BACKGROUND: Urologic guidelines recommend perioperative instillation of chemotherapy after transurethral resection of bladder tumor (TURBT) to decrease tumor recurrence, yet implementation of this recommendation is partial due to associated morbidity. Hypertonic saline destroys cells by osmotic dehydration and might present a safer alternative.
OBJECTIVE: To evaluate the safety of 3% hypertonic saline (Hypersal) intravesical instillation following TURBT in rats and in humans.
METHODS: In 8 rats whose bladders were electrically injured, intravesical blue-dyed Hypersal was administered. We measured serum sodium levels before and after instillation and pathologically evaluated their pelvic cavity for signs of inflammation or blue discoloration. Twenty-four patients were recruited to the human trial (NIH-NCT04147182), 15 comprised the interventional and 10 the control group (one patient crossed over). Hypersal was given postoperatively. Serum sodium was measured before, 1 hour and 12-24 hours after instillation. Adverse effects were documented and compared between the groups.
RESULTS: In rats, average sodium levels were 140.0 mEq/L and 140.3 mEq/L before and following instillation, respectively. Necropsy revealed no signs of inflammation or blue discoloration. In humans the average plasma sodium levels were 138.6 mEq∖L, 138.8 mEq∖L and 137.7 mEq∖L before, 1 hour and 12-24 hours after instillation, respectively. During the postoperative follow-up there was one case of fever. A month after the surgery, dysuria was reported by 5 patients while urgency and hematuria were reported by one patient each. The most severe adverse events were grade 2 on the Clavien-Dindo scale. Adverse events were similar in the control group.
CONCLUSIONS: Hypersal instillation is safe and tolerable immediately after TURBT.

OBJECTIVE: To evaluate the possibility of performing transurethral carboxycryobiopsy (CCB) and carboxycryoextraction (CCE) of a bladder tumor for pathomorphological examination, as well as to perform a comparative analysis of the safety (quality) of biopsy material (tumor tissue) during standard transurethral biopsy and carboxycryobiopsy.
METHODS: In the first experiment in vitro, CCE of bladder tumor fragments obtained after transurethral resection was performed. In the second pilot study, cystoscopy followed by CCB and CCE in a patient with multiple bladder tumors was done. The procedure was performed by transurethral access. During cryopreservation of the bladder tumor, a biopsy was performed. After freezing, the tumor was removed from the bladder and sent for histological examination.
RESULTS: The first experiment showed that cryoextraction of the fragments of a bladder tumor using carbon dioxide (CCE) in vitro is a feasible procedure and allows the evacuation of tumor tissues of various sizes. According to the second experiment, CCB and CCE of the bladder tumor using carbon dioxide allows to obtain a biopsy of a bladder tumor of sufficient size without compression or coagulation artifacts, which contributes to a more accurate histological evaluation.
CONCLUSIONS: Our experiments showed that CCB and CCE of a bladder tumor using carbon dioxide are feasible procedures that contribute to obtaining better biopsy material for pathomorphological examination, and also allows to evaluate the effect of low temperatures of carbon dioxide on the biopsy material (tumor tissue).

