V8-07: En bloc bladder tumor resection: back to oncologic basics

Video

Introductions and Objectives
Fundamental oncologic surgical principles dictate en bloc excision of a tumor with a margin of normal tissue. Conventional piecemeal TURBT is the accepted standard of care for bladder cancer diagnosis and treatment of non-invasive tumors but does not adhere to this basic tenant. In this video we describe currently available techniques in en bloc TURBT.

Methods
In this educational video we review our experiences with transurethral en bloc resection of bladder tumors using monopolar and bipolar electro-resection, holmium and thulium lasers, and the Hybrid Knife.

Results
En bloc bladder tumor resections produce whole specimens ideal for pathological assessment of tumor depth and staging. Unlike piecemeal resections, the en bloc technique also allows the pathologist to determine tumor margin status. Some series have shown a reduction in tumor recurrence rates and prolonged recurrence free survival; however, progression rates remain unchanged. _x000D_ Modified monopolar resection loops with a single electrode have been fashioned for circumferential tumor excision and undermining. Similarly, the bipolar Collins knife can be used in this fashion with saline irrigation and a reduction in obturator reflex and perforation risk. _x000D_ Holmium and thulium laser en bloc excision are also performed with saline irrigation but eliminate obturator reflex completely and minimize perforation risk. Randomized studies have shown excellent specimen quality with muscle in all submitted tissue. _x000D_ The Hybrid Knife translates techniques used in endoscopic excision of localized colon tumors to the bladder. There is an initial hydro-dissection of the tumor and submucosa off of deeper bladder muscle prior to the circumferential electrodissection of the tumor from the bladder wall. The submucosal water cushion minimizes perforation risk and cautery artifact. Studies have shown excellent preservation of tissue architecture and depth of excision for tumor staging.

Conclusions
Transurethral en bloc bladder tumor excision adheres to the principles of cancer surgery by removing the tumor and a margin of normal tissue. Several readily available technologies are adaptable to en bloc excision while newer modalities are being investigated. With its potential oncologic benefits and enhanced patient safety, en bloc excision should be more widely used in the treatment of non-invasive bladder cancer.

Funding: None