En bloc versus conventional resection of primary bladder tumor in terms of presence of detrusor muscle in biopsy specimen: a prospective study

En bloc versus conventional resection of primary bladder tumor in terms of presence of detrusor muscle in biopsy specimen: a prospective study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article En bloc versus conventional resection of primary bladder tumor in terms of presence of detrusor muscle in biopsy specimen: a prospective study Bir Bahadur Thapa, Arvind Kumar Shah, Baikuntha Adhikari, Udita Mishra, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7094925/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Transurethral resection of bladder tumor (TURBT) is the crucial and standard approach in the diagnosis and management of urinary bladder cancer. This study compares conventional piecemeal and en bloc resection techniques in terms of detrusor muscle presence in resected specimens, surgical safety, and feasibility. Methods A prospective comparative study conducted from April 2024 to March 2025 included patients with up to three bladder tumors, measuring ≤ 3 cm, who were alternately assigned to undergo either conventional piecemeal resection or en bloc resection. The primary outcome was the presence of detrusor muscle in the resected specimen. Secondary outcomes included operative time duration, bladder perforation, and obturator reflex. The quality of tissue was assessed by pathologists using a Likert scale. Results Eighty-seven patients were included, 43 in the conventional and 44 in the en bloc group. The baseline characteristics and tumor size were comparable. Presence of detrusor muscle in specimens was higher in en bloc group (97.7% vs 83.7%; p = 0.030). Operative duration was shorter in the en bloc group (35.55 minutes vs 43.42 minutes; p = 0.001). A case of bladder perforation was observed in the conventional group. Pathologists observed better specimen orientation and architecture in the en bloc group. Presence of tumor in re-TURBT was 16.0% in the en bloc group and 28.6% in the conventional group (p = 0.497). Conclusions En bloc resection yielded a higher presence of detrusor muscle and shorter operative duration with better specimen quality compared to conventional piecemeal resection for tumor ≤ 3 cm. Transurethral resection of bladder tumor conventional piecemeal resection en bloc resection detrusor muscle quality of specimen Introduction Transurethral resection of bladder tumor (TURBT) is the standard initial treatment for bladder cancer and remains a cornerstone in the diagnosis, staging, and therapeutic management of the disease [ 1 – 4 ]. The procedure serves several critical purposes: it enables accurate histopathological diagnosis, facilitates precise staging and also aids in risk stratification. These steps are essential for reducing tumor recurrence and preventing disease progression, both of which continue to pose significant challenges in the long-term management of bladder cancer [ 5 ]. Among the various TURBT techniques, conventional TURBT (cTURBT) is the most widely practiced technique. This approach involves piecemeal resection of the tumor. However, the fragmented nature of cTURBT may limit the ability to ensure complete tumor removal, complicate margin assessment, and impair pathological interpretation due to disruption of tissue architecture [ 6 ]. Additionally, the presence of free-floating tumor fragments during the procedure raises concerns about potential tumor cell reimplantation [ 6 , 7 ]. To overcome these limitations, en bloc TURBT (eTURBT) has been proposed as an alternative technique as this method involves resection of the tumor in a single piece along with an adequate margin of surrounding mucosa and underlying detrusor muscle. En bloc resection preserves tissue orientation and integrity, reduces thermal and mechanical artefacts, and enhances pathological evaluation [ 8 , 9 ]. The presence of detrusor muscle in the resected specimen is vital for accurate pathological staging and planning further management [ 10 ]. For accurate staging, the absence of detrusor muscle is significantly associated with higher rates of residual tumor and recurrence, and understaging, except in cases of low-grade Ta tumors [ 11 – 14 ]. This study was conducted to compare the surgical, pathological, and oncological outcomes of conventional and en bloc TURBT, with a particular emphasis on the presence of detrusor muscle in biopsy specimens. Materials and methods A prospective comparative study was conducted at the Department of Urology, National Academy of Medical Sciences, Bir Hospital, Kathmandu, Nepal, from April 2024 to March 2025. Ethical approval was obtained from the Institutional Review Board (approval number: 82/2081/82), and written informed consent was obtained from all participants. Patients with suspected urinary bladder tumors underwent ultrasonography, and further characterization was done using computed tomography intravenous urogram (CT-IVU). After preoperative evaluation, all the patients with primary urinary bladder tumors were alternately assigned to undergo either cTURBT or eTURBT. Inclusion criteria included primary bladder tumors ≤ 3 cm in diameter and a maximum of three lesions. Exclusion criteria included tumors > 3 cm, more than three tumors, and synchronous or previous upper urinary tract urothelial carcinoma. All procedures were performed under spinal anesthesia with ultrasound-guided obturator nerve block by anesthesiologists. White-light cystoscopy was used for tumor assessment and resection. Resection was done using monopolar energy (Covidien 2011, Covidien Ireland Limited) with a cautery loop or Collins knife with the setting of blend cut mode (100 watts) and fulguration (70 watts). In cTURBT, resection was performed in a piecemeal fashion, with separate sampling of the base. In eTURBT, a circumferential incision with a 5 mm peritumoral margin was made, and resection proceeded through the lamina propria until the detrusor muscle layer was visualized. The entire tumor, including its stalk or base, was excised en bloc along the muscle plane. Tissue was retrieved using a resection loop or Ellik evacuator; large specimens