Die En bloc-Resektion von Blasentumoren (ERBT) – eine Bestandsaufnahme

Zusammenfassung

Hintergrund Als Limitationen der konventionellen transurethralen Resektion von Harnblasentumoren (cTURB) als Standardverfahren zur Detektion und Behandlung von nicht muskelinvasivem Blasenkrebs (NMIBC) sind Stagingfehler aufgrund unzureichender Resektionstiefe ebenso wie die intravesikale Fragmentierung der Proben, die eine histopathologische Begutachtung erschweren, bekannt. Diese Übersichtsarbeit soll die aktuelle Datenlage zur En bloc-Resektion von Harnblasentumoren (ERBT) beleuchten und das große Potenzial der Technik hervorheben.

Patienten/Material und Methoden Auswertung der relevanten, PubMed-gelisteten Originalartikel, Übersichtsarbeiten und Metaanalysen zu den Suchbegriffen „bladder cancer” und „en bloc”.

Ergebnisse Die ERBT bietet eine durchgängig hochwertige Resektionsqualität mit wechselnden Nachweisraten von Tunica muscularis in den Resektionsproben. Diese ist der Surrogatmarker der Resektionsqualität in Hinblick auf muskelinvasive Tumoren. Die ERBT kann mit allen Energiequellen, auch in Kombination (Hybridverfahren), sicher durchgeführt werden. Die aktuellen Daten zeigen, dass kein signifikanter Unterschied in Bezug auf die perioperative Morbidität im Vergleich zur cTURB besteht. In Bezug auf die Rezidivraten kann noch keine abschließende Beurteilung getroffen werden, da hier die Datenlage zum Teil kontrovers ist.

Schlussfolgerung Die ERBT hat in den letzten Jahren an Bedeutung gewonnen. Die vermuteten Vorteile gegenüber der cTURB wie bessere Probenqualität und bessere histopathologische Beurteilbarkeit und damit verbessertes Staging scheinen sich für Tumoren mit einer Größe bis zu 4 cm zu bestätigen. Die Auswirkungen auf die Tumorrezidivrate bleibt Gegenstand zukünftiger Studien auf diesem Gebiet.

Abstract

Limitations inherent in the conventional transurethral resection of bladder tumours, the standard approach for diagnosis and treatment of bladder cancer, are well known: staging errors due to insufficient resection depth as well as intravesical tumour fragmentation, both of which make histopathological evaluation difficult. The purpose of this review is to present recent clinical data on the en-bloc resection of bladder tumours (ERBT), which has been demonstrated to offer a high potential to overcome these limitations. The recent findings show that ERBT provides a good resection quality with varying detection rates for tunica muscularis, which is a surrogate marker for resection quality regarding muscle-invasive tumours. ERBT can be performed using all energy sources. Available data show no relevant difference with regard to perioperative morbidity compared with cTURB. No conclusions can be drawn regarding the impact of ERBT on recurrence as the data are partly controversial. This has to be defined by further studies.

Schlüsselwörter

Harnblasenkrebs - En bloc Resektion - Laser - transurethrale Resektion - Blasentumor

Keywords

bladder cancer - bladder carcinoma - en-bloc resection of bladder tumour - laser - transurethral resection - bladder tumour

