Mathias Wolters

Current evidence for transurethral laser therapy of non-muscle invasive bladder cancer

IntroductionBladder cancer is the second most common malignancy of urologic tumors. Back in 1976, lasers were added to the endourological armetarium for bladder tumor treatment. Despite nowadays’ standard procedure for staging and treating non-muscle invasive bladder tumor by transurethral resection of bladder tumors (TURB) via a wire loop, laser resection techniques for bladder tumor came back in focus with the introduction of Ho:YAG and not to mention recently Tm:YAG lasers. This review aims to display the current evidence for these techniques.Materials and methodsThroughout April 2010, MEDLINE and the Cochrane central register of controlled trials were searched previously for the following terms: “Laser, resection, ablation, coagulation, Nd:YAG Neodym, HoYAG: Holmium, Tm:YAG Thulium and transitional carcinoma, bladder, intravesical.”ResultsEleven articles on Ho:YAG and 7 on Tm:YAG were identified. Searches by Cochrane online library resulted in no available manuscripts.ConclusionToday, Nd:YAG does not play any role in treatment of lower urinary tract transitional cell carcinoma. Ho:YAG and Tm:YAG seem to offer alternatives in the treatment of bladder cancer, but still to prove their potential in larger prospective randomized controlled studies with long-term follow-up. Future expectations will show whether en bloc resection of tumors are preferable to the traditional “incise and scatter” resection technique, in which is contrary to all oncological surgical principles. For the primary targets, here are within first-time clearance of disease, in addition to low in-fields and out-of-fields recurrence rates.

Transurethral anatomical enucleation of the prostate with Tm:YAG support (ThuLEP): review of the literature on a novel surgical approach in the management of benign prostatic enlargement

AbstractPurpose Retrograde transurethral anatomical enucleation of the prostate is gaining momentum as a new concept in transurethral surgery of benign prostatic hyperplasia. Its adaptation is boosted by the familiarity of urologists with the finger-assisted anatomical enucleation of the adenoma during open prostatectomy and the combination of this well-established concept with the minimal invasive characteristics of transurethral surgery. The thulium laser appears as an ideal energy source for such operation. In this work, current evidence on thulium laser-assisted anatomical enucleation of the prostate (ThuLEP) is being reviewed. Materials and MethodsA comprehensive literature review was performed on Medline, PubMed, and Cochrane databases retrieving all literature on thulium laser-assisted prostatectomy between 2006 and 2015. Experimental studies, review articles and editorial comments as well as studies on thulium laser-assisted approaches other than ThuLEP (i.e., ThuVEP, ThuVAP or ThuVARP) were excluded from the analysis.ResultsIn total, six original articles on either surgical technique or clinical outcomes were retrieved. With regard to functional results, ThuLEP presented no significant differences toward the standard treatment (TURP/HoLEP) arm in two randomized controlled trials and favorable outcomes in available prospective cohorts. Observed morbidity was minimum and comparable with the rest of transurethral literature.ConclusionsThuLEP literature is still very limited. Based on the available data, the approach is safe and effective, demonstrating favorable outcomes, comparable with the current standard treatment options. Further documentation of ThuLEP outcomes is necessary to define the optimum indications of this novel technique.

Current evidence for transurethral en bloc resection of non-muscle-invasive bladder cancer

Abstract Introduction : Despite todays standard procedure for staging and treating non-muscle-invasive bladder cancer by transurethral resection via a wire loop (TURBT), several other publications have dealt with a different concept of en bloc resection of bladder tumors using different energy sources. Material and methods : MEDLINE and the Cochrane central register were searched for the following terms: en bloc, mucosectomy, laser, resection, ablation, Neodym, Holmium, Thulium, transitional cell carcinoma. Results : Fourteen research articles dealing with en bloc resection of non-muscle-invasive bladder cancer could be identified (modified resection loops: six, laser: six, waterjet hydrodissection: two). Conclusion : En bloc resection of bladder tumors >1 cm can be performed safely with very low complication rates independent of the power source. By using laser, complication rates might even be decreased, based on their good hemostatic effect and by avoiding the obturator nerve reflex. A further advantage seems to be accurate pathologic staging of en bloc tumors. Randomized controlled trials are still needed to support the assumed advantages of en bloc resection over the standard TURBT with regard to primary targets: First-time clearance of disease, accurate staging and recurrence rates.