were fragmented into 2–3 pieces for removal. Hemostasis was secured in all cases. A three-way Foley catheter was inserted, and continuous bladder irrigation was initiated postoperatively and discontinued on postoperative day one. Intravesical Mitomycin C was instilled within six hours of resection when no contraindications were noted. Ten cases in the cTURBT group and 12 cases in the eTURBT group were discharged on the first postoperative day, whereas other cases were discharged on the second postoperative day. Operative details were documented using a standardized bladder mapping template and an eight-item checklist recommended by the European Association of Urology (EAU) guidelines 2024 [ 15 ]. Patients were initially followed up on 10th postoperative days with histopathology reports. Re-TURBT was performed within 6 weeks in cases of pT1 or high-grade tumors, absence of detrusor muscle and incomplete resection as per the 2024 EAU Guidelines [ 15 ]. Further management was guided by histopathological findings and risk stratification. A blinded qualitative assessment of all pathological specimens was conducted by five independent pathologists. Three key histological parameters were scored using a 5-point Likert scale: (1) orientation and tissue architecture, (2) artefactual changes (e.g., cautery or crush artefacts), and (3) presence and quality of muscularis propria (detrusor muscle). Scores ranged from 1 (poor quality/severe artefacts) to 5 (excellent quality/minimal artefacts). The primary outcome was the presence of detrusor muscle in the pathological specimen. Secondary outcomes included operative duration, obturator reflex, bladder perforation, and status of lateral and deep resection margins. Bladder perforation was diagnosed intraoperatively by direct cystoscopic visualization or postoperatively via cystogram or ultrasonography. Data were collected using a structured proforma and analyzed using Statistical Package for the Social Sciences (SPSS) version 25. Descriptive and comparative statistics were applied. Categorical variables were analyzed using Chi-square or Fisher's exact tests, and continuous variables with Student's t-test. A p-value < 0.05 was considered statistically significant. Results Eighty-seven patients who fulfilled the inclusion criteria underwent TURBT during the period, out of which 43 were in the cTURBT group and 44 were in the eTURBT group. The mean tumor size, number and location of the tumor were comparable between the two groups (Table I). Perforation occurred in one case with cTURBT group (1/43, 2.3%). Mean operative time was significantly lower in the eTURBT group in comparison to the cTURBT group (35.55 min vs 43.42 min; p = 0.002) (Table II). The presence of microscopic detrusor muscle was significantly higher in the eTURBT group compared to the cTURBT group (43/44, 97.7% vs 36/43, 83.7%; p = 0.038). The distribution of T stages of tumors was similar in the two groups. Although there was a lower rate of presence of tumor in re-TURBT in the eTURBT group, this difference was not statistically significant (4/25, 16.0% vs 6/21, 28.6%, p = 0.497). One case of pathological tumor upgradation was observed in the cTURBT group, involving progression from pT1 high grade to pT2 high grade on re-TURBT. No cases of T stage upgradation were detected in the eTURBT group (Table II). Feedback from the pathologist showed that the orientation and tissue architecture had mean scores of 4 (largely interpretable) in the cTURBT group and 5 (clearly interpretable) in the eTURBT group. Artefactual changes were rated as mild (score 4) in the cTURBT group and minimal or absent (score 5) in the eTURBT group. Similarly, the quality of the muscularis propria was rated as mostly intact (score 4) in the cTURBT group and clearly intact (score 5) in the eTURBT group. Discussion The key indicators of a high-quality TURBT include the completeness of tumor removal, status of resection margins, and the presence of detrusor muscle in the specimen. The presence of detrusor muscle in the pathologic specimen is a well-recognized surrogate parameter of high-quality resection [ 8 , 16 ]. In addition to better preservation of architecture for pathological assessment, the eTURBT technique may provide sufficient size and depth of resection and accurate pathological diagnosis. Hashem et al. (2021) reported an 8.5% incidence of bladder perforation in cTURBT, while eTURBT had 0%, indicating a significant reduction in complications with en bloc resection [ 7 ]. D'Andrea et al. (2023) reported perforation in 12% of cases in cTURBT and 5.6% in eTURBT out of 194 cases in each group, again demonstrating a lower complication rate in eTURBT [ 17 ]. In the current study, the eTURBT group had no bladder perforations while the cTURBT group had one. This could be attributed to improved visualization, controlled tumor excision, early control of bleeding, and reduced deep muscle injury in eTURBT. D'Andrea et al. (2023) reported an obturator reflex incidence of 16% in cTURBT and 8.4% in eTURBT, indicating that eTURBT nearly halves the risk [ 17 ]. Similarly, the current study showed that the obturator reflex occurred in cTURBT only (4/43, 9.3%; p-value = 0.038). Absence of obturator reflex (0%) in the eTURBT group in the current study could be due to better visualization, precise tumor excision, and minimal electrical energy dispersion. Owing to the intermittent burst technique in eTURBT, in contrast to continuous current in cTURBT. However, it could not be concluded, as the procedure was done in obturator block in all cases; hence, it won't be fair to comment about the prevention of jerks with eTURBT based on the current study. Zhang et al. (2020) and D'Andrea et al. (2023) reported almost similar operative times in the two groups [ 17 , 18 ]. In contrast to this finding, the current study showed the mean operative time was significantly shorter in eTURBT (35.55 min) compared to cTURBT (43.97 min) (p = 0.001). Similarly, Li et al. (2024) reported that eTURBT was more time-efficient, particularly for small to medium-sized tumors, with a mean operative time approximately 10 minutes shorter than cTURBT [ 19 ]. Less operative time in eTURBT compared to cTURBT was potentially due to more precise tumor removal and reduced need for repeated coagulation and resection cycles. The current study showed that eTURBT is more effective in obtaining detrusor muscle during transurethral resection (p = 0.030). Similarly, D'Andrea et al. (2023) suggested eTURBT was superior to cTURBT in retrieval of detrusor muscle (80.7% vs. 71.1%; p = 0.01) in their randomized, multicentric trial in 384 patients with up to three cTa-T1 NMIBC tumors of 1–3 cm in size [ 17 ]. Hashem A et al. (2021) reported 98% significant improvement in holmium laser en-bloc resection (HolERBT) over 62% in cTURBT (98% vs 62%; p < 0.0019) among 100 patients with NMIBC who were randomly allocated to cTURBT or HolERBT [ 7 ]. 