^* Im Namen des EBRUC-(En Bloc Resection of Urothelial Cancer) Konsortiums

• Literatur

• 1 Ploeg M, Aben KK, Kiemeney LA. The present and future burden of urinary bladder cancer in the world. World J Urol 2009; 27: 289-293
• 2 Leal J, Luengo-Fernandez R, Sullivan R. et al. Economic Burden of Bladder Cancer Across the European Union. Eur Urol 2016; 69: 438-447
• 3 Burger M, Catto JW, Dalbagni G. et al. Epidemiology and risk factors of urothelial bladder cancer. Eur Urol 2013; 63: 234-241
• 4 Alfred WitjesJ, Lebret T, Comperat EM. et al. Updated 2016 EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer. Eur Urol 2017; 71: 462-475
• 5 Babjuk M, Bohle A, Burger M. et al. EAU Guidelines on Non-Muscle-invasive Urothelial Carcinoma of the Bladder: Update 2016. Eur Urol 2017; 71: 447-461
• 6 Ray ER, O'Brien TS. Should urologists be spending more time on the golf course?. BJU Int 2007; 100: 728-729
• 7 Wilby D, Thomas K, Ray E. et al. Bladder cancer: new TUR techniques. World J Urol 2009; 27: 309-312
• 8 Hansel DE, Amin MB, Comperat E. et al. A contemporary update on pathology standards for bladder cancer: transurethral resection and radical cystectomy specimens. Eur Urol 2013; 63: 321-332
• 9 Onishi T, Sugino Y, Shibahara T. et al. Randomized controlled study of the efficacy and safety of continuous saline bladder irrigation after transurethral resection for the treatment of non-muscle-invasive bladder cancer. BJU Int 2017; 119: 276-282
• 10 Herr HW, Donat SM. Quality control in transurethral resection of bladder tumours. BJU Int 2008; 102: 1242-1246
• 11 Sfakianos JP, Kim PH, Hakimi AA. et al. The effect of restaging transurethral resection on recurrence and progression rates in patients with nonmuscle invasive bladder cancer treated with intravesical bacillus Calmette-Guerin. J Urol 2014; 191: 341-345
• 12 Brausi M, Collette L, Kurth K. et al. Variability in the recurrence rate at first follow-up cystoscopy after TUR in stage Ta T1 transitional cell carcinoma of the bladder: a combined analysis of seven EORTC studies. Eur Urol 2002; 41: 523-531
• 13 Grimm MO, Steinhoff C, Simon X. et al. Effect of routine repeat transurethral resection for superficial bladder cancer: a long-term observational study. J Urol 2003; 170: 433-437
• 14 Divrik RT, Yildirim U, Zorlu F. et al. The effect of repeat transurethral resection on recurrence and progression rates in patients with T1 tumors of the bladder who received intravesical mitomycin: a prospective, randomized clinical trial. J Urol 2006; 175: 1641-1644
• 15 Lazica DA, Roth S, Brandt AS. et al. Second transurethral resection after Ta high-grade bladder tumor: a 4 5-year period at a single university center. Urol Int 2014; 92: 131-135
• 16 Vasdev N, Dominguez-Escrig J, Paez E. et al. The impact of early re-resection in patients with pT1 high-grade non-muscle invasive bladder cancer. Ecancermedicalscience 2012; 6: 269
• 17 Mariappan P, Zachou A, Grigor KM. et al. Detrusor muscle in the first, apparently complete transurethral resection of bladder tumour specimen is a surrogate marker of resection quality, predicts risk of early recurrence, and is dependent on operator experience. Eur Urol 2010; 57: 843-849
• 18 Gontero P, Sylvester R, Pisano F. et al. The impact of re-transurethral resection on clinical outcomes in a large multicentre cohort of patients with T1 high-grade/grade 3 bladder cancer treated with bacille Calmette-Guerin. BJU Int 2016; 118: 44-52
• 19 Migliari R, Buffardi A, Ghabin H. Thulium Laser Endoscopic En Bloc Enucleation of Nonmuscle-Invasive Bladder Cancer. J Endourol 2015; 29: 1258-1262
• 20 Kramer MW, Rassweiler JJ, Klein J. et al. En bloc resection of urothelium carcinoma of the bladder (EBRUC): a European multicenter study to compare safety, efficacy, and outcome of laser and electrical en bloc transurethral resection of bladder tumor. World J Urol 2015; 33: 1937-1943
• 21 Kramer MW, Wolters M, Cash H. et al. Current evidence of transurethral Ho:YAG and Tm:YAG treatment of bladder cancer: update 2014. World J Urol 2015; 33: 571-579
• 22 Kramer MW, Abdelkawi IF, Wolters M. et al. Current evidence for transurethral en bloc resection of non-muscle-invasive bladder cancer. Minim Invasive Ther Allied Technol 2014; 23: 206-213
• 23 Kawada T, Ebihara K, Suzuki T. et al. A new technique for transurethral resection of bladder tumors: rotational tumor resection using a new arched electrode. J Urol 1997; 157: 2225-2226
• 24 Das A, Gilling P, Fraundorfer M. Holmium laser resection of bladder tumors (HoLRBT). Tech Urol 1998; 4: 12-14
• 25 Karl A, Herrmann TR. En bloc resection of urothelial cancer within the urinary bladder: the upcoming gold standard?. Re: Kramer MW, Wolters M, Cash H, Jutzi S, Imkamp F, Kuczyk MA, Merseburger AS, Herrmann TR. Current evidence of transurethral Ho:YAG and Tm:YAG treatment of bladder cancer: update 2014. World J Urol 2015; 33: 581-582
