Chapter 7
Surgical Techniques & Surveillance
Bipolar en bloc resection (ESD), re-staging TURBT indications, blue light cystoscopy, and evidence-based post-operative surveillance schedules for high-grade NMIBC.
Bipolar En Bloc Resection (ERBT / ESD)
En bloc resection of bladder tumour (ERBT), also referred to as endoscopic submucosal dissection (ESD) of bladder tumours, represents a paradigm shift from conventional transurethral resection of bladder tumour (cTURBT). Unlike cTURBT which fragments the tumour into multiple chips, ERBT removes the entire lesion as a single specimen including the underlying detrusor muscle layer, providing superior pathological assessment and potentially reducing recurrence.
Bipolar ESD Technique — Step by Step
- Tumour Marking: Circumferential marking 5–10 mm from the tumour margin using bipolar coagulation dots.
- Submucosal Injection: Inject saline or glycine solution submucosally to create a fluid cushion elevating the tumour from the detrusor layer. This step is optional for experienced operators but recommended for flat lesions.
- Circumferential Incision: Using a bipolar loop or Collins knife at the marked boundary, incise the mucosa and submucosa circumferentially around the tumour base.
- Submucosal Dissection: Dissect the plane between the tumour/submucosa and the detrusor muscle using bipolar energy in a retrograde fashion (distal to proximal). The saline irrigation medium eliminates obturator nerve reflex risk.
- En Bloc Retrieval: Retrieve the specimen en bloc using an Ellik evacuator or grasping forceps. Orient the specimen for pathological assessment (ink the deep margin if needed).
- Base Biopsy & Haemostasis: Take a separate biopsy from the tumour bed (deep muscle) for staging confirmation. Achieve haemostasis with bipolar coagulation.
Energy Modalities for En Bloc Resection
| Modality | Medium | ONR Risk | Key Advantage |
|---|---|---|---|
| Bipolar (PlasmaKinetic) | Normal saline | None | No TUR syndrome; widely available |
| Holmium Laser (HoLEBT) | Normal saline | None | Precise cutting; minimal thermal damage |
| Thulium Laser (TmERBT) | Normal saline | None | Excellent haemostasis; thin cutting zone |
| Monopolar (conventional) | Glycine/Sorbitol | High (lateral wall) | Widely available; low cost |
| HybridKnife (ESD) | Normal saline | None | Waterjet + electrocautery; GI ESD adapted |
Clinical Evidence: ERBT vs. Conventional TURBT
| Study | Design | 1-yr Recurrence | Key Finding |
|---|---|---|---|
| Teoh et al. 2023 (Hong Kong RCT) | Multicentre RCT, 13 centres | ERBT 28.5% vs. TURBT 38.1% | Non-inferior; trend toward superiority |
| Global ERBT Registry 2026 | 74 institutions, 27 countries, n=2630 | — | 97% technical success; 85% clear margins in NMIBC |
| Pereira et al. EAU 2026 (HoLEBT) | Prospective RCT, tumours >3 cm | Comparable DFS | Perforation 2.2% vs 21.6% (p=.006); 0% ONR |
| Basile et al. 2025 (Meta-analysis) | Systematic review & meta-analysis | Lower with ERBT | Lower ONR risk; higher detrusor muscle presence |
"This global data suggests that en bloc resection is no longer an experimental technique, but a surgical approach ready for broader adoption."
— Yanagisawa T, Global ERBT Registry, EAU 2026Re-staging TURBT (Repeat TUR)
Re-staging transurethral resection (reTUR) is a critical step in the management of high-risk NMIBC. It serves dual purposes: therapeutic (removing residual tumour) and staging (detecting understaging of the initial resection). All major guidelines (AUA, EAU, IBCG) recommend reTUR for T1 tumours and in cases where the initial resection is deemed incomplete.
Indications for Re-staging TURBT
Absolute Indications
- All T1 high-grade tumours
- Incomplete initial resection
- Absence of detrusor muscle in specimen (except TaLG and primary CIS)
- Large or multifocal high-grade Ta
May Be Omitted When
- Complete en bloc resection with clear deep margin and detrusor present
- Small solitary TaHG with detrusor in specimen
- Primary CIS without papillary component (if mapping biopsies adequate)
Timing & Outcomes
| Parameter | Recommendation |
|---|---|
| Timing | 2–6 weeks after initial TURBT (IBCG recommendation) |
| Residual tumour rate | 33–55% for T1 tumours at reTUR |
| Upstaging rate | 4–25% upstaged to T2 (muscle-invasive) |
| Impact on progression | Progression 7% with reTUR vs. 31% without (Sfakianos et al.) |
"A second TURBT should be performed in all T1 tumours and whenever the initial resection was incomplete. This is both a therapeutic and a staging procedure."
— EAU Guidelines on NMIBC, 2024ERBT & Re-staging: A Changing Paradigm
With en bloc resection providing complete specimens with clear margins and detrusor muscle presence rates >85%, some experts argue that re-staging TURBT may be safely omitted after a well-performed ERBT with confirmed clear deep margins. However, this remains controversial and prospective validation is ongoing.
