Speaker: Badrinath Konety, United States
Important Takeaways
-
Benefits of En Bloc Resection: Offers better sampling of detrusor muscle, reduces bladder perforation rates, and improves specimen integrity, potentially lowering the need for a second TURBT.
-
Challenges: Limited suitability for large tumours (>3 cm) due to removal difficulties; ideal for smaller tumours (1–3 cm) and intermediate-risk cases.
-
Impact on Recurrence Rates: No clear reduction in recurrence observed in randomized trials compared to standard TURBT, though en bloc resection results in fewer operator-related complications, such as bladder perforation.
-
Techniques: Can be performed using bipolar loops, lasers (holmium, thulium), or hot knives, with the goal of intact tumour removal without fragmentation.
-
Ideal Candidates: Best suited for small, papillary tumours; intermediate-risk patients benefit most, while high-risk cases may still require standard TURBT.
Key Highlights
Key Objectives of TURBT:
The objectives of TURBT include complete tumour resection with detrusor muscle in the specimen, minimal bleeding, and avoiding bladder perforation. A key concern during standard TURBT is tumour fragmentation, which may increase recurrence risks. En bloc resection addresses this by removing the tumour in one piece, ensuring no fragments are left behind.
Techniques for En Bloc Resection:
Dr. Konety showcased a video of a 2.5 cm tumour removed en bloc using a bipolar loop. While the technique is not particularly complex, challenges arise with larger tumours requiring morcellation or other extraction techniques to avoid fragmentation.
Randomised Trials and Recurrence Rates:
Multiple trials have compared en bloc resection with standard TURBT, focusing on outcomes like recurrence rates and detrusor muscle sampling. While en bloc resection achieved a 10% improvement in detrusor muscle sampling, no significant difference in recurrence-free survival was found over 12 to 24 months. However, en bloc resection showed lower rates of bladder perforation and reflux, suggesting fewer technical complications.
Recent Study and Ideal Candidates:
Dr. Konety talked about a 2023 multi-institutional study from Hong Kong which reported a 9% improvement in recurrence-free survival with en bloc resection, though it fell short of statistical significance. Small tumours (1–3 cm) and intermediate-risk cases benefited most from en bloc resection, while high-risk tumours saw no significant advantage. Standard TURBT remains preferable for larger tumours or those with complex anatomy.
Key Considerations:
Dr. Konety reiterated that while en bloc resection offers better specimen quality and fewer perforations, it poses challenges for sessile tumours or those near sensitive areas like the ureteral orifice. Extraction of large specimens also requires careful handling to prevent fragmentation.
Conclusion:
Dr. Konety concluded that En bloc TURBT, performed with various energy sources, is effective for tumors ≤3 cm, offering comparable muscle sampling to standard TURBT, with potential benefits like reduced residual tumor, lower recurrence, fewer bladder perforations, and improved pathological evaluation, though it does not impact progression; however, specimen extraction can be challenging.
Société Internationale d'Urologie Congress, 23-26 October 2024, New Delhi, India.
