Bipolar Transurethral Resection of Bladder Tumour (bTURBT) has drawbacks, including piecemeal resection, reliance on surgeon’s intuition for completeness, separate muscularis-propria (MP) sampling, and potential for thermal damage of specimen. Additionally, Obturator Nerve Reflex (ONR) is not fully eliminated. This study investigates if Holmium Laser en bloc Resection of Bladder Tumour (HoLERBT) can address these issues by comparing clinical and pathological outcomes between bTURBT and HoLERBT (primary objective- thermal artefacts in specimens).

This ethics-approved (PG Thesis/2022-23/40), CTRI registered (CTRI/2022/08/045042) open-label, parallel-group, prospective-non-randomised-study was conducted at a single-centre between August 2022 and March 2024. Patients with tumours ≤ 4 cm and ≤ 4 in number were included. Intervention was decided post-cystoscopy. HoLERBT involved en-bloc retrieval of tumors with MP. Specimens were assessed for degree of thermal artefacts qualitatively and quantitatively, and an Overall-Artefact-Score (OAS) was assigned. The ability to subclassify T1 tumors (T1a/T1b/T1c) was evaluated.

Ninety-one (51 bTURBT, 40 HoLERBT) patients were analysed. HoLERBT specimens exhibited significantly fewer thermal-artefacts both quantitatively and qualitatively [OAS 3(3-4) vs 2(2-2); p<0.001]. Surgeons preferred bTURBT for larger tumors (median 30 vs 21mm, p 0.001). HoLERBT had lower ONR (37.25% vs 0%, p<0.001), higher Mitomycin-C instillation rates (64.71% vs 90%, p0.007), quicker resection and hemostasis times, though retrieval took longer. HoLERBT allowed better T1 subclassification (40% vs 80%, p0.040) and superior resection margin evaluation (2.16% vs 100%, p<0.001). Perioperative complications except ONR-related perforation (15.6% vs 0%, p<0.001) were comparable.

HoLERBT is a safe and effective technique, yielding higher quality histopathological specimens, better R0 resection, and enhanced T1 sub-staging. It eliminates ONR and improves Mitomycin-C instillation rates compared to bTURBT.