7 Gallioli A et al. (2022) found that the rate of detrusor muscle presence for eTURBT was noninferior to that for cTURBT (94% vs. 95%; p = 0.8) among 248 patients (108 in cTURBT and 140 in eTURBT) [ 20 ]. This could be due to precise cutting with better visualization of the plane with coagulation of feeding vessels. The current study identified the presence of tumor in 21.7% of patients undergoing re-TURBT, with a lower rate of presence of tumor in the eTURBT group than in the cTURBT group; however, this difference was statistically insignificant (p = 0.497). One case of pathological tumor upgradation was observed in the cTURBT group, involving progression from pT1 high grade to pT2 high grade at re-TURBT. No cases of upgradation were detected in the eTURBT group; two cases remained Ta, and two cases remained T1. Similarly, Yanagisawa T et al. (2024), in a meta-analysis, found that in T1 patients initially treated with cTURBT, the pooled rates of any residual tumors and upstaging on re-TURBT were 31.4% and 2.8%, respectively [ 21 ]. A propensity score-matched analysis reported that the rate of any residual tumor on re-TURBT was significantly lower in the eTURBT group compared to the cTURBT group (15% vs. 36%; p = 0.029), indicating improved quality of resection with eTURBT [ 22 ]. Qualitative assessment by the panel of pathologists in the current study implied that eTURBT yielded higher quality specimens with well-oriented tissue architecture and fewer artefactual changes (cautery effect and crush artefact), improving diagnostic precision and potentially impacting clinical decision-making. Similarly, Kannan et al. suggested that eTURBT is a technique that has chances of high-quality detrusor muscle sampling with minimizing crush artifacts and cautery damage [ 23 ]. The present study has certain limitations. Sample size was relatively small, and the follow-up period was short-term, restricting the ability to assess long-term outcomes and recurrence rates. Conclusion En bloc TURBT demonstrated a higher presence of detrusor muscle in specimens with primary bladder tumors fewer than or equal to 3, with a size up to 3 cm. Moreover, eTURBT had the shorter operative time and yielded higher-quality specimens, improving diagnostic precision and potentially impacting clinical decision-making. Declarations Competing interests The authors have no competing interests to declare that are relevant to the content of this article. Ethics approval This study was reviewed and approved by the Institutional Review Board of National Academy of Medical Sciences, Kathmandu (registration number 82/2081/82). The study did not involve animals. Consent to participate Written informed consent was obtained from the patient who were involved in the study. Consent to publish Data availability Funding No funding was received to conduct this study. Author Contribution B.B.T.: Study execution, data collection,data analysis, editing and article writing.A.S.: Study concept, design, Critical revision, and final manuscript editing.P.M.S.: Study execution and Critical revision of the manuscript.B.A., A.K.S., U.M.: Critical revision of the manuscript.N.R., J.K.M, R.S.: Study execution Acknowledgments B.B.T.: Study execution, data collection,data analysis, editing and article writing. A.S.: Study concept, design, Critical revision, and final manuscript editing. P.M.S.: Study execution and Critical revision of the manuscript. B.A., A.K.S., U.M.: Critical revision of the manuscript. N.R., J.K.M, R.S.: Study execution References Nieder AM, Brausi M, Lamm D, et al. Management of stage T1 tumors of the bladder: International Consensus Panel. Urology . 2005;66(6, Supplement 1):108-125. doi:https://doi.org/10.1016/j.urology.2005.08.066 Mostafid H, Babjuk M, Bochner B, et al. Transurethral Resection of Bladder Tumour: The Neglected Procedure in the Technology Race in Bladder Cancer. Eur Urol . 2020;77(6):669-670. https://doi:10.1016/j.eururo.2020.03.005 Babjuk M, Burger M, Capoun O, et al. European Association of Urology Guidelines on Non–muscle-invasive Bladder Cancer (Ta, T1, and Carcinoma in Situ). Eur Urol . 2022;81(1):75-94. https://doi:10.1016/j.eururo.2021.08.010 McCarthy JF. A New Apparatus for Endoscopic Plastic Surgery of the Prostate, Diathermia and Excision of Vesical Growths. J Urol . 1931;26(5):695-696. https://doi:10.1016/S0022-5347(17)72812-1 Suarez-Ibarrola R, Soria F, Abufaraj M, et al. 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Cureus . 15(7):e42523. https://doi:10.7759/cureus.42523 Tables Table I – Baseline characteristics of participants Parameter cTURBT (n = 43) eTURBT (n = 44) p - value Median age, in years (IQR) 65 (56 -71) 59.50 (50 -71) 0.085 Sex, n (%) 0.061 Male 30 (69.8%) 38 (86.4%) Female 13 (30.2%) 5 (13.6%) Mean tumor size, in mm 24.26 ± 4.23 22.02 ± 7.76 0.100 Mean number of tumors 1.53 ± 0.70 1.48 ± 0.70 0.702 Tumor location 0.481 Right lateral wall 10 (23.3%) 14 (31.8%) Left lateral wall 13 (24.2%) 9 (20.5%) Anterior wall 1 (2.3%) 0(0) Posterior wall 18 (41.9%) 20 44.5%) Trigone 0(0) 1 (2.3%) Dome 1 (2.3%) 0(0) IQR – Interquartile range Table II – Clinico-pathologic features of participants Parameter cTURBT (n = 43) eTURBT (n = 44) P - value Perforation, n (%) 0.309 Yes 1 (2.3%) 0(0) No 42 (97.7%) 44 (100%) Obturator reflex, n (%) 0.038 Yes 4 (9.3%) 0(0) No 39(90.7%) 44 (100%) Mean operative time, mins 43.42 ± 10.08 35.55 ± 11.60 0.001 Macroscopic detrusor muscle present, n (%) 43 (100%) 44 (100%) Microscopic detrusor muscle in the specimen, n (%) 0.030 Present 36 (83.7%) 43 (97.7%) Absent 7 (16.3%) 1 (2.3%) pT stage, n (%) 0.486 No tumor 2 (6.1%) 0(0) pTa 23 (53.5%) 24 (54.5%) pT1 14 (32.6%) 17 (38.6%) pT2 4 (9.3%) 3 (6.8%) Grade (WHO 2004), n (%) 0.336 Low 19 (44.2%) 19 (43.2%) High 22 (51.2%) 25 (56.8%) Re-TURBT, n (%) 21 (48.8%) 25 (56.8%) Presence of tumor in Re-TURBT, n (%) 0.497 Yes 6 (28.6%) 4 (16%) No 15 (71.4%) 21 (84%) Re-TURBT pT stage, n (%) 0.720 No tumor 15 (71.7%) 21 (84%) pTa 2 (9.5%) 2 (8%) pT1 3 (14.3%) 2 (8%) pT2 1 (4.8%) 0 (0) Upgradation of tumor, n (%) Pathologist feedback on quality of specimen, n (pathologist) 1(4.8) 0 (0) Orientation and tissue architecture 4 (largely interpretable) 5 5 (clearly interpretable) 5 Artefactual changes 4 (mild) 5 5 (minimal or absent) 5 Quality of the muscularis propria 4 (mostly intact) 5 5 (clearly intact) 5 Additional Declarations No competing interests reported. 