Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : June | Volume : 17 | Issue : 6 | Page : PC01 - PC05 Full Version

Comparison of Bipolar and Monopolar Transurethral Resection of Bladder Tumours: A Randomised Clinical Study


Published: June 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/56810.17998
MD Faizul Haque, Samir Swain, Aparajita Mishra, Sabyasachi Panda, Datteswar Hota

1. Associate Professor, Department of Urology, SCB Medical College, Cuttack, Odisha, India. 2. Consultant, Department of Urology, SCB Medical College, Cuttack, Odisha, India. 3. Associate Professor, Department of Urology, SCB Medical College, Cuttack, Odisha, India. 4. Consultant, Department of Urology, SCB Medical College, Cuttack, Odisha, India. 5. Consultant, Department of Urology, SCB Medical College, Cuttack, Odisha, India.

Correspondence Address :
Dr. Md Faizul Haque,
Associate Professor, Department of Urology, SCB Medical College, Cuttack-753007, Odisha, India.
E-mail: docfaiz2k5@gmail.com

Abstract

Introduction: The standard treatment of Urinary Bladder Cancer (UBC) is Transurethral Resection of Bladder Tumours (TURBT) commonly using a monopolar resection system. Bipolar-TURBT (B-TURBT) is associated with better haemostasis than Monopolar-TURBT (M-TURBT). Despite this, there exists controversy whether B-TURBT can completely replace M-TURBT.

Aim: To assess the perioperative outcomes of B-TURBT and compare it with the conventional monopolar system (M-TURBT).

Materials and Methods: The present randomised clinical study was conducted in the Department of Urology at SCB Medical College, Cuttack, Odisha, India between January 2018 and January 2020. Fifty patients of either sex, aged >18 years with urinary bladder tumour size of ≤4 cm were included in the study. Patients were randomly assigned into B-TURBT and M-TURBT treatment groups. Demographic data (age and sex), morphology, location, shape, grade, stages of transitional cell carcinoma, degree of artifact were analysed and compared. Data were analysed using Statistical Package for the Social Sciences (SPSS) version 23.0. The qualitative and quantitative variables between the groups were compared using independent sample t-test and chi-square test, respectively. A p-value <0.05 was considered statistically significant.

Results: A total of 50 patients with UBC were evaluated in the present study where the majority of patients were male 45 (90.0%) with mean age 60.9 years. The most common morphologies were papillary tumour (28.0%), broad solid mass (22.0%), and papillary solitary (22.0%). Total 25 patients underwent M-TURBT and 25 patients underwent B-TURBT. Older patients (>55 years) had a higher rate of severe artifact compared to younger patients (<55 years). The B-TURBT had a significantly lower rate of artifact compared to M-TURBT (p-value <0.001). The need for secondary procedure was comparatively higher in M-TURBT than in bipolar resection (p-value=0.253). The obturator jerk and bladder perforation were not observed in this study.

Conclusion: The B-TURBT had a lower incidence of severe artifact and restaged TURBT as compared to M-TURBT. Thus, B-TURBT is a safer and more effective treatment for patients with UBC.

Keywords

Artifact, Bladder perforation, Haemostasis, Papillary tumour

Urothelial carcinoma of urinary bladder is one of the most common urological malignancies which is enormously rising in India and worldwide with a prevalence rate of 1.8% in Indians (1). As per the GLOBOCAN 2020, bladder cancer is the most frequently encountered cancer among men. It was estimated to have nearly 440,864 new cases of bladder cancer per year accounting for 4.4% of total new detected cases globally (2).

TURBT is the cornerstone of diagnosis of bladder cancer and remains as an initial therapy of the urothelial carcinoma of urinary bladder (3). Monopolar systems used for resection of urinary bladder utilise patients’ bodies as electrical conduits. The heat generated from M-TURBT mainly facilitates the cutting of tissues (4). Unfortunately, it is associated with obturator jerk, intraoperative bleeding, bladder perforation, and desiccation of small cells (5). The introduction of bipolar technology is acquiring recognition among urologists for its efficacy in TUR of urothelial carcinoma of urinary bladder with fewer complications (5). In this technique, the electric current flowing between the active and passive pole situated on a specifically developed sheath completes the circuit, without passing through the patient (6). Moreover, B-TURBT is associated with better haemostasis with a lesser risk for developing obturator jerk and further damage (7),(8).

Despite this, whether B-TURBT can completely replace M-TURBT as a safer alternative for TUR, it remains controversial as the previous studies comparing bipolar to monopolar energies for TUR provided conflicting results (9),(10),(11),(12).

