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En-bloc transurethral resection vs. conventional transurethral resection for primary non-muscle invasive bladder cancer: A meta-analysis
Resección transuretral en bloque vs. resección transuretral convencional para el cáncer de vejiga primario no músculo-infiltrante: metaanálisis
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(a) Axial contrast-enhanced CT image revealing a low-enhancing renal mass (arrow) in a 72-year-old man. (b) Axial contrast-enhanced CT image showing a low-attenuating renal mass with peripheral enhancement (arrow) in a 72-year-old woman. (c) Sagittal T1-weighted MR image demonstrating a low-intensity mass at the bladder dome (arrow) in a 55-year-old man. (d) Granulomatous prostatitis in a 71-year-old man. The axial CT image shows possible extraprostatic extension (arrow). (e) A penile nodule was seen just proximal to the glans penis in a 71-year-old man. The axial T1-weighted MR image demonstrates a low-intensity nodule with peripheral hyperintensity (arrow).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "T. Soda, Y. Tashiro, S. Koike, R. Ikeuchi, T. Okada" "autores" => array:5 [ 0 => array:2 [ "nombre" => "T." "apellidos" => "Soda" ] 1 => array:2 [ "nombre" => "Y." "apellidos" => "Tashiro" ] 2 => array:2 [ "nombre" => "S." 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Di, H. Li, C. He, H. Peng" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Y." "apellidos" => "Di" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "H." "apellidos" => "Li" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "He" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:4 [ "nombre" => "H." "apellidos" => "Peng" "email" => array:1 [ 0 => "penghongliang_sci@outlook.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Urology, Hongqi Hospital Affiliated to Mudanjiang Medical University, Heilongjiang, China" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Urology, The Fourth Hospital of Changsha, Hunan, China" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resección transuretral en bloque vs. resección transuretral convencional para el cáncer de vejiga primario no músculo-infiltrante: metaanálisis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1163 "Ancho" => 3341 "Tamanyo" => 442980 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A forest plot of the catheterization-time of the En-bloc transurethral-resection compared with the conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Bladder-cancer is one of the most common genitourinary diseases. Over half a million new bladder-cancer subjects were diagnosed worldwide in 2018, with almost 200 thousand subjects’ cancer deaths. Bladder-tumor accounts for 7% of new cancer diagnoses and 4% of new deaths in men.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> For non-muscle-invasive bladder-cancer, conventional-transurethral-resection of bladder-tumor and intravesical chemotherapy or Bacille–Calmette–Guerin is the standard management.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The identification of detrusor muscle in the specimen is a vital factor for upcoming management and prognosis. Though, staging is regularly incorrect due to burning of the resected tissues and detrusor absence by transurethral-resection of bladder-tumor. Problems e.g. obturator-nerve-reflex and bladder-perforation might occur through the resection of lateral wall tumors, which is related to urinary-extravasation and neoplasm-seeding.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Also, the bladder-tumor resected into parts is conflicting with the principle of tumor-free practice. Engilbertsson et al. had shown that conventional-transurethral-resection of bladder-tumor encouraged the bladder-tumor cell-seeding into the blood-circulation.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Though, it is now unidentified whether conventional-transurethral-resection of bladder-tumors will raise the rate of metastasis. After the transurethral-resection of bladder-tumor, the possibility of recurrence rate reaches up to 60% per year for TaT1, depending on the EORTC score and imperfect resection.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> So, to accomplish the whole resection, En-bloc transurethral-resection of bladder-tumors has been increasingly used in the management of bladder-tumors through the past years.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It can resect neoplasm with a 1 cm margin from the tumor base, separate detrusor muscle, and connective tissue, and comply with oncological principles. Also, the ability to eliminate the neoplasm might produce the value of shorter intervention time, since it avoids piece-by-piece removal by conventional-transurethral-resection of bladder-tumor, moreover elongated by the need to do frequent hemostasis to increase visibility.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> HybridKnife, needle electrode, and laser are the chief techniques for En-bloc transurethral-resection of bladder-tumor. A chain of studies comparing En-bloc transurethral-resection of bladder-tumor and conventional-transurethral-resection of bladder-tumor have been conveyed.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–30</span></a> Though the clinical recurrence rate among the two methodologies is controversial, fewer intraoperative and postoperative problems were witnessed with En-bloc transurethral-resection of bladder-tumor. Several meta-analyses showed that En-bloc transurethral-resection of bladder-tumor had a lower 24-month recurrence rate than conventional-transurethral-resection of bladder-tumor. Though, four recent randomized control-trials showed that no significant difference was observed in terms of 12-month, 18-month, or 24-month recurrence rate.