En Bloc Resection of Bladder Tumors: Ready for Prime Time?

Without doubt, the method of choice for intravesical resection of bladder tumors is conventional transurethral resection of bladder tumor (cTURBT). However, there has long been an ambition to overcome its biggest limitation, tumor fragmentation. Possible consequences include cell seeding and poor specimen quality, including missing detrusor muscle, thermal tissue damage, and tissue fragmentation. En bloc resection of bladder tumor (ERBT) represents an alternative technique for resection of intravesical tumors of >1 cm in one piece. Various studies over the last two decades have demonstrated that the method is safe and feasible, although reporting of complications was not based on the Clavien-Dindo classification in most cases [1]. Our own study group recently showed that ERBT can be performed with either laser energy or electrical current without any differences in terms of specimen quality [2]. The question has been raised as towhether ERBT is ready for guideline implementation. Apart from a multitude of retrospective cohort or comparison studies, only two prospective, randomized trials on ERBT have been published [3,4]. Both studies were performed in China, and details on statistical preparation, patient selection, and definitions of primary and secondary goals are missing. Thus, there is still an urgent need to compare ERBT with cTURBT in a thoroughly planned trial. There is no doubt that ERBT has huge potential. ERBT provides specimens of high quality that are easy for pathologists to read. In theory, this may sustainably change the view on secondary resection, lead to faster decisions on subsequent treatments, and influence patient prognosis. In addition, it has been proved that lasers such as holmium and thulium are attractive energy sources [5]. With their excellent hemostatic effect, such lasers may become the treatment of choice for patients taking anticoagulants other than aspirin. Many questions are still not answered. What are the basic requirements for ERBT suitability? How many patients are eligible? Is it possible to perform ERBT on tumors at the bladder neck? What should we do with tumors of >3 cm that cannot be extracted in one piece? Is a bag always required for tumor retrieval? Is ERBT able to influence tumor recurrence and progression? Can it lower overall costs? Two studies are currently under way that may have the power to influence our daily work. The Hybrid-Blue study compares ERBT using the HybridKnife (Erbe, Tubingen, Germany) with cTURBT. The urotechnology section of the European Association of Urology also started an initiative to provide data on ERBT. This led to the En Bloc Resection of Urothelial Carcinoma (EBRUC) project. Phase 1 provides analyses based on retrospective data and is currently ongoing [2]. Phase 2 is a European, multi-institutional, prospective, randomized study in which ERBT (laser and electrical) will be compared to cTURBT to provide robust data on the questions raised above. These two studies will either confirm our doubts or promote our enthusiasm.

Transurethral en bloc resection of nonmuscle invasive bladder cancer: trend or hype.

Purpose of review Inherent limitations of conventional transurethral resection of bladder tumors as the standard approach for diagnosis and treatment of bladder cancer are well know: staging error because of insufficient assessment of resection depth as well as intravesical tumor fragmentation that complicates histopathological evaluation. The purpose of this review is to present recent clinical data on en bloc resection of bladder tumor (ERBT) that has been demonstrated to offer high potential to overcome these limitations. Recent findings The recently published studies confirm the results our previous reviews for laser ERBT and current-based ERBT from 2014. ERBT provides a better resection quality with up to 95% presence lamina muscularis propria as surrogate marker for quality. It can be performed using all energy sources. Available data demonstrate with all due limitations of reporting quality no relevant difference with regard to perioperative morbidity compared with conventional transurethral resection of bladder tumors. No conclusions can be drawn regarding the impact of ERBT on recurrence as data are controversial. Summary ERBT has gained momentum in the past years. The hypothesized advantages over conventional TURBT seem to manifestate for tumors up to 3 or 4 cm in size with regard to staging, specimen quality, and analyzability in pathological evaluation in general. The impact on recurrence remains to be defined by further studies.

Deep Surgical Site Infections after Open Radical Cystectomy and Urinary Diversion Significantly Increase Hospitalisation Time and Total Treatment Costs.