Previous studies did not find any significant difference related to blood loss, obturator nerve reflex, operative time, catheterisation time, need for secondary procedure, and recurrence-free survival rate (13),(14).

Therefore, the present study efforts are made to compare the impact of bipolar and monopolar resection on obturator nerve reflex, degree of artifacts, muscularis propria invasion, need for secondary procedure, obturator jerk, and bladder perforation.

Material and Methods

This was a single center randomised, clinical trial conducted in the Department of Urology at SCB Medical College, Cuttack, Odisha, India between January 2018 and January 2020. The study was conducted in accordance with ethical principles that are consistent with the Declaration of Helsinki. The study protocol was approved by Institutional Review Board/Ethics Committee (SCB Medical College and Hospital, Cuttack, Odisha; Approval No.: 55). Written informed consent was obtained from all the patients.

Inclusion criteria: The patients with UBC undergoing TURBT were evaluated in this study. Patients of either sex, aged >18 years, with patients with urinary bladder tumour size of ≤4 cm on Contrast Enhanced Computed Tomography (CECT) scan were included in the study.

Exclusion criteria: Patients with recurrent bladder tumours, metastatic disease, tumour size of >4 cm, young patients aged ≤18 years, or who were not giving consent or unfit for general anaesthesia were excluded from the present study.

Sample size calculation: Sample size (N) was calculated using 80% power and a 95% significance level for obturator jerk. Assuming a 30% incidence for the M-TURBT and a 5% incidence for the B-TURBT (12). The sample size was determined with the formula:

N=K×P1(1-P1)+P2(1-P2)/ (P1-P2)2

Where: N=sample size;
P1=prevalence of obturator jerk in M-TURBT;
P2=prevalence of obturator jerk in B-TURBT;
K=constant (The significance level was set as α=0.05).

A sample size of 25 in each arm was calculated using above formula, estimating a drop out of 10%.

Study Procedure

Spinal or General Anaesthesia (GA) was used for performing all the surgeries. Urology specialists having experience in performing both monopolar and B-TURBT conducted the surgery. GA and endotracheal intubation were carried out by placing the patient in supine position. Further, the patient was placed in the lithotomy position followed by cleaning of perineal skin with the antiseptic povidone-iodine solution (10%). The obturator nerve block was not performed before the procedure; TURBT was performed after a routine cystourethroscopy.

M-TURBT and B-TURBT (8): Monopolar resection was performed with a Storz Vaporcut (Karl Storz Endoscopy, Culver City, CA) (4 mm) resection loop 1.5% in case of M-TURBT, glycine was used as the irrigant. It was performed with a U-shaped cutting loop, 26 Fr continuous flow resectoscope with a 30° telescope, and an electrosurgical generator with power settings of 120 W for cutting and 80 W for coagulating using glycine irrigation. Bipolar resections resectoscope (Gyrus-AMCI TM, Superpulse generator, USA) was carried out using a plasma-kinetic superpulse generator with power settings of 100 W for cutting and 80 W for coagulating using normal saline irrigation. A thin plasmakinetic superloop was used to conduct resection, with normal saline as an irrigant. At the end of the operation, 26 Fr outer sheath with 24 Fr inner sheath 3-way Foley catheter was placed in all patients with continuous saline irrigation until the urine efflux was completely clean (8). In uncomplicated cases, a Foley catheter was removed after 24 to 48 hour and the patient was discharged. All patients underwent complete TURBT and deep muscle biopsies (resection loop) were taken in each patient. The specimen was observed for histopathological examination.

All patients with bladder tumour were evaluated with demographic characteristics (age and sex), morphology, size, stages of invasion (15), grade (16), and location of tumour, degree of artifact (17), and perioperative outcomes including age wise analysis with patients >55 years and ≤55 years were compared between B-TURBT and M-TURBT.

The American Joint Committee on Cancer (AJCC) Tumour-Node-Metastasis (TNM) system is widely used staging system to predict bladder cancer patient prognosis. T describes the growth of main (primary) tumour through the bladder wall, N indicates any lymph node involvement ranges from, and M indicates the metastasis of cancer at locations distant from the bladder such as lymph nodes or organs like the liver or lungs (15).

Stage pT1 bladder carcinoma: Invasion into lamina propria, but not into muscularis propria.
Stage pT2 bladder carcinoma: Tumour invasion into muscularis propria. It is subclassified into two categories:
pT2a- invasion of cancer less than one-half of the depth of muscular propria and
pT2b- invasion of cancer greater than one-half of the muscle wall.
Stage pT3 bladder carcinoma: Invasion of tumour into perivesical soft tissue or spread to the prostate, uterus, or vagina (15).

