En bloc resection of bladder tumors: challenges and unmet needs in 2021

Plain language summary Transurethral resection of bladder tumor remains the standard-of-care for non-muscle invasive bladder cancer. The procedure is the first-line diagnostic test and treatment for early-stage bladder cancer. However, the poor post-operative outcomes relevant to the surgical technique have led to constant questioning of its efficacy for years. A novel procedure, en bloc resection of bladder tumor (ERBT), has come to the forefront. This represents an attractive method that can be accomplished by a breadth of energy delivery systems. Thus far, this technique appears feasible, safe and efficient, providing excellent and precise histological specimens. Despite the recent surge in studies reporting on ERBT, well-designed, properly conducted randomized controlled trials examining the technique's long-term efficacy are still lacking and excitedly anticipated in the years to come. The present article gives an overview of current knowledge surrounding the role of ERBT, outlines the existing challenges and unmet needs, and provides future perspectives on the management of non-muscle invasive bladder cancer. Non-muscle invasive bladder cancer accounts for the majority of new bladder cancer diagnoses, and endoscopic transurethral resection of bladder tumor (TURBT) represents the standard-of-care. Although a relatively safe and common procedure, TURBT is often hampered by the questionable quality of resection. The evolution of surgical techniques has brought en bloc resection of bladder tumor (ERBT) to the forefront. ERBT has emerged as an alternative to conventional TURBT, incorporating a more delicate en bloc sculpting and tumor excision, in contrast to 'piecemeal' resection by conventional TURBT. ERBT appears safe, feasible and effective with demonstrably higher rates of detrusor muscle in the pathologic specimen, all while providing better staging and obviating the need for a re-TURBT in selected patients. However, the method's adoption in the field is still limited. This review summarizes the recent evidence relevant to ERBT while further highlighting the technique's limitations and unmet needs.