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21:01:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":597196,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7094925/v1/fc686a86-bd44-421c-8e55-f08583c119df.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"En bloc versus conventional resection of primary bladder tumor in terms of presence of detrusor muscle in biopsy specimen: a prospective study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTransurethral resection of bladder tumor (TURBT) is the standard initial treatment for bladder cancer and remains a cornerstone in the diagnosis, staging, and therapeutic management of the disease [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The procedure serves several critical purposes: it enables accurate histopathological diagnosis, facilitates precise staging and also aids in risk stratification. These steps are essential for reducing tumor recurrence and preventing disease progression, both of which continue to pose significant challenges in the long-term management of bladder cancer [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAmong the various TURBT techniques, conventional TURBT (cTURBT) is the most widely practiced technique. This approach involves piecemeal resection of the tumor. However, the fragmented nature of cTURBT may limit the ability to ensure complete tumor removal, complicate margin assessment, and impair pathological interpretation due to disruption of tissue architecture [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Additionally, the presence of free-floating tumor fragments during the procedure raises concerns about potential tumor cell reimplantation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. To overcome these limitations, en bloc TURBT (eTURBT) has been proposed as an alternative technique as this method involves resection of the tumor in a single piece along with an adequate margin of surrounding mucosa and underlying detrusor muscle. En bloc resection preserves tissue orientation and integrity, reduces thermal and mechanical artefacts, and enhances pathological evaluation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe presence of detrusor muscle in the resected specimen is vital for accurate pathological staging and planning further management [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. For accurate staging, the absence of detrusor muscle is significantly associated with higher rates of residual tumor and recurrence, and understaging, except in cases of low-grade Ta tumors [\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study was conducted to compare the surgical, pathological, and oncological outcomes of conventional and en bloc TURBT, with a particular emphasis on the presence of detrusor muscle in biopsy specimens.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eA prospective comparative study was conducted at the Department of Urology, National Academy of Medical Sciences, Bir Hospital, Kathmandu, Nepal, from April 2024 to March 2025. Ethical approval was obtained from the Institutional Review Board (approval number: 82/2081/82), and written informed consent was obtained from all participants.\u003c/p\u003e\u003cp\u003ePatients with suspected urinary bladder tumors underwent ultrasonography, and further characterization was done using computed tomography intravenous urogram (CT-IVU). After preoperative evaluation, all the patients with primary urinary bladder tumors were alternately assigned to undergo either cTURBT or eTURBT. Inclusion criteria included primary bladder tumors\u0026thinsp;\u0026le;\u0026thinsp;3 cm in diameter and a maximum of three lesions. Exclusion criteria included tumors\u0026thinsp;\u0026gt;\u0026thinsp;3 cm, more than three tumors, and synchronous or previous upper urinary tract urothelial carcinoma.\u003c/p\u003e\u003cp\u003eAll procedures were performed under spinal anesthesia with ultrasound-guided obturator nerve block by anesthesiologists. White-light cystoscopy was used for tumor assessment and resection. Resection was done using monopolar energy (Covidien 2011, Covidien Ireland Limited) with a cautery loop or Collins knife with the setting of blend cut mode (100 watts) and fulguration (70 watts).\u003c/p\u003e\u003cp\u003eIn cTURBT, resection was performed in a piecemeal fashion, with separate sampling of the base. In eTURBT, a circumferential incision with a 5 mm peritumoral margin was made, and resection proceeded through the lamina propria until the detrusor muscle layer was visualized. The entire tumor, including its stalk or base, was excised en bloc along the muscle plane. Tissue was retrieved using a resection loop or Ellik evacuator; large specimens were fragmented into 2\u0026ndash;3 pieces for removal. Hemostasis was secured in all cases. A three-way Foley catheter was inserted, and continuous bladder irrigation was initiated postoperatively and discontinued on postoperative day one.