Introduction: Deep surgical site infections (DSSI) usually require secondary treatments. The aim of this study was to compare the total length of hospitalisation (LOH), intensive care unit (ICU) duration, and total treatment costs in patients with DSSI versus without DSSI after open radical cystectomy (ORC) and urinary diversion. Material and Methods: Prospective case-control study in a tertiary care hospital in patients after ORC with urinary diversion during April 2008 to July 2012. DSSI was defined based on Centers for Disease Control and Prevention criteria. Matched-pair analysis for patients with versus without DSSI was done in 1:2 ratios. Patients with superficial surgical site infections (SSI) were excluded from analysis. Results: In total, 189 operations were performed. Thirty-eight patients (20.1%) developed SSI of which 28 patients (14.8%) had DSSI. Out of 28 patients, 27 (96.4%) were with DSSI and required surgical re-intervention. Due to insufficient matching criteria, 11 patients with DSSI were excluded from analyses. Consequently, 17 patients with DSSI were matched with 34 patients without DSSI. Significant differences were seen for median overall LOH (30 vs. 18 days, p < 0.001), median ICU duration (p = 0.024), and median overall treatment costs (€17,030 vs. €11,402, p = 0.011). Conclusions: DSSI significantly increases LOH (67%) and treatment costs (49%), adding up to a financial loss for the hospital of approximately €5,500 in patients with DSSI.

Development of a clinical algorithm for treating urethral strictures based on a large retrospective single-center cohort

Aim: To analyze clinical data from male patients treated with urethrotomy and to develop a clinical decision algorithm. Materials and methods: Two large cohorts of male patients with urethral strictures were included in this retrospective study, historical (1985-1995, n=491) and modern cohorts (1996-2006, n=470). All patients were treated with repeated internal urethrotomies (up to 9 sessions). Clinical outcomes were analyzed and systemized as a clinical decision algorithm. Results: The overall recurrence rates after the first urethrotomy were 32.4% and 23% in the historical and modern cohorts, respectively. In many patients, the second procedure was also effective with the third procedure also feasible in selected patients. The strictures with a length ≤ 2 cm should be treated according to the initial length. In patients with strictures ≤ 1 cm, the second session could be recommended in all patients, but not with penile strictures, strictures related to transurethral operations or for patients who were 31-50 years of age. The third session could be effective in selected cases of idiopathic bulbar strictures. For strictures with a length of 1-2 cm, a second operation is possible for the solitary low-grade bulbar strictures, given that the age is > 50 years and the etiology is not post-transurethral resection of the prostate. For penile strictures that are 1-2 cm, urethrotomy could be attempted in solitary but not in high-grade strictures. Conclusions: We present data on the treatment of urethral strictures with urethrotomy from a single center. Based on the analysis, a clinical decision algorithm was suggested, which could be a reliable basis for everyday clinical practice.

Laser versus electrical en bloc resection of bladder tumors: Results of a European multicenter study (EBRUC).

310 Background: The quality of transurethral resection of bladder tumors strongly determines patient’s tumor after-care and prognosis. En bloc resection of bladder tumors (ERBT) might improve staging quality, perioperative morbidity and influence tumor recurrence. This is the first European multi-center study which was initiated by ESUT and was conducted to evaluate the safety, efficacy and recurrence rates of electrical vs. laser ERBT. Methods: Transurethral ERBT was performed on 221 prospectively collected patients in six academic centers with either monopolar/bipolar current or holmium/thulium laser energy. Staging quality measured by detrusor muscle involvement, various perioperative/surgical parameters and 12 months follow-up data were analyzed. Results: 156 and 65 patients were treated with electrical and laser ERBT, respectively. Median tumor size was 2.1 cm with biggest up to 5 cm. Detrusor muscle was available in 97.3%. A switch to conventional TURBT was significantly more frequent in the electri...

Adenocarcinoma of the urinary bladder, mesonephroid type: a rare case

Primary adenocarcinoma of the urinary bladder is a rare disease. It occurs in 0.5–2% of all bladder cancers and is discussed as the malignant counterpart of nephrogenic adenomas. We report a 46-year-old white female presented with gross hematuria for clinical examination. Histopathology revealed pT2, Pn1, L1, G2 adenocarcinoma of the bladder and carcinoma in situ according to the TNM classification. Computed tomography scan diagnostic was unremarkable. Patients with adenocarcinoma of the urinary bladder should be treated vigorously and without time delay. Only 7 cases of adenocarcinoma in the urinary bladder (mesonephroid) have been described until now. We present a case of clear cell adenocarcinoma of the urinary bladder, mesonephroid type that early diagnosed and till now 3 months after the cystectomy without symptoms and without complications.