UNASSIGNED: Synthetic magnetic resonance imaging (MRI) can provide quantitative information about inherent tissue properties and synthesize tailored contrast-weighted images simultaneously in a single scan. This study aimed to investigate the clinical feasibility of synthetic MRI in bladder tumors.
UNASSIGNED: A total of 47 patients (37 males; mean age: 66±10 years old) with postoperative pathology-confirmed papillary urothelial neoplasms of the bladder were enrolled in this retrospective study. A 2-dimensional (2D) multi-dynamic multi-echo pulse sequence was performed for synthetic MRI at 3T. The overall image quality, lesion conspicuity, contrast resolution, resolution of subtle anatomic structures, motion artifact, blurring, and graininess of images were subjectively evaluated by 2 radiologists independently using a 5-point Likert scale for qualitative analysis. The signal intensity ratio (SIR), signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were measured for quantitative analysis. Linear weighted Kappa, Wilcoxon\'s signed-rank test, and the Mann-Whitney U-test were used for statistical analysis.
UNASSIGNED: The interobserver consistency was excellent (κ values: 0.607-1). Synthetic T1-weighted (syn-T1w) and synthetic T2-weighted (syn-T2w) images obtained scores of 4 in most subjective terms, which were relatively smaller than those of conventional images. The SIR and SNR of syn-T1w were significantly higher than those of con-T1w images (SIR 2.37±0.86 vs. 1.47±0.20, P<0.001; SNR 21.83±9.43 vs. 14.81±3.30, P<0.001). No difference was found in SIR between syn-T2w and conventional T2-weighted (con-T2w) images, whereas the SNR of the syn-T2w was significantly lower (8.79±4.06 vs. 26.49±6.80, P<0.001). Additionally, the CNR of synthetic images was significantly lower than that of conventional images (T1w 1.41±0.72 vs. 2.68±1.04; T2w 1.40±0.87 vs. 4.03±1.55, all P<0.001).
UNASSIGNED: Synthetic MRI generates morphologic magnetic resonance (MR) images with diagnostically acceptable image quality in bladder tumors, especially T1-weighted images with high image contrast of tumors relative to urine. Further technological improvements are needed for synthetic MRI to reduce noise. Combined with T1, T2, and proton density (PD) quantitative data, synthetic MRI has potential for clinical application in bladder tumors.

UNASSIGNED: Vesical Imaging Reporting and Data System (VIRADS) score was developed to standardize the reporting and staging of bladder tumors on pre-operative multiparametric magnetic resonance imaging. It helps in avoiding unnecessary repeat transurethral resection of bladder tumor in high-risk non-muscle-invasive bladder cancer patients. This study was done to determine the validity of VIRADS score prospectively for the diagnosis of muscle-invasive bladder cancer.
UNASSIGNED: This study was conducted from March 2019 to March 2020 at Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan, India. Patients admitted with the provisional diagnosis of bladder tumor were included as participants. All these patients underwent a 3 Tesla mpMRI to obtain a VIRADS score before they underwent transurethral resection of bladder tumor and these data were analyzed to evaluate the correlation of pre-operative VIRADS score with muscle invasiveness of the tumor in final biopsy report.
UNASSIGNED: A cut-off of VIRADS ≥4 for prediction of detrusor muscle invasion yielded a sensitivity of 79.4%, specificity of 94.2%, positive predictive value of 90.0%, negative predictive value of 87.5%, and diagnostic accuracy of 86.4%. A cut off of VIRADS ≥3 for prediction of detrusor muscle invasion yielded a sensitivity of 91.2%, specificity of 78.8%, positive predictive value of 73.8%, negative predictive value of 93.2%, and accuracy of 83.7%. The receiver operating curve showed the area under the curve to be 0.922 (95% confidence interval: 0.862-0.983).
UNASSIGNED: VIRADS score appears to be an excellent and effective pre-operative radiological tool for the prediction of detrusor muscle invasion in bladder cancer.

Background The majority of bladder cancer patients are elderly and have various comorbidities, increasing the risk of complications following general anesthesia. Spinal anesthesia with a selective obturator nerve block (ONB) is an alternative to general anesthesia for transurethral resection of bladder tumor (TURBT); however, incomplete ONB can cause adductor muscle spasm. The objective of this study was to assess if the ultrasound-guided interfascial injection approach is compatible with the blind nerve stimulating technique for ONB in bladder cancers undergoing TURBT. Methodology A total of 50 ONBs were performed for TURBTs under spinal anesthesia and were divided into two groups, that is, ONB with nerve stimulation control group (group RD1) and an experimental ultrasound-guided interfascial injection group (group RD2). During TURBT surgeries, one urology assistant determined obturator reflex grade (I-IV) at 15 minutes after injection completion in both groups. Results A success rate of 88% was achieved in group RD1 compared to 76% in group RD2, which was clinically significant. Three cases failed to achieve complete ONB in group RD1, and six cases in group RD2 failed to achieve complete ONB. One case in group RD1 and two cases in group RD2 exhibited grade II obturator re-flex during the surgery. Conclusions Ultrasound-guided interfascial injection approach was inferior to the ultrasound-guided nerve stimulating technique for ONB at the inguinal crease; hence, we recommend using both ultrasound and nerve stimulators for ONB.