\u003c/p\u003e\u003cp\u003eIntravesical Mitomycin C was instilled within six hours of resection when no contraindications were noted. Ten cases in the cTURBT group and 12 cases in the eTURBT group were discharged on the first postoperative day, whereas other cases were discharged on the second postoperative day. Operative details were documented using a standardized bladder mapping template and an eight-item checklist recommended by the European Association of Urology (EAU) guidelines 2024 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePatients were initially followed up on 10th postoperative days with histopathology reports. Re-TURBT was performed within 6 weeks in cases of pT1 or high-grade tumors, absence of detrusor muscle and incomplete resection as per the 2024 EAU Guidelines [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Further management was guided by histopathological findings and risk stratification.\u003c/p\u003e\u003cp\u003eA blinded qualitative assessment of all pathological specimens was conducted by five independent pathologists. Three key histological parameters were scored using a 5-point Likert scale: (1) orientation and tissue architecture, (2) artefactual changes (e.g., cautery or crush artefacts), and (3) presence and quality of muscularis propria (detrusor muscle). Scores ranged from 1 (poor quality/severe artefacts) to 5 (excellent quality/minimal artefacts).\u003c/p\u003e\u003cp\u003eThe primary outcome was the presence of detrusor muscle in the pathological specimen. Secondary outcomes included operative duration, obturator reflex, bladder perforation, and status of lateral and deep resection margins. Bladder perforation was diagnosed intraoperatively by direct cystoscopic visualization or postoperatively via cystogram or ultrasonography.\u003c/p\u003e\u003cp\u003eData were collected using a structured proforma and analyzed using Statistical Package for the Social Sciences (SPSS) version 25. Descriptive and comparative statistics were applied. Categorical variables were analyzed using Chi-square or Fisher's exact tests, and continuous variables with Student's t-test. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eEighty-seven patients who fulfilled the inclusion criteria underwent TURBT during the period, out of which 43 were in the cTURBT group and 44 were in the eTURBT group. The mean tumor size, number and location of the tumor were comparable between the two groups (Table I).\u003c/p\u003e\u003cp\u003ePerforation occurred in one case with cTURBT group (1/43, 2.3%). Mean operative time was significantly lower in the eTURBT group in comparison to the cTURBT group (35.55 min vs 43.42 min; p\u0026thinsp;=\u0026thinsp;0.002) (Table II). The presence of microscopic detrusor muscle was significantly higher in the eTURBT group compared to the cTURBT group (43/44, 97.7% vs 36/43, 83.7%; p\u0026thinsp;=\u0026thinsp;0.038). The distribution of T stages of tumors was similar in the two groups. Although there was a lower rate of presence of tumor in re-TURBT in the eTURBT group, this difference was not statistically significant (4/25, 16.0% vs 6/21, 28.6%, p\u0026thinsp;=\u0026thinsp;0.497). One case of pathological tumor upgradation was observed in the cTURBT group, involving progression from pT1 high grade to pT2 high grade on re-TURBT. No cases of T stage upgradation were detected in the eTURBT group (Table II).\u003c/p\u003e\u003cp\u003eFeedback from the pathologist showed that the orientation and tissue architecture had mean scores of 4 (largely interpretable) in the cTURBT group and 5 (clearly interpretable) in the eTURBT group. Artefactual changes were rated as mild (score 4) in the cTURBT group and minimal or absent (score 5) in the eTURBT group. Similarly, the quality of the muscularis propria was rated as mostly intact (score 4) in the cTURBT group and clearly intact (score 5) in the eTURBT group.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe key indicators of a high-quality TURBT include the completeness of tumor removal, status of resection margins, and the presence of detrusor muscle in the specimen. The presence of detrusor muscle in the pathologic specimen is a well-recognized surrogate parameter of high-quality resection [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In addition to better preservation of architecture for pathological assessment, the eTURBT technique may provide sufficient size and depth of resection and accurate pathological diagnosis.\u003c/p\u003e\u003cp\u003eHashem et al. (2021) reported an 8.5% incidence of bladder perforation in cTURBT, while eTURBT had 0%, indicating a significant reduction in complications with en bloc resection [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. D'Andrea et al. (2023) reported perforation in 12% of cases in cTURBT and 5.6% in eTURBT out of 194 cases in each group, again demonstrating a lower complication rate in eTURBT [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In the current study, the eTURBT group had no bladder perforations while the cTURBT group had one. This could be attributed to improved visualization, controlled tumor excision, early control of bleeding, and reduced deep muscle injury in eTURBT.\u003c/p\u003e\u003cp\u003eD'Andrea et al. (2023) reported an obturator reflex incidence of 16% in cTURBT and 8.4% in eTURBT, indicating that eTURBT nearly halves the risk [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Similarly, the current study showed that the obturator reflex occurred in cTURBT only (4/43, 9.3%; p-value\u0026thinsp;=\u0026thinsp;0.038). Absence of obturator reflex (0%) in the eTURBT group in the current study could be due to better visualization, precise tumor excision, and minimal electrical energy dispersion. Owing to the intermittent burst technique in eTURBT, in contrast to continuous current in cTURBT. However, it could not be concluded, as the procedure was done in obturator block in all cases; hence, it won't be fair to comment about the prevention of jerks with eTURBT based on the current study.\u003c/p\u003e\u003cp\u003eZhang et al. (2020) and D'Andrea et al. (2023) reported almost similar operative times in the two groups [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In contrast to this finding, the current study showed the mean operative time was significantly shorter in eTURBT (35.55 min) compared to cTURBT (43.97 min) (p\u0026thinsp;=\u0026thinsp;0.001). Similarly, Li et al. (2024) reported that eTURBT was more time-efficient, particularly for small to medium-sized tumors, with a mean operative time approximately 10 minutes shorter than cTURBT [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Less operative time in eTURBT compared to cTURBT was potentially due to more precise tumor removal and reduced need for repeated coagulation and resection cycles.