• 26 Kramer MW, Wolters M, Herrmann TR. En Bloc Resection of Bladder Tumors: Ready for Prime Time?. Eur Urol 2016; 69: 967-968
• 27 Nagele U, Kugler M, Nicklas A. et al. Waterjet hydrodissection: first experiences and short-term outcomes of a novel approach to bladder tumor resection. World J Urol 2011; 29: 423-427
• 28 Chen X, Liao J, Chen L. et al. En bloc transurethral resection with 2-micron continuous-wave laser for primary non-muscle-invasive bladder cancer: a randomized controlled trial. World J Urol 2015; 33: 989-995
• 29 Kramer MW, Bach T, Wolters M. et al. Current evidence for transurethral laser therapy of non-muscle invasive bladder cancer. World J Urol 2011; 29: 433-442
• 30 Liu H, Wu J, Xue S. et al. Comparison of the safety and efficacy of conventional monopolar and 2-micron laser transurethral resection in the management of multiple nonmuscle-invasive bladder cancer. J Int Med Res 2013; 41: 984-992
• 31 Wolters M, Kramer MW, Becker JU. et al. Tm:YAG laser en bloc mucosectomy for accurate staging of primary bladder cancer: early experience. World J Urol 2011; 29: 429-432
• 32 Bach T, Huck N, Wezel F. et al. 70 vs 120 W thulium:yttrium-aluminium-garnet 2 microm continuous-wave laser for the treatment of benign prostatic hyperplasia: a systematic ex-vivo evaluation. BJU Int 2010; 106: 368-372
• 33 Teichmann HO, Herrmann TR, Bach T. Technical aspects of lasers in urology. World J Urol 2007; 25: 221-225
• 34 He D, Fan J, Wu K. et al. Novel green-light KTP laser en bloc enucleation for nonmuscle-invasive bladder cancer: technique and initial clinical experience. J Endourol 2014; 28: 975-979
• 35 Geavlete B, Multescu R, Georgescu D. et al. Narrow band imaging cystoscopy and bipolar plasma vaporization for large nonmuscle-invasive bladder tumors--results of a prospective, randomized comparison to the standard approach. Urology 2012; 79: 846-851
• 36 Comploj E, Dechet CB, Mian M. et al. Perforation during TUR of bladder tumours influences the natural history of superficial bladder cancer. World J Urol 2014; 32: 1219-1223
• 37 Venkatramani V, Panda A, Manojkumar R. et al. Monopolar versus bipolar transurethral resection of bladder tumors: a single center, parallel arm, randomized, controlled trial. J Urol 2014; 191: 1703-1707
• 38 Sugihara T, Yasunaga H, Horiguchi H. et al. Comparison of perioperative outcomes including severe bladder injury between monopolar and bipolar transurethral resection of bladder tumors: a population based comparison. J Urol 2014; 192: 1355-1359
• 39 Kramer MW, Altieri V, Gil-Villa S. et al. Current evidence of transurethral en bloc resection of non-muscle invasive bladder cancer: update 2016. EU focus 2016; DOI: 10.1016/j.euf.2016.12.004. [im Druck]
• 40 Bach T, Muschter R, Herrmann TR. et al. Technical solutions to improve the management of non-muscle-invasive transitional cell carcinoma: summary of a European Association of Urology Section for Uro-Technology (ESUT) and Section for Uro-Oncology (ESOU) expert meeting and current and future perspectives. BJU Int 2015; 115: 14-23
• 41 Ukai R, Hashimoto K, Iwasa T. et al. Transurethral resection in one piece (TURBO) is an accurate tool for pathological staging of bladder tumor. Int J Urol 2010; 17: 708-714
• 42 Hurle R, Lazzeri M, Colombo P. et al. "En Bloc" Resection of Nonmuscle Invasive Bladder Cancer: A Prospective Single-center Study. Urology 2016; 90: 126-130
• 43 Chen J, Zhao Y, Wang S. et al. Green-light laser en bloc resection for primary non-muscle-invasive bladder tumor versus transurethral electroresection: A prospective, nonrandomized two-center trial with 36-month follow-up. Lasers Surg Med 2016; 48: 859-865
• 44 Fritsche HM, Otto W, Eder F. et al. Water-jet-aided transurethral dissection of urothelial carcinoma: a prospective clinical study. J Endourol 2011; 25: 1599-1603
• 45 Xishuang S, Deyong Y, Xiangyu C. et al. Comparing the safety and efficiency of conventional monopolar, plasmakinetic, and holmium laser transurethral resection of primary non-muscle invasive bladder cancer. J Endourol 2010; 24: 69-73
• 46 Zhu Y, Jiang X, Zhang J. et al. Safety and efficacy of holmium laser resection for primary nonmuscle-invasive bladder cancer versus transurethral electroresection: single-center experience. Urology 2008; 72: 608-612
• 47 De Nunzio C, Franco G, Cindolo L. et al. Transuretral resection of the bladder (TURB): analysis of complications using a modified Clavien system in an Italian real life cohort. Eur J Surg Oncol 2014; 40: 90-95
• 48 Muto G, Collura D, Giacobbe A. et al. Thulium:yttrium-aluminum-garnet laser for en bloc resection of bladder cancer: clinical and histopathologic advantages. Urology 2014; 83: 851-855
• 49 Wu YP, Lin TT, Chen SH. et al. Comparison of the efficacy and feasibility of en bloc transurethral resection of bladder tumor versus conventional transurethral resection of bladder tumor: A meta-analysis. Medicine (Baltimore) 2016; 95: e5372