Blue Light Cystoscopy (BLC)
Blue light cystoscopy (BLC) with hexaminolevulinate (HAL) is a photodynamic diagnostic technique that significantly improves the detection of non-muscle invasive bladder cancer, particularly carcinoma in situ (CIS) which is often invisible under standard white light cystoscopy (WLC). HAL is instilled intravesically 1 hour before the procedure; it is preferentially absorbed by neoplastic cells and converted to fluorescent porphyrins that emit red-pink fluorescence under blue-violet light (380–450 nm).
Clinical Evidence for BLC
| Outcome | BLC vs. WLC | Evidence |
|---|---|---|
| Additional CIS detection | +25–30% more CIS lesions detected | Daneshmand 2018 (Phase III) |
| Additional Ta/T1 detection | +14–25% more papillary tumours | Meta-analysis (Burger 2013) |
| Recurrence reduction | 9–12 month RFS improvement | Stenzl et al. 2010 |
| Office-based surveillance | Flexible BLC detects recurrences missed by WLC | Phase III China (2023) |
Guideline Recommendations
- AUA/SUO 2024: Clinicians should offer BLC at the time of TURBT when available, particularly for CIS or high-risk disease.
- EAU 2024: Use photodynamic diagnosis (PDD) with HAL-guided biopsies when CIS is suspected or in high-risk patients.
- NCCN: Consider BLC for initial TURBT and surveillance in patients with CIS or high-grade disease.
"Blue light cystoscopy in the operating room significantly improves the detection of carcinoma in situ and detects lesions that are missed with white light cystoscopy."
— Daneshmand S et al., Phase III BLC Trial, J Urol 2018Post-Operative Surveillance Schedule
Structured surveillance is essential for all NMIBC patients due to the high risk of recurrence and progression. The intensity and duration of follow-up are determined by risk stratification. The first cystoscopy at 3 months post-TURBT is the most important prognostic indicator.
Risk-Stratified Surveillance Protocol
| Time Point | Low Risk | Intermediate Risk | High Risk |
|---|---|---|---|
| 3 months | Cystoscopy | Cystoscopy + cytology | Cystoscopy + cytology |
| 6 months | — | Cystoscopy + cytology | Cystoscopy + cytology |
| 9 months | — | Cystoscopy + cytology | Cystoscopy + cytology |
| 12 months | Cystoscopy | Cystoscopy + cytology | Cystoscopy + cytology + imaging |
| Year 2 (every 6 mo) | — | Cystoscopy + cytology | Cystoscopy + cytology q3mo |
| Year 3 (every 6 mo) | Cystoscopy annually | Cystoscopy + cytology | Cystoscopy + cytology q4mo |
| Year 4–5 | Annual cystoscopy | Annual cystoscopy + cytology | Cystoscopy + cytology q6mo |
| Beyond 5 years | Discharge or annual | Annual cystoscopy | Lifelong annual cystoscopy + cytology |
Upper Tract Imaging
- High-risk patients: CT urography annually or every 2 years to evaluate for upper tract urothelial carcinoma (UTUC).
- CIS patients: Annual upper tract imaging recommended due to field effect and higher UTUC risk.
- Low-risk patients: Upper tract imaging not routinely required unless symptoms develop.
Surveillance Modalities Summary
| Modality | Role | Sensitivity | Notes |
|---|---|---|---|
| White light cystoscopy | Standard surveillance | 62–84% | May miss flat CIS |
| Blue light cystoscopy | Enhanced detection | 92–97% | Superior for CIS; requires HAL |
| Urine cytology | Adjunct to cystoscopy | High for HG (90%+) | Low sensitivity for LG |
| CT urography | Upper tract evaluation | 85–95% | Annual for high-risk; radiation exposure |
| Urine biomarkers | Investigational adjunct | Variable | Cxbladder, UroVysion, NMP22 |
"The first cystoscopy at 3 months after TURBT is the most important prognostic indicator. A tumour-free status at 3 months is associated with significantly better long-term outcomes."
— EAU Guidelines on NMIBC Follow-up, 2024Key References
- Teoh JYC, et al. En bloc resection vs conventional TURBT: multicentre RCT from Hong Kong. Eur Urol. 2023;84(4):390-399.
- Yanagisawa T, et al. Global ERBT Registry — first descriptive analysis. Presented at EAU 2026. Abstract A0081.
- Pereira M, et al. HoLEBT vs TURBT for large NMIBC: prospective RCT. Presented at EAU 2026. Abstract LB010.
- Basile G, et al. En bloc vs conventional TURBT: systematic review & meta-analysis. Eur Urol Open Sci. 2025;73:102-115.
- Yanagisawa T, et al. Repeat TUR for T1 NMIBC: systematic review. Eur Urol Focus. 2024;10(1):28-40.
- Bhirud DP, et al. When to avoid restaging TURBT. Indian J Urol. 2022;38(4):273-278.
- Daneshmand S, et al. Blue light cystoscopy with HAL: Phase III trial. J Urol. 2018;199(5):1158-1165.
- Burger M, et al. Photodynamic diagnosis of NMIBC: meta-analysis. Eur Urol. 2013;64(5):846-854.
- Stenzl A, et al. HAL-guided BLC reduces recurrence. J Urol. 2010;184(5):1907-1913.
- EAU Guidelines on Non-muscle-invasive Bladder Cancer. 2024 Edition.
- AUA/SUO Guideline: Non-Muscle Invasive Bladder Cancer. 2024 Amendment.