\u003c/p\u003e\u003cp\u003eThe current study showed that eTURBT is more effective in obtaining detrusor muscle during transurethral resection (p\u0026thinsp;=\u0026thinsp;0.030). Similarly, D'Andrea et al. (2023) suggested eTURBT was superior to cTURBT in retrieval of detrusor muscle (80.7% vs. 71.1%; p\u0026thinsp;=\u0026thinsp;0.01) in their randomized, multicentric trial in 384 patients with up to three cTa-T1 NMIBC tumors of 1\u0026ndash;3 cm in size [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Hashem A et al. (2021) reported 98% significant improvement in holmium laser en-bloc resection (HolERBT) over 62% in cTURBT (98% vs 62%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.0019) among 100 patients with NMIBC who were randomly allocated to cTURBT or HolERBT [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003csup\u003e7\u003c/sup\u003e Gallioli A et al. (2022) found that the rate of detrusor muscle presence for eTURBT was noninferior to that for cTURBT (94% vs. 95%; p\u0026thinsp;=\u0026thinsp;0.8) among 248 patients (108 in cTURBT and 140 in eTURBT) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This could be due to precise cutting with better visualization of the plane with coagulation of feeding vessels.\u003c/p\u003e\u003cp\u003eThe current study identified the presence of tumor in 21.7% of patients undergoing re-TURBT, with a lower rate of presence of tumor in the eTURBT group than in the cTURBT group; however, this difference was statistically insignificant (p\u0026thinsp;=\u0026thinsp;0.497). One case of pathological tumor upgradation was observed in the cTURBT group, involving progression from pT1 high grade to pT2 high grade at re-TURBT. No cases of upgradation were detected in the eTURBT group; two cases remained Ta, and two cases remained T1. Similarly, Yanagisawa T et al. (2024), in a meta-analysis, found that in T1 patients initially treated with cTURBT, the pooled rates of any residual tumors and upstaging on re-TURBT were 31.4% and 2.8%, respectively [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A propensity score-matched analysis reported that the rate of any residual tumor on re-TURBT was significantly lower in the eTURBT group compared to the cTURBT group (15% vs. 36%; p\u0026thinsp;=\u0026thinsp;0.029), indicating improved quality of resection with eTURBT [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eQualitative assessment by the panel of pathologists in the current study implied that eTURBT yielded higher quality specimens with well-oriented tissue architecture and fewer artefactual changes (cautery effect and crush artefact), improving diagnostic precision and potentially impacting clinical decision-making. Similarly, Kannan et al. suggested that eTURBT is a technique that has chances of high-quality detrusor muscle sampling with minimizing crush artifacts and cautery damage [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe present study has certain limitations. Sample size was relatively small, and the follow-up period was short-term, restricting the ability to assess long-term outcomes and recurrence rates.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEn bloc TURBT demonstrated a higher presence of detrusor muscle in specimens with primary bladder tumors fewer than or equal to 3, with a size up to 3 cm. Moreover, eTURBT had the shorter operative time and yielded higher-quality specimens, improving diagnostic precision and potentially impacting clinical decision-making.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003cp\u003eThis study was reviewed and approved by the Institutional Review Board of National Academy of Medical Sciences, Kathmandu (registration number 82/2081/82). The study did not involve animals.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003cp\u003eWritten informed consent was obtained from the patient who were involved in the study.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003cp\u003eData availability\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eNo funding was received to conduct this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eB.B.T.: Study execution, data collection,data analysis, editing and article writing.A.S.: Study concept, design, Critical revision, and final manuscript editing.P.M.S.: Study execution and Critical revision of the manuscript.B.A., A.K.S., U.M.: Critical revision of the manuscript.N.R., J.K.M, R.S.: Study execution\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e\u003cp\u003eB.B.T.: Study execution, data collection,data analysis, editing and article writing.\u003c/p\u003e\u003cp\u003eA.S.: Study concept, design, Critical revision, and final manuscript editing.\u003c/p\u003e\u003cp\u003eP.M.S.: Study execution and Critical revision of the manuscript.\u003c/p\u003e\u003cp\u003eB.A., A.K.S., U.M.: Critical revision of the manuscript.\u003c/p\u003e\u003cp\u003eN.R., J.K.M, R.S.: Study execution\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNieder AM, Brausi M, Lamm D, et al. 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Transurethral en bloc resection of nonmuscle invasive bladder cancer: trend or hype. \u003cem\u003eCurr Opin Urol\u003c/em\u003e. 2017;27(2):182-190. https://doi:10.1097/MOU.0000000000000377\u003c/li\u003e\n\u003cli\u003eMastroianni R, Brassetti A, Krajewski W, et al. Assessing the Impact of the Absence of Detrusor Muscle in Ta Low-grade Urothelial Carcinoma of the Bladder on Recurrence-free Survival. \u003cem\u003eEur Urol Focus\u003c/em\u003e. 2021;7(6):1324-1331. https://doi:10.1016/j.euf.2020.08.007\u003c/li\u003e\n\u003cli\u003eGontero P, Birtle A, Comp\u0026eacute;rat E, et al. EAU Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and CIS). \u003cem\u003eINVASIVE Bladder CANCER\u003c/em\u003e. Published online 2024.