strategies for bladder cancer (BC) in German-speaking countries. MATERIALS AND METHODS: A 14-item web-based survey was distributed among members of the German, Austrian, and Swiss Associations of Urology, addressing physicians who perform cystoscopies and transurethral resection of bladder tumors (TURB). RESULTS: The survey was responded to by 308 of 5,564 urologists with a mean age of 49.5 years (response rate: 5.5%). The majority of participants (57.3%) practice in an outpatient setting. White light cystoscopy only is used by 60.2%, with additional photodynamic diagnosis and narrow band imaging by 36.8 and 12.5%, respectively. Endoscopic findings are documented in written form by 93.5%, followed by image capture (33.7%) and a central data archive (20.8%). Inpatient hospital urologists document cystoscopic findings by freehand drawing (21.4 vs. 11.4%, p = 0.017), and with a fixed bladder scheme (31.3 vs. 7.4%, <0.05) significantly more frequently. Cystoscopic findings are mainly conveyed to other health professionals in written form (77.4%), and significantly more often by inpatient urologists (p < 0.05). CONCLUSIONS: Significant differences exist in the approach to documenting and communicating cystoscopic BC findings. Accurate graphic documentation of lesions, visualization of the mucosa's totality, and meticulous consultation of previous surgical reports require improvements to reduce recurrence and progression rates.

Role of surgeon experience in the outcome of transurethral resection of bladder tumors.

PURPOSE: The purpose of the study is to assess the quality of transurethral resection of bladder tumors (TURBTs) performed by "senior" and "junior" urologists in terms of detrusor muscle (DM) presence at the initial resection and presence of missed and residual tumors at second-look TURBT. PATIENTS AND METHODS: An analytic prospective cohort study included 171 patients with stage T1 and Ta bladder cancer who had undergone an initial TURBT. Patients were divided into two groups according to surgeon experience. Group 1 (116 patients) operated on by senior surgeons (consultants and trainees in year 5 or 6) and Group 2 (55 patients) operated on by junior surgeons (trainees below year 5). All patients underwent second-look TURBT (by a senior urologist) within 2-6 weeks after the initial resection. The outcome of the initial and re-TURBT represented with regard to the surgeon experience. RESULTS: There is a statistically significant difference between senior and junior surgeons regarding the presence or absence of DM in the initial resection (P = 0.001). A significant relation between the presence of residual tumors in re thermodynamic uncertainty relation (TUR) in relation to the initial operator was found (P = 0.03). Re-TURBT of patients in Group 1 (initially operated on by experienced surgeons) revealed that 57.7% had tumor-free resection while 36.2% had residual tumors, 5.2% had missed lesion and only 0.9% had concurrent residual and missed tumors. In contrast, from Group 2 (55 patients operated by junior surgeons) 47.3% had residual tumor, 21.8% had missed lesions, and 9.1% had concurrent residual and missed tumors in re-TUR. CONCLUSIONS: Nonmuscle invasive bladder cancer treated with TURBT should be managed as any other major oncologic procedure. TURBT should be performed by an experienced surgeon or with very close supervision when done by training urologist.

Therapeutic benefit of second-look transurethral resection of bladder tumors for newly diagnosed T1 bladder cancer: a single-center experience.

PURPOSE: In recent years, second-look transurethral resection of bladder tumors (TURBT) has been recommended for patients with stage T1 bladder cancer after the initial TURBT for restaging and deciding the subsequent treatment. However, we believe that second-look TURBT has therapeutic benefits, such as low incidence of recurrence and progression. Therefore, we compare the differences in long-term outcome between patients who did and did not accept second-look TURBT for stage T1 bladder cancer. METHODS: We assessed 504 patients diagnosed with urothelial carcinoma who underwent initial TURBT between January 2012 and December 2016 at a single medical center; of these patients, 177 were diagnosed with T1 bladder cancer during the initial TURBT, and we excluded no muscle from the specimen in the initial TURBT. The patients were categorized into groups 1 and 2 based on the acceptance of second-look TURBT, which was performed within 4-14 weeks after the initial TURBT. Group 1 underwent second-look TURBT, but group 2 did not. Both groups were followed-up for recurrence-free survival (RFS) and progression-free survival (PFS), and the risk factors for recurrence and progression were analyzed. RESULTS: In total, 93 (52.5%) patients in group 1 underwent second-look TURBT, and 84 (47.5%) in group 2 did not. The 2-year RFS rates were 74.6% and 60.0% and the PFS rates were 91.2% and 87.5% in groups 1 and 2, respectively. CONCLUSION: This study demonstrated higher recurrence-free and progression-free survival rates for patients who underwent second-look TURBT. This result emphasizes the importance of second-look TURBT in stage T1 bladder cancer not only for restaging but also for therapeutic benefit.

