ESOU 2019: Is En-Bloc TUR the Best Staging Tool?

Prague, Czech Republic (UroToday.com) Dr. Bernard Malavaud from France made the case for en-bloc TUR for non-muscle invasive bladder cancer (NMIBC).  Dr. Malavaud notes that the goal of staging is to “setup the stage for a play at the theater” – for example, the T stage for a cancer lesion. There are several visual parameters according to Dr. Malavaud that can assist a urologist in predicting the aggressiveness of a bladder tumor on endoscopy:

1. Size: <0.5 cm vs >3 cm
2. Pedicle: thin stalk vs stout vs sessile
3. Fronds: solid vs coalescent vs thin
4. Cytology: negative vs high-grade

This is important as a good endoscopy carries a wealth of information regarding T-stage.

There are several important points for achieving an en bloc resection of a bladder tumor as noted by Dr. Malavaud:

  • The plane of dissection
  • The prograde dissection
  • Intermittent bursts of plasma kinetic energy
  • Sharp and blunt dissection
  • Innovative handling of the loop – used to “lift” and “push” the tumor
One of the benefits of an en bloc resection is that the structure of the specimen is retained. This allows for confident analysis of the tumor’s deep extension and margins and makes it easier for the pathologist to assess the depth of tumor growth. Furthermore, this also allows confirmation of muscle presence and in cases of T1 high-grade tumors, depth of lamina propria invasion. Dr. Malavaud also highlights that an en bloc resection is amenable to aggressive, deep resections in small T2 tumors that may subsequently be offered conservative management.

Dr. Malavaud says that it is often difficult for pathologists to accurately assess bladder cancer T-stage. As noted in a classic paper from the 1990s, among 90 specimens assessed by 11 histopathologists, there was poor (kappa statistic 0.41) agreement of disease stage1. Indeed, a pathologist’s confidence in the specimen is related to the quality of the resection (ie. en bloc), the presence of detrusor muscle, lack of cautery artifact, and ease of analysis.

Dr. Malvaud concluded with the following take-home message slide advocating for en bloc resection of NMIBC tumors:
UroToday ESOU19 Is En Bloc TUR the Best Staging Tool

Presented by: Bernard Malavaud, MD, Ph.D., FEBU, professor of Urology, Toulouse Medical School

Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Twitter: @zklaassen_md, at the 16th Meeting of the European Section of Oncological Urology, #ESOU19, January 18-20, 2019, Prague, Czech Republic

References:
1. Robertson AJ, Beck JS, Burnett RA, et al. Observer variability in histopathological reporting of transitional cell carcinoma and epithelial dysplasia in bladders. J Clin Pathol 1990 Jan;43(1):17-21.