Collins loop en bloc Resection ( ClebR) for accurate staging of primary non muscle-invasive bladder cancer : Early experience

Rodolfo Hurle1, Gianluigi Taverna1, Mauro Seveso1, Guido Giusti1, Luigi Castaldo1, Luisa Pasini1, Pierpaolo Graziotti1
  • 1 Istituto Clinico Humanitas (Rozzano)

Objective

A primary aim of transurethral resection of bladder tumors is to determine the depth of invasion or clinical stage. Transurethral resection is a stochastic procedure subject to variations in tumor type, surgical technique and pathological evaluation.
Any improvements in submitting tissue that may facilitate the accurate evaluation
of tumor involvement of superficial and deeper layers of thebladder wall would be welcome.
Exact pathological staging of bladder cancer is crucial for determination of further treatment. One limiting factor is the surgical ‘incise and scatter’ technique that might contribute to tumour recurrence.
En bloc resection techniques are en emerging issue. All tumors may be resected by this technique and submitted for pathological review as a 1-piece specimen.
We present initial results with using a Collins loop (with a cutting current) en bloc resection ( CLebR) of bladder tumours for treatment and accurate staging of solitary transitional cell carcinoma of the bladder.

Methods and results

From June through decembere 2012, A total of 11 men and 4 women 44 to 86 years old (average age 63.5) with non muscle –invasive bladder cancer (NMIBC) underwent transurethral en bloc resection with the muscle layer using a Collins Loop. Tumor size was 1 to 30 mm. Inclusion criteria were solitary or maximum two lesions, treatment naive patients ; tumour localisation of the bladder neck were excluded. En bloc resection was applied to all of tumours. On 11 of the 15 patients, a re-resection was performed after 6 weeks.Transurethral resection was performed with a video camera through a 26Fr continuous resectoscope .The bladder wall is incised around the lesion
using a Collins loop, starting from apparently ‘ normal ’ mucosa surrounding the base and then extending through the subepithelial connective tissue, muscularis mucosae and muscularis propria strata as decribed previously by Naselli . During the procedure, the bladder is filled to a medium capacity and while inclining the loop to avoid any serious perforation, the muscular fibres are sectioned cautiously from the periphery to the centre of the lesion base . The resected 1-piece specimen was grasped with a loop electrode and retrieved. After bladder tumor resection the resected base was observed carefully to assess perforation and bleeding. Glistening globules of fat in the depths of the wound in the bladder wall must be visualized, so that the wound is not deepened further, but they are not cause for much concern. Cold cup or loop electrode biopsy of the resected base and around the resected tumor was also done Resected specimens were sent for pathological evaluation. Resection was performed with a continuous irrigation system to prevent excessive bladder wall distention and bladder perforation.

Discussion

Results
This technique has been used in 15 (21 lesions)consecutive patients. Tissue slides crossing the center of the tumor correctly determined the depth of cancer invasion as stages pTa to pT2. Pathological evaluation revealed 4 patient with pTa low-grade, 1 patients with pTa High grade , 6 patients with pT1 high grade and 4 with pT2 high grade. All of the resected specimens provided detrusor muscle, and all biopsies were positive for muscle cells. No uncontrollable bleeding, perforation or other serious complications were observed. Bladder irrigation was mandatory in only 50% of the patients. All patients were catheter-free within 24 hours of surgery.
All patients affected by NMIBC were underwent to re-resection 6 weeks after initial treatment and none of these showed residual disease

Discussions
Conventional bladder tumor transurethral resection involves a few problems. The procedure is not necessarily easy, the bleeding point may be concealed by the tumor stalk, the procedure makes coagulation difficult and decreases visualization, and it is sometimes impossible to resect the mass en bloc, resulting in an evaluation of pathological depth that is not necessarily accurate. In addition, tumor cells scatter as the tumor is fragmented and, thus, the possibility of implantation cannot be excluded. The knife electrode used in our study made it possible to obtain a reasonable amount of tissue with the muscle layer.
In addition, the electrode was in the center of the field of vision and we marked and incised tumor at the bladder wall. Tissue slides crossing the center of the tumor correctly determined the depth of cancer invasion.
The largest tumor resected by this technique was about 30 mm.
We believe that this procedure is useful for any type of tumor, including multiple or large lesions, to determine ac curate pathological findings. Furthermore, biopsy specimens were obtained from the tumor base and surrounding tissue.

Conclusion
CLebR has been proven safe and effective for both, treatment and pathological staging of primary NMIBC ,therefore could be an appropriate tool for accurate staging with possibly lower scattering potential for the assessment and treatment of patients with NMIBC.
We propose to confirm this results by comparing en bloc resection as described with
conventional loop resection and submitting tissue for pathological evaluation that is blinded to the method of surgical resection used

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