The risk factors of urinary tract infection after transurethral resection of bladder tumors.

PURPOSE: Few studies mention the necessity of antimicrobial prophylaxis (AMP) for transurethral resection of bladder tumor (TURBT) and the risk factors for postoperative urinary tract infections (UTIs) after TURBT. To evaluate the necessity of AMP and to detect the risk of UTIs, we examined the perioperative clinical factors. METHODS: 687 patients who underwent TURBT between 2006 and 2017 at Hiroshima Prefectural Hospital were examined retrospectively. We defined the postoperative UTIs as febrile UTIs (≥ 38 °C). The AMP for the TURBT that we used was mostly cephalosporin generation 1. The association between the perioperative clinical/pathological factors and postoperative UTIs was assessed by logistic regression retrospectively. RESULTS: 21 patients (3.1%) suffered from postoperative UTIs, and almost all of them were successfully treated with the immediate administration of antibiotics. Univariate analysis showed that past pelvic radiotherapy (p = 0.024, odds ratio (OR) 6.00), tumor size (≥ 2cm) (p = 0.008, OR 3.38), age (≥ 75 years) (p = 0.036, OR 2.65), preoperative hospital stay (≥ 5 days) (p = 0.017, OR 3.76), asymptomatic pyuria (p = 0.038, OR 2.54) and bacteriuria (p = 0.044, OR 2.97) were all associated with postoperative UTIs. CONCLUSIONS: We demonstrated that AMP was effective for patients who underwent TURBT, and history of pelvic radiotherapy, high age, preoperative hospital stay and a certain tumor size were the risk factors as well as pyuria and bacteriuria of postoperative UTIs.

Meta-analysis of efficacy and safety of continuous saline bladder irrigation compared with intravesical chemotherapy after transurethral resection of bladder tumors.

PURPOSE: We performed a meta-analysis to confirm the efficacy and safety of continuous saline bladder irrigation compared with intravesical chemotherapy after transurethral resection for the treatment of non-muscle invasive bladder cancer. METHODS: Randomized controlled trials of continuous saline bladder irrigation compared with intravesical chemotherapy were searched using MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. The data were evaluated and statistically analyzed using RevMan version 5.3.0. RESULTS: Four studies including 861 participants which compared continuous saline bladder irrigation with intravesical chemotherapy were considered. One-year recurrence-free survival [odds ratio (OR) = 0.76, 95% CI = 0.55-1.05, p = 0.09]; 2-year recurrence-free survival (OR = 0.94, 95% CI = 0.71-1.25, p = 0.68); the median period to first recurrence (OR = - 1.01, 95% CI = - 2.96 to 0.94, p = 0.31); the number of tumor progression (OR = 0.80, 95% CI = 0.54-1.17, p = 0.25); and the number of recurrence during follow-up (OR = 1.12, 95% CI = 0.84-1.50, p = 0.43) suggested that two methods of postoperative perfusion had no significant differences. In terms of safety, including macrohematuria, frequency of urination and bladder irritation symptoms, continuous saline bladder irrigation showed better tolerance than intravesical chemotherapy. CONCLUSION: Continuous saline bladder irrigation seems to provide a better balance between prevention of recurrence and local toxicities than intravesical chemotherapy after transurethral resection of bladder tumors.

Transurethral Resection of Bladder Tumors: Next-generation Virtual Reality Training for Surgeons.