\u003c/li\u003e\n\u003cli\u003eKim LHC, Patel MI. Transurethral resection of bladder tumour (TURBT). \u003cem\u003eTransl Androl Urol\u003c/em\u003e. 2020;9(6):3056-3072. https://doi:10.21037/tau.2019.09.38\u003c/li\u003e\n\u003cli\u003eD\u0026rsquo;Andrea D, Soria F, Hurle R, et al. En Bloc Versus Conventional Resection of Primary Bladder Tumor (eBLOC): A Prospective, Multicenter, Open-label, Phase 3 Randomized Controlled Trial. \u003cem\u003eEur Urol Oncol\u003c/em\u003e. 2023;6(5):508-515. doi:https://doi.org/10.1016/j.euo.2023.07.010\u003c/li\u003e\n\u003cli\u003eZhang J, Wang L, Mao S, et al. Transurethral en bloc resection with bipolar button electrode for non-muscle invasive bladder cancer. \u003cem\u003eInt Urol Nephrol\u003c/em\u003e. 2018;50(4):619-623. https://doi:10.1007/s11255-018-1830-0\u003c/li\u003e\n\u003cli\u003eLi D xiong, Yu Q xin, Wu R cheng, Wang J, Feng D chao, Deng S. Efficiency of transurethral en-bloc resection vs. conventional transurethral resection for non-muscle-invasive bladder cancer: An umbrella review. \u003cem\u003eCancer Med\u003c/em\u003e. 2024;13(11):e7323. https://doi.org/10.1002/cam4.7323\u003c/li\u003e\n\u003cli\u003eGallioli A, Diana P, Fontana M, et al. En Bloc Versus Conventional Transurethral Resection of Bladder Tumors: A Single-center Prospective Randomized Noninferiority Trial. \u003cem\u003eEur Urol Oncol\u003c/em\u003e. 2022;5(4):440-448. https://doi:10.1016/j.euo.2022.05.001\u003c/li\u003e\n\u003cli\u003eYanagisawa T, Mori K, Motlagh RS, et al. En Bloc Resection for Bladder Tumors: An Updated Systematic Review and Meta-Analysis of Its Differential Effect on Safety, Recurrence and Histopathology. \u003cem\u003eJ Urol\u003c/em\u003e. 2022;207(4):754-768. https://doi:10.1097/JU.0000000000002444\u003c/li\u003e\n\u003cli\u003eMp08-08 en bloc resection versus conventional turbt for t1hg bladder cancer: a propensity score-matched analysis. SciSpace - Paper. https://doi:10.1097/ju.0000000000003223.08\u003c/li\u003e\n\u003cli\u003eKannan D, Sekaran PG, Sankaran S, et al. The Impact of En-bloc Transurethral Resection of Bladder Tumour on Clinical, Pathological and Oncological Outcomes: A Cohort Study. \u003cem\u003eCureus\u003c/em\u003e. 15(7):e42523. https://doi:10.7759/cureus.42523\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable I\u003c/strong\u003e \u0026ndash; Baseline characteristics of participants\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ecTURBT\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 43)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eeTURBT\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 44)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ep - value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eMedian age, in years (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e65 (56 -71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e59.50 (50 -71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.085\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eSex, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e30 (69.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e38 (86.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e13 (30.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e5 (13.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eMean tumor size,\u0026nbsp;in mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e24.26 \u0026plusmn; 4.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e22.02 \u0026plusmn; 7.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eMean number of tumors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e1.53 \u0026plusmn; 0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e1.48 \u0026plusmn; 0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.702\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eTumor location\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.481\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eRight lateral wall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e10 (23.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e14 (31.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eLeft lateral wall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e13 (24.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e9 (20.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eAnterior wall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ePosterior wall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e18 (41.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e20 44.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eTrigone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Dome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIQR \u0026ndash; Interquartile range\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable II\u003c/strong\u003e \u0026ndash; Clinico-pathologic features of participants \u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ecTURBT\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 43)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eeTURBT\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 44)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eP - value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003ePerforation, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.309\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e42 (97.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e44 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eObturator reflex, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.038\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (9.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e39(90.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e44 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eMean operative time, mins\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e43.42 \u0026plusmn; 10.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e35.55 \u0026plusmn; 11.60\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eMacroscopic detrusor muscle present,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e43 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e44 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eMicroscopic detrusor muscle in the specimen, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.030\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e36 (83.