Thulium laser: the new kid ‘en bloc’
Reviewed by Hamid Abboudi

Transurethral resection of bladder tumour (TURBT) is considered the gold standard for management of bladder cancer. Residual rates of 15-53% at second TURB and upstaging rates of 4-29% with muscle invasion have been reported. The quality and result of the initial TURBT strongly determine the patient’s prognosis. The authors here aimed to evaluate if thulium laser en bloc enucleation of bladder tumour (THuLEBT) offers any advantage over monopolar resection of non muscle invasive bladder cancer (NMIBC) without increasing complications. Fifty-eight patients (group A) with a single papillary bladder tumour more than 1cm diameter were prospectively recruited to undergo ThuLEBT. A similar cohort of patients who underwent traditional TURBT (group B) by the same surgeon was used to compare the two procedures. Re-resection and cold cup biopsy of the tumour base were negative for bladder cancer persistence or recurrence in all patients with NMIBC treated with ThuLEBT. In-group B, seven patients were found with disease persistence. In eight cases of TURBT patients, no muscle was identified while in all cases of ThuLEBT muscle was identified. At mean follow-up of 20 months the authors identified recurrences in 20.6% of patients; however, all recurrences were away from the primary resection site. In the ThuLEBT group there was no documented obturator kick, no bladder perforation, no significant intraoperative bleeding or postoperative bleeding. The potential advantages for en bloc enucleation include: more accurate reporting of depth invasion, less charring and thermal damage to tissue and less bleeding. The drawbacks to en bloc include: tumour size and location; however, group A included eight cases around the ureteral orifice and 12 on the bladder dome, with no associated injuries to the ureter or bladder with a mean tumour diameter of 2.5cm. Despite there being no statistically significant differences in recurrence rate between the two groups and the small case numbers in this study, the findings are promising. 

Thulium laser endoscopic en bloc enucleation of non muscle-invasive bladder cancer.
Migliari R, Buffardi A, Ghabin H.
JOURNAL OF ENDOUROLOGY
2015;29(11):1258-62.