Prediction of recurrence and progression and the choice of type of management are largely based on stage and grade; however, these prognostic features are limited in the prediction of clinical outcomes. The objective was to investigate the relation between the apparent diffusion coefficient (ADC) value and recurrence and progression of T1G3 of urothelial carcinoma after transurethral resection of the bladder tumor (TURBT) and Bacillus Calmette-Guérin instillation.
This prospective study included 65 patients with single bladder mass T1G3 less than 3 cm without carcinoma in situ or lymphovascular invasion. Mean ADC values of the tumors were compared between patients with and without recurrence and progression following TURBT. The relation of ADC value and other factors were determined by univariate and multivariate analyses. The following tests were used to test differences for significance: difference and association of qualitative variable by χ2 test; differences between quantitative independent groups by t-test or Mann-Whitney U test; survival by Kaplan-Meier; Cox regression (or Cox proportional hazards model) was used to analyze the effect of several risk factors on time until event (recurrence and progression); correlation by Pearson or Spearman, and we calculated the most suitable cutoff and validity by receiver operating characteristic curve.
In relation to recurrence, smoking, nonpapillary shape and higher size, and lower ADC were significant predictors for recurrence. In relation to progression, female sex, nonpapillary shape, and lower ADC were significant predictors for progression. Multivariate analysis showed that ADC < 1.09 was the only significant independent predictors for recurrence. Also, it showed that ADC < 0.98 was the only significant independent predictors for progression.
Low ADC value group of T1G3 bladder cancer showed significant recurrence and progression than high ADC value group of T1G3 bladder cancer. ADC value in conjunction with other risk stratifications will have a promising role in stratifying patients with T1G3 who need to proceed to early radical cystectomy versus conservative treatment.

BACKGROUND: En-bloc resection of bladder tumors achieves complete tumor removal, improves the quality of resection, decreases perioperative complication, and potentially improves recurrence rates.
OBJECTIVE: To assess the efficacy and safety of holmium laser en-bloc resection (HolERBT) versus conventional transurethral resection of bladder tumor (cTURBT).
METHODS: Between September 2015 and September 2018, 100 patients with non-muscle-invasive bladder cancer were randomly allocated to cTURBT or HolERBT.
UNASSIGNED: The primary endpoint was detection of residual tumor in reTURBT specimens at 4 wk after the primary resection. Operative parameters, specimen quality, perioperative complications, and recurrence-free survival (RFS) were compared. Independent sample t tests, χ2 tests, and Kaplan-Meier curves were used, as appropriate.
CONCLUSIONS: The patient and tumor baseline characteristics were comparable between the groups. Residual tumors were detected in 7% and 27.7% of cases after HolERBT and cTURBT, respectively (p=0.01). Detrusor muscle was sampled in 98% of HolERBT and 62% of cTURBT cases (p<0.001). Lamina propria invasion substaging was feasible in only 68.2% of HolERBT and 18.4% of cTURBT cases (p<0.001). Following HolERBT, catheterization time (p<0.001) and hospital stay (p=0.001) were shorter when compared to cTURBT. Immediate postoperative instillation of chemotherapy in indicated cases was feasible for 100% of the HolERBT group and 91.5% of the cTURBT group (p=0.04). After follow-up of 20 ± 9.9 mo (13-36), RFS was 31.76 mo (95% confidence interval [CI] 28.67-34.86) in the HolERBT group and 28.25 mo (95% CI 24.87-31.64) in the cTURBT group (hazard ratio 0.43, 95% CI 0.17-1.1; p=0.07). However, this study was not powered to detect a difference in RFS.
CONCLUSIONS: Compared to cTURBT, HolERBT is a safer procedure for bladder tumor resection. It fulfills the oncological criteria of optimized resection with less residual tumor and better specimen quality.
UNASSIGNED: En-bloc resection of bladder cancer tumors using a holmium laser is safer than the conventional technique. It has the advantages of less residual tumor and better specimen quality, with a similar tumor recurrence rate. This study is registered at ClinicalTrials.gov as NCT02555163.

