Erb tendourology section

1. Hol-YAG laser En Block
Resection Of Bladder Tumors
Ahmed Eliwa MD
Lecturer of urology Urology Dept
Zagazig University

2. What's the place of laser ERBT in the
modern practice of urology?

3. • What's the gold standard ?
• What are the problems with Monopolar TUR-
BT
• Why enblock resection
• Why Hol YAG laser in enblock resection
• advantages and disadvantages of enblock
resection

4. • The goal of TURB in TaT1 BC
is to
• make the correct diagnosis
and completely
• remove all visible lesions.

5. 5.10.1 Strategy of the
procedure
• A complete resection is essential to
achieve a good prognosis.
• A complete resection can be achieved by
either resection in fractions or en-bloc
resection
• Resection in fractions (separate resection
of the exophytic part of the tumour, the
underlying bladder wall and the edges of
the resection area) provides good
information about the vertical and
horizontal extent of the tumour [87] (LE: 3
Brausi, M., et al 2002
Richterstetter, M., et al 2012

6. cTUR-BT

7. TURBT
bleeding
Ob J
Incomplete
resection
Histopathol
ogy
Oncologic
outcomes

8. Oncologic outcomes
• The standard TURB technique involves
piecemeal resection of the tumour, which runs
counter to established oncological principles
of removing tumour intact.
• liberates tumour cells into the bladder.
• Albarran and Imbert that bladder cancer
recurrence was caused by implantation of
floating tumour cells.

9. • the standard TURB approach may explain the
high (50–70%) recurrence rates for superficial
bladder cancer [13]
• Dome
• Multifocal Tumours Are Monoclonal,
Indicating a common origin
[Boyd P, Burnand K 1974]
[Hafner C et al 2001].

10. Histopathology

12. • absence of detrusor muscle in the specimen is
associated with a significantly higher risk of
residual disease, early recurrence and tumour
understaging (LE: 2b).
Mariappan, P., et al. 2010

13. Obturator jerk

14. Bleeding

17. Conclusions:
Transurethral en block resection is a safe and
useful technique that also provides sufficient
material for pathological evaluation.

19. • En bloc resection of UBC is an emerging technique that
allows for the resection of bladder tumors >1 cm.
• feasible whether electrical current or laser energy is
used.
• Staging quality was excellent and reached nearly 100 %.
• Complications were relatively low
• differences between electrical and laser energy were
marginal.

20. Conclusion:
• ETURBT might prove to be preferable
alternative to CTURBT management of
nonmuscle invasive bladder carcinoma.
• ETURBT is associated with shorter HT and
CT, less complication rate, and lower
recurrence free rate.
• high-qualified specimen for the
pathologic diagnosis.
• Well designed randomized controlled
trials are needed to make results
comparable.

21. Survival-tumor free
• 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;48:859–65.
• [13] 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;41:1081–107.
• [14] Zhong C, Guo S, Tang Y, et al. Clinical observation on 2 micron laser for
• non-muscle-invasive bladder tumor treatment: single-center experience.
• World J Urol 2010;28:157–61.
• [15] 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.
• [16] 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;
• 72:608–12.

23. 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.

24. Conclusions:
• EBTUR is a safe procedure
• The presence of detrusor muscle in the specimen is high if
compared with historical series of conventional TUR.
• recurrence rate is comparable.
• The objective advantage of a proper histological assessment
suggests to perform EBTUR instead of conventional TUR,
when feasible.

25. The question has been raised as to
whether ERBT is ready for
guideline implementation.
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,

26. 5.10.1 Strategy of the
procedure
• En-bloc resection using monopolar or bipolar current,
Thulium-YAG or Holmium-YAG laser is feasiblein
selected exophytic tumours.
• It provides high quality resected
specimens with the presence of detrusor muscle
in 96-100% of cases [88-91] (LE 3).
• The technique selected is dependent on the size and
location of the tumour and experience of the surgeon.

28. Merits
• Excellent hemostasis
• No obturator jerk
• High quality specimen
• 2nd resection
• Tissue effect
• can be performed using all
energy sources
Demerits
• tumors of >3 cm extraction
• overall costs
• Standarizing the
techniqueLearning

29. What's the place of laser ERBT in the
modern practice of urology?
• High risk patients
with bleeding
tendency or
anticoagulation
• When tumour
staging is inadequate
for making clinical
decision
• Plan B for obturator
jerk