Outcomes: The primary outcome of the present study was to evaluate the presence of muscularis propria and invasion of muscularis propria and degree of cautery artifact in each specimen. The secondary outcome was to evaluate the efficacy of monopolar and B-TURBT along with complete tumour resection, need for secondary procedure, obturator jerk, and bladder perforation.

Definition: Cautery artifact is enlarged inflamed connective tissue fibers, blurring of nuclei, and vacuolisation as a consequence of the heating loop contact. It can be observed virtually in pathological specimens when M-TURBT and B-TURBT is used for TURBT, but can vary in severity (18). Based upon percentage of resected specimen involved the severity of cautery artifacts was categorised into absent (none), mild (<25%), moderate (25-50%), severe (>50%) (17).

Allocation concealment and blinding: Randomisation was done by the operating room technician and allocation concealment was done by a sealed envelopes. The surgery was then performed according of the randomisation results. Until the patient was on the operating table, the surgeon performing the procedure had no knowledge to which arm the patient had been assigned. A single central pathologist analysing all the samples was blinded to the procedure performed.

(Table/Fig 1) shows the CONSORT flow diagram.

Statistical Analysis

Data were analysed using SPSS version 23.0 (IBM Corporation, USA). Descriptive statistics were used to describe categorical variables (frequency and percentages) and continuous variables {mean and Standard Deviation (SD) or median and range (depending on the normality of data)}. Shapiro-Wilk test assessed the normal distribution of quantitative data. The Independent Sample t-test was used for the continuous variables and the Chi-square test for the categorical variables. A p-value <0.05 was considered statistically significant.

Results

A total of 50 patients with UBC undergoing TURBT were included in the analysis. The mean age was 60.9 years. The majority of patients were male 45 (90.0%) with male-female ratio of 9:1. The most common morphologies were papillary tumour (28%), broad solid mass (22%), and papillary solitary (22%). While, other less common morphologies reported were papillary broad-base tumour, solid, solitary broad-base solid, solitary solid, papillary solid, solitary broad-base papillary. Total 27 (54.0%) patients had low grade transitional cell carcinoma and 22 (44.0%) patients had high grade transitional cell carcinoma. Pathological results revealed 22 (44.0%) pTa low grade, 18 (36.7%) pT1 high grade, 8 (16.3%) and 2 (4.1%) pT2 high grade urothelial carcinomas. During the study period, 25 patients underwent M-TURBT and 25 patients underwent B-TURBT (Table/Fig 2).

Age groupwise analysis: The most common morphologies in the younger age group were papillary tumour (29.4%) and broad solid mass (23.5%). While in the case of older age group the most common morphologies were papillary solitary tumour (30.3%) and papillary tumour (27.3%) (p-value=0.065). Older patients (>55 years) had a higher rate of severe artifact compared to younger patients (≤55 years). The need for the secondary procedure was comparatively higher for older patients than for younger patients (48.5% vs. 23.5%) (Table/Fig 3).

Procedure wise analysis: There were 50 patients in the study, 25 in each of the two groups. In both the groups, the numbers of male patients were higher (B-TURBT: 92.0% vs. 8.0% and M-TURBT: 88.0% vs. 12.0%) than female patients. The mean age in M-TURBT and B-TURBT groups were 60.3 and 61.4 years, respectively (p-value=0.800). The most common morphologies in the B-TURBT group were papillary tumour (24%) and broad solid mass (28%). The proportion of muscularis propria invasion (pTa) (52.0% vs. 36.0%), lamina propria invasion (pT1) (40.0% vs. 32.0%) was higher in patients who underwent M-TURBT than B-TURBT. While the proportion of muscularis propria invasion (pT2) was higher in patients who underwent B-TURBT than M-TURBT (p-value=0.142). While in the case of M-TURBT the most common morphologies were papillary tumour (32.0%) and papillary solitary tumour (24.0%). The proportion of low and high grade urothelial carcinomas between B-TURBT and M-TURBT groups (p=0.142).

Bipolar resection had a significantly lower rate of artifact compared to monopolar resection (p-value<0.001). The need for secondary procedure was comparatively higher in M-TURBT than in bipolar resection (p-value=0.253). The findings of obturator jerk and bladder perforation were not reported in this study (Table/Fig 4).

Discussion

A TURBT is the gold standard for the initial management of bladder cancer (19). The present study compared the feasibility and safety of M-TURBT versus B-TURBT technique in the management of bladder cancer. The salient observations from the present study were: i) male preponderance; ii) the most common morphologies were papillary tumour, broad solid mass, and papillary solitary; iii) the results showed that older patients (>55-year-old) had a higher rate of severe artifact than younger patients (≤55 years); iv) bipolar resection had a significantly lower incidence of severe artifact compared to monopolar resection; v) need for the secondary procedure was comparatively higher in M-TURBT than in bipolar resection; vi) obturator jerk and bladder perforation was not found in this study.

