الفهرس 
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Abstract
SUMMARY
ransurethral resection of bladder tumors (TURBT) using a
wire loop still remains the gold-standard treatment for
non-muscle invasive bladder cancer (NMIBC). The goal of any
bladder tumor endoscopic approach is to make the correct
diagnosis and to remove all visible lesions.
On the other hand, the unacceptably high early
recurrence rates after first resection as well as the significant
complications of standard monopolar resection, consisting of
bladder wall perforation, intra- and postoperative bleeding,
urinary retention by clots, obturator nerve stimulation, tumoral
spilling and urethral strictures also demanded the search for
new alternatives.
Bladder tumors characterized by specific features such as
their location in places that are difficult to access (bladder
dome, anterior bladder wall) or subject to obturator nerve
stimulation (lateral bladder walls) as well as their size (larger
than 3 cm) particularly imposed the search for surgical
improvement.
Bipolar electrosurgical techniques gathered increasing
acknowledgement during the recent years, providing significant
advantages in terms of improved hemostasis, decreased
obturator nerve stimulation rate and good safety in patients with
certain specific conditions such as anticoagulant therapy,
cardiac pacemakers etc. The studies published during the recent
years’ demonstrated the advantages of bipolar vaporization
both in BPH and bladder tumors’ endoscopic procedures.
Subjectively, this type of vaporization did not alter the
visual characteristics of the anatomical layers, thus enabling the
surgeon to differentiate the tumoral tissue, the muscular fibers
of the bladder wall as well as the clear boundaries of the
operating area with increased accuracy.
Furthermore, although preliminary in this previous
report, pathologic grade and staging information were not
compromised despite the vaporization process.
A total number of 50 cases that fit the inclusion criteria
that will be admitted in the period between August 2012 and
August 2014 will be enrolled in the study [An intervention
study (Randomized controlled clinical trial)]. Patients will be
equally divided into 2 groups, Group A will undergo TURBT
and group B will undergo BPV-BT.
All patients underwent a standard investigation protocol.
The BPV-BT procedure started with a comprehensive
cystoscopy, determining the presence, size and location of all
existing tumors.
The next step consisted of tumor biopsy performed with
the same bipolar resectoscope and a thin resection loop, aiming
to obtain a pathological specimen that would include tumoral
tissue and the underlying muscle layer, in view of a complete
pathological analysis.
The main stage was represented by the actual plasma
vaporization, during which the hemispherical shaped new
type of electrode displaying a plasma corona on its surface
was gradually moved in direct contact with the tumoral tissue.
Tumor vaporization was applied until the muscular layer
of the bladder wall was clearly exposed.
Subsequently, the bipolar resection of the center and
margins of the tumoral bed was performed for pathological
confirmation of the complete tumor removal.
As regards the TURBT arm, conventional monopolar
transurethral resection of the bladder tumors was done using
Storz 26 Fr continuous flow resectoscope with the hot loop
electrode. Power was maintained at the default settings.
Single immediate postoperative intravesical
chemotherapy was given to all cases according to the EAU
Guidelines unless bladder perforation is suspected after the
TURBT or if significant hematuria is present.
The sizes of the tumors was ranging from 2.5 to 5.5 cm
with a mean size of 3.5 ± 0.87 cm for the TURBT group,
whereas the BPV-BT group tumors sizes was ranging from 2.5
to 5.3 cm with a mean of 3.7 ± 0.83 cm.
Intraoperative obturator nerve reflex occurred in 4 (16%)
cases of the TURBT group while the BPV-BT group passed
without experiencing such complication (0%).
As regards the TURBT group, Intraoperative blood
transfusion was ranging from 0 to 1 unit of packed RBCs with a
median of 0 units, and was required only in 3 cases (12%),
while no cases (0%) required Intraoperative blood transfusion
in the BPV-BT group.
Regarding Intraoperative perforation, it happened in 5
Cases (20%) of the TURBT group (A), 4 cases (16%) were
extra peritoneal managed conservatively, 2 of them (50%) were
due to intraoperative obturator nerve reflex and 1 case (4%)
was intraperitoneal and managed surgically.
Whereas the BPV-BT group (B) had no cases (0%) of
intraoperative perforation.
There was a statistically significant difference between
both groups as regarding the mean change in sodium levels
between the postoperative and the preoperative data in both
groups (p = 0.005).
And there was also a highly statistically significant
difference between both groups as regarding the mean change
in the hemoglobin levels between the postoperative and the
preoperative data in both groups (p = 0.000).
Postoperative hospital stay in the TURBT group (A),
ranged from 1 to 6 days with a mean of 1.88 ± 1.16 days,
whereas ranged from 1 to 3 days with a mean of 1.24 ± 0.52
days in the BPV-BT group (B).
The catheter time was ranging from 1 to 14 days with a
mean of 3.4 ± 3.8 days in the TURBT group (A) (prolonged
due to perforations), while ranged from 1 to 10 days with a
mean of 1.5 ± 1.8 days in the BPV-BT group (B) (prolonged
only in one case due to iatrogenic urethral injury.
The overall tumor recurrence, although numerically,
whether at same site or another site was higher in the TURBT
group (A) 15 recurrences to 8 recurrences in the BPV-BT group
(B), still not yet statistically significant difference, and this may
be attributed to the small sample size (p = 0.586).
There was no statistically significant difference between
both groups as regarding the tumor grade (p = 0.667), or stage
(p = 0.755) progression.
Finally, we may conclude that the bipolar plasma
vaporization seems to represent a promising endoscopic
treatment alternative for NMIBC patients, with good efficacy
and reduced morbidity in cases of large bladder tumors.
Longer follow up and larger sample sizes are needed to
properly comment on the effect of BPV-BT on tumor
recurrence and progression.