BACKGROUND: The number of virtual reality (VR) simulators is increasing. The aim of this prospective trial was to determine the benefit of VR cystoscopy (UC) and transurethral bladder tumor resection (TURBT) training in students. DESIGN, SETTING, AND PARTICIPANTS: Medical students without endoscopic experience (n=51, median age=25 yr, median 4th academic year) were prospectively randomized into groups A and B. After an initial VR-UC and VR-TURBT task, group A (n=25) underwent a video-based tutorial by a skilled expert. Group B (n=26) was trained using a VR training program (Uro-Trainer). Following the training, every participant performed a final VR-UC and VR-TURBT task. Performance indicators were recorded via the simulator. Data was analyzed by Mann-Whitney U test. INTERVENTION: VR cystoscopy and TURBT. RESULTS AND LIMITATIONS: No baseline and post-training differences were found for VR-UC between groups. During baseline, VR-TURBT group A showed higher inspected bladder surface than group B (56% vs 73%, p=0.03). Subgroup analysis detected differences related to sex before training (male: 31.2% decreased procedure time; 38.1% decreased resectoscope movement; p=0.02). After training, significant differences in procedure time (3.9min vs 2.7min, p=0.007), resectoscope movement (857mm vs 529mm, p=0.005), and accidental bladder injury (n=3.0 vs n=0.88, p=0.003) were found. Male participants showed reduced blood loss (males: 3.92ml vs females: 10.12ml; p=0.03) after training. CONCLUSIONS: Measuring endoscopic skills within a virtual environment can be done easily. Short training improved efficacy and safety of VR-TURBT. Nevertheless, transfer of improved VR performance into real world surgery needs further clarification. PATIENT SUMMARY: We investigated how students without endoscopic experience profit from simulation-based training. The safe environment and repeated simulations can improve the surgical training. It may be possible to enhance patient's safety and the training of surgeons in long term.

Ten-Year Review of Perioperative Complications After Transurethral Resection of Bladder Tumors: Analysis of Monopolar and Plasmakinetic Bipolar Cases.

OBJECTIVES: To evaluate the rate of perioperative complications after plasmakinetic bipolar and monopolar transurethral resection of bladder tumor (BTURB and MTURB). In addition, the study identifies patient and procedure characteristics associated with early complications. PATIENTS AND METHODS: Retrospective review was conducted on patients undergoing transurethral resection of bladder tumor procedures at a single institution from 2003 to 2013 to assess the 30-day complication rates associated with BTURB and MTURB. RESULTS: Four hundred twenty-seven patients met inclusion criteria and underwent 586 procedures (379 BTURB and 207 MTURB). Baseline patient demographics, tumor stage, and tumor grade were similar in BTURB and MTURB cohorts. The overall complication rate was 34.3% for MTURB and 26.7% for BTURB. The most frequent complications were acute urinary retention (AUR) 11%, hematuria 8%, and urinary tract infection (UTI) 7%. There was no statistical difference in rates of AUR, hematuria, UTI, or readmission for continuous bladder irrigation or hemostasis procedures between BTURB and MTURB cohorts. There was a trend toward lower perforation rate during BTURB (2.6% vs 5.8%). In multivariate logistic regression analysis, MTURB, male gender, and large resections were predictive of overall complications. Male gender was associated with hematuria and AUR. Large bladder tumor resection size was also associated with increased risk of overall complications and AUR. CONCLUSION: BTURB was associated with a lower risk of overall complications, but there was no difference in the rate of hematuria in the two cohorts. Male gender and large tumor size are associated with higher risk of early complications.

Effect of ultrasound-guided obturator nerve block in prevention of obturator nerve reflex in transurethral resection of bladder tumor / 临床麻醉学杂志

Objective Comparing obturator nerve reflex in different anesthesia,to investigate the incidence of obturator nerve reflex in transurethral resection of bladder tumor.Methods A total of 160 patients with lateral wall of bladder tumors were included,who required a TURBT,were randomly divided into four groups:general anesthesia group (group G),combined spinal-epidural anesthesia group (group C),combined spinal-epidural anesthesia compounding intravenous anesthesia group (group V),combined spinal-epidural anesthesia compounding obturator nerve block group (group O),n =40 in each group.The incidence of obturator nerve reflex was recorded.Results Incidence of obturator nerve reflex in group O (7.5％) was lower than in group C (32.5％,P=0.005) and group V (40.0％,P=0.001).There was no significant difference between group G (5.0％) and group O (P =0.644).Conclusion Both combined spinal-epidural anesthesia with obturator nerve block and general anesthesia can effectively prevent obturator nerve reflex.