LETTER TO EDITOR
Year : 2020  |  Volume : 36  |  Issue : 3  |  Page : 236

Re: Maheshwari PN, Arora AM, Sane MS, Jadhao VG. Safety, feasibility, and quality of holmium laser en bloc resection of nonmuscle invasive bladder tumors: A single-center experience. Indian J Urol 2020;36:106-11

Swarnendu Mandal¹, Suvradeep Mitra², Sumit Agrawal¹, Manoj K Das¹, Prasant Nayak^1
1 Department of Urology, AIIMS, Bhubaneswar, Odisha, India
² Department of Pathology, AIIMS, Bhubaneswar, Odisha, India

Correspondence Address:
Dr. Swarnendu Mandal
Department of Urology, AIIMS, Bhubaneswar, Odisha
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/iju.IJU_198_20

1. In four patients, the tumor was large (largest being 40 mm) and could not be evacuated with an Ellick's evacuator. In such cases, a glass Toomey syringe can remove a large tumor because it creates greater negative pressure. The trick of using it is to keep the bladder relatively empty and apply negative suction with the syringe. Cutting/morcellation of the tumor in the bladder theoretically leads to tumor cell scatter and increases the risk of implantation, thus defeating one of the purposes of en bloc resection
2. Thermal damage due to monopolar/bipolar leads to artifacts, making histopathological examination (HPE) difficult, leading to errors in reporting. Qualitative and quantitative thermal damage on the HPE specimen has been described by Murugavaithianathan et al.^[2] Thermal damage was quantified into three grades according to the quantity of thermal artifacts.^[2] Grade 1 is defined as thermal artifacts involving less than one-third of the entire specimen. Tissues with one-third to two-thirds thermal artifacts were categorized as Grade 2, and tissues with more than two-thirds thermal artifacts were categorized as Grade 3. Thermal damage was also qualitatively analyzed according to the following grades: Grade 0 is defined as no thermal damage; Grade 1 included those specimens where cellular structures were identifiable and not impaired; Grade 2 included those with impaired cellular structure and nuclei but readable with difficulty; and Grade 3 included those with complete loss of cellular architecture and not readable. Do we encounter such damages with laser?
3. The authors mention improvement in the detection of detrusor muscle from 75% (in first 20 patients) to 85% (in the next 20 patients) and to 93% (in the final 20 patients) due to improvement in surgeon experience. Higher chance of detection of detrusor is another advantage of en bloc resection. Thus, it has to also be evaluated whether the technique (i.e., bipolar versus laser) or the human behind the machine is the reason behind these discrepancies? Further studies with both the techniques and different surgeons have to be planned in future to understand this
4. We all know that the limitation is high cost of 100 W laser and bipolar en bloc TURBT is a cheaper substitute.

References

1.	Maheshwari PN, Arora AM, Sane MS, Jadhao VG. Safety, feasibility, and quality of holmium laser en-bloc resection of nonmuscle invasive bladder tumors – A single-center experience. Indian J Urol 2020;36:106-11.     [Full text]
2.	Murugavaithianathan P, Devana SK, Mavuduru R, Kumar S, Singh SK, Mandal AK, et al. Bipolar transurethral resection of bladder tumor provides better tissue for histopathology but has no superior efficacy and safety: A randomized controlled trial. J Endourol 2018;32:1125-30.