OBJECTIVE: To investigate the effect of NBI assisted white light transurethral resection of bladder tumor (TURBT) in the treatment of bladder urothelial carcinoma and to summarize the experience of narrow band imaging (NBI) operation.
METHODS: Patients with bladder urothelial carcinoma were selected, and TURBT was performed after anesthesia. First of all, the bladder tumor was found and resected under white light. Then we replaced with NBI, looked for suspicious lesions and resected them, The specimens excised under white light and NBI were collected separately. The number, location and pathological results of the lesions under white light were recorded, and the residual lesions under NBI were also recorded. To evaluate the effect of NBI, the ratio of residual bladder tumor was calculated. The cases were divided into three groups according to the time sequence. The clinical data of each group were collected and the learning curve of TURBT under NBI assisted white light was observed.
RESULTS: A prospective study of 45 patients with bladder tumor from April 2018 to January 2020, including 32 males and 13 females, aged from 23 to 89 years, with an average age of 65.2 years. All the operations were successfully completed, without obvious complications after operation. Nine cases were single and 36 cases were multiple. The maximum diameter of the tumors was 0.5 to 4.0 cm, with an average of 2.2 cm. The histopathology of the resected tissue under white light was urothelial carcinoma, and 19 cases (42.2%) were pathologically positive by NBI resection. The 45 cases were divided into three groups according to the time sequence, 15 cases in each group. The true positive rate of NBI was 33.3%, 46.7% and 46.7%, respectively, and the false positive rate was 60.0%, 46.7% and 26.7%, respectively in the three groups.
CONCLUSIONS: TURBT is an effective way to treat bladder urothelial cancer, NBI is an effective supplement of white light, which can increase the detection rate of bladder cancer and reduce post-operative recurrence. The NBI light source has a certain learning curve. With the increase of cases, the false-positive rate of NBI is gradually reduced. After the NBI operator has rich experience, the recognition degree of flat tumor is gradually improved under white light, and the residual rate of NBI is reduced after the removal under white light.

BACKGROUND: Endoscopic urological procedures (transurethral resection of the prostate TURP/transurethral resection of bladder tumor TURBT) are not without risk of significant bleeding. This risk is due to the vascular nature of the tissues and their high levels of fibrinolytic enzymes in the tissues and urine. This study was conducted to evaluate the safety and efficacy of the antifibrinolytic agent tranexamic acid (TXA) in reducing blood loss in patients undergoing TURP/TURBT and transfusion requirement.
METHODS: This study was a prospective, randomized, double-blind, placebo controlled clinical trial. One hundred and thirty-one patients of ASA physical status I or II, undergoing TURP (60 patients) or TURBT (71 patients) were randomly allocated to receive IV TXA: bolus of 10mg/kg at the induction of anesthesia followed by infusion of 1mg/kg/h intraoperatively and for 24h postoperatively or an equal volume of saline (control group). Blood loss was evaluated in terms of reduction in the serum hemoglobin level (delta Hb=Hb H24-Hb H0).
RESULTS: There was no difference between two groups in terms of transfusion requirements and episodes of retention. TXA did not significantly reduce mean blood loss compared with placebo during TURP (1.37±0.69 vs. 1.72±1.23g/dL respectively, P=0.256) or TURBT (1.15±0.95 vs. 1.07±0.88g/dL; P=0.532). No thrombotic complications were noted in any patient.
CONCLUSIONS: Tranexamic acid did not reduce transfusion requirements or perioperative blood loss in transurethral resection of the prostate or bladder tumor.
METHODS: 4.

OBJECTIVE: The primary aim of the study was to evaluate the safety and efficacy of bipolar energy in resecting bladder tumors.
METHODS: The study was done between March 2012 and February 2013. This is a prospective quasi-randomized study evaluating the safety and efficacy of bipolar energy in transurethral resection of bladder tumours (TURBT). Institutional Ethics Committee approval was obtained. Informed consent was taken from all patients. Patients were randomized into two groups of 50 each to undergo either monopolar TURBT or bipolar TURBT using glycine and saline irrigation solutions, respectively.
RESULTS: Most important of all, the means of variables were compared between the two energy sources to know the difference between them and its significance. Hematocrit level, resection time and obturator jerks had significant values.
CONCLUSIONS: The results of this study indicated that bipolar resection of bladder tumours have lower incidence of complications especially bleeding, TUR syndrome, obturator jerks and bladder perforation. Bipolar TURBT is safe and efficacious in managing bladder tumours.