The sex differences in bladder cancer appear to have a higher incidence in men than in women. Bolat D et al., found a similar incidence of higher prevalence of male patients over female patients (Men: n=72; women: n=8) (8). In another study, Teoh JY et al., reported men predominance over women in UBC (20). Similarly, the present study also revealed the same trend related to the sex ratio (M:F=9:1). In the present study, higher number of patients had low grade disease (n=27, 54%) which is consistent with Hashad MM et al., (n=115, 57.5%) and Bolat D et al., (n=58, 73.4%) (7),(8); however, 36.7% patients had pT1 (lamina propria invasion) similar to Bolat D et al., (8).

Histologically, common morphological characteristics of UBC are papillary carcinoma, solid, and tubular and depending on the cell aspect, eosinophilic, and basophilic carcinomas (21). T1 lesions may have either a papillary or a broad-based appearance and T2 consists of higher lesions generally have heterogeneous hypointense or mixed signal solid based appearance (22),(23). In the present study, most common morphologies of UBC were papillary tumour, broad solid mass, and papillary solitary.

The incidence of cautery artifact mainly relies on the amount of heat generated during resection, duration of loop contact with tissue, loop size, and tissue composition (22). Venkatramani V et al., demonstrated a significantly lower incidence of severe cautery artifact in the B-TURB than in the M-TURBT (25 vs. 46.7%, p-value=0.0096) (11). Recently published meta-analysis study also noted lower risk of thermal damage for B-TURBT relative to those treated via M-TURBT {Relative Risk (RR)=0.66; 95% CI=0.55-0.78; p-value <0.0001} (24). In concordance with previous studies, the present study demonstrates that B-TURBT is more effective and safer that exhibits a lower incidence of severe cautery artifact than M-TURBT. Further, in contrast to the above aforementioned literature, the other three randomised clinical trials revealed that there were no statistically significant differences between B-TURBT and M-TURBT with regards to cautery artifact incidence (8),(13),(25).

A previous prospective study by Bolat D et al., revealed that complete resection was comparatively higher for B-TURBT than M-TURBT (89.2% vs. 78.5%) (8). Murugavaithianathan P et al., conducted a randomised clinical trial assessing the efficacy of M-TURBT and B-TURBT. The results alluded that complete resection of the tumours was noted in all cases, in both groups. Moreover, the restaged TURBT was associated with the M-TURBT technique (26). This outcome is consistent with the results of the present study wherein need for secondary TURBT was highly associated with M-TURBT than B-TURBT.

Most urologists face a major concern of achieving complete resection of the bladder tumour without any contraindications. An incidence of obturator jerk during TURBT mainly depends upon the site of the tumour and type anaesthesia used (27). In the previous prospective study, evaluating short-term outcomes of M-TURBT and B-TURBT, the incidence of obturator reflex was significantly higher in patients who underwent M-TURBT than B-TURBT (16.7% vs. 2.1%, p-value=0.007) (14). In another study, obturator reflex was significantly higher in the M-TURBT group, than in the B-TURBT group (p-value=0.025) (28). Additionally, Del Rosso A et al., Mashni J et al., and Liem EIML et al., reported equal incidence of obturator jerks between both techniques (13),(27),(29). In contrast to these studies, the present study did not reported the incidence of obturator jerk in both groups. Conversely, Gupta NP et al., and Ozer K et al., reported a significantly the higher incidence of obturator jerks in three patients for B-TURBT due to higher power setting of the bipolar machine (30),(31).

Limitation(s)

There were certain limitations in the present study. The present study did not analyse the serum electrolyte levels. Lastly, this was a single centre, single arm study with a smaller sample size which restricts the overall inference in terms of safety and efficacy of TURBT technique to generalised population.

Conclusion

The M-TURBT and B-TURBT are feasible techniques for the management of UBC. The B-TURBT has a lower incidence of severe artifact and a lower rate of restaged TURBT as compared to M-TURBT. Thus, the present study recommends B-TURBT as a safer and more effective treatment for patients with UBC.

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DOI and Others

DOI: 10.7860/JCDR/2023/56810.17998

Date of Submission: Apr 01, 2022
Date of Peer Review: Jun 29, 2022
Date of Acceptance: Jan 30, 2023
Date of Publishing: Jun 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 26, 2022
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• iThenticate Software: Dec 13, 2022 (23%)

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