The long term outcome of combined NBI – plasma vaporization approach in large NMIBT cases – A prospective, randomized controlled comparison to the standard management

Geavlete B., Multescu R., Georgescu D., Moldoveanu C., Stanescu F., Jecu M., Geavlete P.

“Saint John” Emergency Clinical Hospital, Dept. of Urology, Bucharest

Introduction & Objectives

A prospective, randomized, comparison between narrow band imaging (NBI) cystoscopy and bipolar plasma vaporization (BPV) versus standard white light cystoscopy (WLC) and monopolar transurethral resection of bladder tumors (TURBT) was performed, aiming to evaluate the long term recurrence rates specific to the 2 approaches in cases of large non-muscle invasive bladder tumors (NMIBT).

Material & Methods

A total of 220 patients with at least one apparently (NMIBT) over 3 cm were included in the trial based on abdominal ultrasound, computer tomography and flexible WLC. In one arm, 110 patients underwent WLC, NBI cystoscopy and BPV, while cases in the second arm only benefited from WLC and TURBT. A single postoperative mitomycin-C instillation standard monopolar Re-TUR at 4 weeks and one year’ BCG immunotherapy were applied in all NMIBT cases. The follow-up protocol included ultrasound, urinary cytology and WLC, performed every 3 months for a period of 2 years and every 6 months in the 3rd and 4th year.

Results

In the NBI-BPV series, the CIS (94.6% versus 67.6%), pTa (93% versus 82.4%) and overall NMIBT (94.9% versus 84.3%) detection rates were significantly improved for NBI cystoscopy by comparison to WLC. NBI diagnosed significantly more cases of additional tumors (30.5% versus 9.5%) as well as extended tumoral margins in 10.5% of patients. The obturator nerve stimulation (3.2% versus 18.6%), bladder wall perforation (1.1% versus 7.2%), mean hemoglobin level drop (0.2 g/dl versus 0.9 g/dl) and postoperative bleeding (1.1% versus 6.2%) rates were significantly reduced for BPV when compared to TURBT. The catheterization period (47.2 versus 73.6 hours) and hospital stay (2.9 versus 4.1 days) were significantly shorter subsequent to BPV. The overall (6.3% versus 17.5%) and primary site (4.2% versus 13.4%) Re-TUR residual tumors’ rates were significantly lower for NBI-BPV patients. The 1 (7.9% versus 17.8%), 2 (11.5% versus 25.8%), 3 (16.3% versus 33.3%) and 4 (19.5% versus 37%) years’ NMIBT recurrence rates were significantly reduced in the NBI-BPV group when compared to the WLC-TURBT series.

Conclusions

NBI cystoscopy displayed significantly improved diagnostic accuracy and BPV emphasized superior efficacy, reduced morbidity and faster postoperative recovery in large NMIBT cases. The NBI-BPV technique provided a lower Re-TUR residual tumors’ rate as well as reduced 1, 2, 3 and 4 years’ recurrence rates by comparison to the standard approach.

Acknowledgement: This paper is supported by the Sectoral Operational Programme Human Resources Development (SOP HRD), financed from the European Social Fund and by the Romanian Government under the contract number POSDRU/159/1.5/S/137390/