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e43 (97.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e7 (16.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003epT stage, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.486\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eNo tumor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (6.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003epTa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e23 (53.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e24 (54.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003epT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e14 (32.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e17 (38.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003epT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (9.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 (6.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eGrade (WHO 2004), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.336\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e19 (44.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e19 (43.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e22 (51.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e25 (56.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eRe-TURBT, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e21 (48.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e25 (56.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003ePresence of tumor in Re-TURBT, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.497\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4 (16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e15 (71.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e21 (84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eRe-TURBT pT stage, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.720\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eNo tumor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e15 (71.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e21 (84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003epTa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (9.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003epT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003epT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eUpgradation of tumor, n (%)\u003c/p\u003e\n \u003cp\u003ePathologist feedback on quality of specimen, n (pathologist)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1(4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eOrientation and tissue architecture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e4 (largely interpretable)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e5 (clearly interpretable)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eArtefactual changes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e4 (mild)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e5 (minimal or absent)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eQuality of the muscularis propria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e4 (mostly intact)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003e5 (clearly intact)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Transurethral resection of bladder tumor, conventional piecemeal resection, en bloc resection, detrusor muscle, quality of specimen","lastPublishedDoi":"10.21203/rs.3.rs-7094925/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7094925/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eTransurethral resection of bladder tumor (TURBT) is the crucial and standard approach in the diagnosis and management of urinary bladder cancer. This study compares conventional piecemeal and en bloc resection techniques in terms of detrusor muscle presence in resected specimens, surgical safety, and feasibility.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA prospective comparative study conducted from April 2024 to March 2025 included patients with up to three bladder tumors, measuring\u0026thinsp;\u0026le;\u0026thinsp;3 cm, who were alternately assigned to undergo either conventional piecemeal resection or en bloc resection. The primary outcome was the presence of detrusor muscle in the resected specimen. Secondary outcomes included operative time duration, bladder perforation, and obturator reflex. The quality of tissue was assessed by pathologists using a Likert scale.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eEighty-seven patients were included, 43 in the conventional and 44 in the en bloc group. The baseline characteristics and tumor size were comparable. Presence of detrusor muscle in specimens was higher in en bloc group (97.7% vs 83.7%; p\u0026thinsp;=\u0026thinsp;0.030). Operative duration was shorter in the en bloc group (35.55 minutes vs 43.42 minutes; p\u0026thinsp;=\u0026thinsp;0.001). A case of bladder perforation was observed in the conventional group. Pathologists observed better specimen orientation and architecture in the en bloc group. Presence of tumor in re-TURBT was 16.0% in the en bloc group and 28.6% in the conventional group (p\u0026thinsp;=\u0026thinsp;0.497).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eEn bloc resection yielded a higher presence of detrusor muscle and shorter operative duration with better specimen quality compared to conventional piecemeal resection for tumor\u0026thinsp;\u0026le;\u0026thinsp;3 cm.\u003c/p\u003e","manuscriptTitle":"En bloc versus conventional resection of primary bladder tumor in terms of presence of detrusor muscle in biopsy specimen: a prospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-21 07:26:55","doi":"10.21203/rs.3.rs-7094925/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bc7517c1-83ee-4a4d-b126-e067f4789e02","owner":[],"postedDate":"July 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-06T20:53:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-21 07:26:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7094925","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7094925","identity":"rs-7094925","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}