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,10–12</span></a> the present meta-analysis aimed to evaluate the effect of En-bloc transurethral-resection compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">This meta-analysis is organized according to the epidemiology statement, after the established methodology.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study selection</span><p id="par0015" class="elsevierStylePara elsevierViewall">The main objective of this study was to compare the effect of En-bloc transurethral-resection compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer using the following tools e.g. odds-ratio (OR), mean-difference (MD), frequency rate, or relative-risk, and confidence-interval of 95%.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The search was narrowed to English, and inclusion criteria were not restricted by study type or size. Studies with no correlation were exempted from the study, e.g. editorials, review-articles letters, and commentary. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> exhibits the mode of analysis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The article inclusion criteria were classified and integrated into the meta-analysis when<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0030" class="elsevierStylePara elsevierViewall">The study was a randomized control-trial, prospective-study, or retrospective-study.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0035" class="elsevierStylePara elsevierViewall">The target population was primary non-muscle-invasive bladder-cancer subjects</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0040" class="elsevierStylePara elsevierViewall">The intervention program was En-bloc transurethral-resection and conventional-transurethral-resection</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0045" class="elsevierStylePara elsevierViewall">The study comprised comparisons between En-bloc transurethral-resection and conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer.</p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall">The next exclusion criteria were adopted among the intervention groups <ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">1.</span><p id="par0055" class="elsevierStylePara elsevierViewall">Studies that did not determine the effect of En-bloc transurethral-resection compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">2.</span><p id="par0060" class="elsevierStylePara elsevierViewall">Studies with management other than En-bloc transurethral-resection and conventional-transurethral-resection.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">3.</span><p id="par0065" class="elsevierStylePara elsevierViewall">Studies that did not concentrate on the influence of comparative-outcomes.</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Identification</span><p id="par0070" class="elsevierStylePara elsevierViewall">PICOS principle was the protocol for the search-strategy and asserted the critical elements of PICOS as P (population): primary non-muscle-invasive bladder-cancer subjects; I (intervention/exposure): En-bloc transurethral-resection and conventional-transurethral-resection; C (comparison): En-bloc transurethral-resection and conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer; O (outcome): twelve-month recurrence, twenty-four-month recurrence, catheterization-time, catheterization-time, length-of-hospital-stay, postoperative bladder-irrigation-duration, operation-time, obturator-nerve-reflex, bladder-perforation, and urethral-stricture; and S (study design): had no limitation. We conducted a systematic and brief search on MEDLINE/PubMed, Google-Scholar, Embase, OVID, and Cochrane Library until January 2022, by a combination of keywords and correlated words for En-bloc transurethral-resection, conventional-transurethral-resection, primary non-muscle-invasive bladder-cancer, recurrence, catheterization-time, length-of-hospital-stay, postoperative bladder-irrigation-duration, operation-time, obturator-nerve-reflex, bladder-perforation, and urethral-stricture. The selected studies were pooled in EndNote software to exclude the duplicates. Additionally, a thorough screening on the title and abstracts were done to erase any data that did not show any influence of En-bloc transurethral-resection and conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects on the outcomes studied. Related pieces of information were collected from the remaining studies.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Screening</span><p id="par0075" class="elsevierStylePara elsevierViewall">Subject-related and study-related data characteristics were considered for the collection and classification of data, and it was pooled into a standardized-form. The categorization was made into the standard form like the surname of the first author, duration of the trial, place of practice, design of the study, subject-type, sample-size, categories, demography, treatment-methodology, information-source, method of evaluation (both qualitative and quantitative), statistical-analysis, and primary outcome-evaluation.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Methodological quality was assessed by the “risk of bias tool” adopted from Cochrane-Handbook for Systematic-Reviews of Interventions-Version 5.1.0. This meta-analysis recommended that if a trial with inclusion-criteria is based on the standards mentioned earlier, any conflicts that arose during the data collection by two reviewers must be resolved through discussion and when necessary by the “corresponding-author” to ensure the quality of the methodology. When there were different data from one study based on the evaluation of the relationship, we extracted them separately.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">The level of risk of bias is counted in the assessment criteria</span><p id="par0085" class="elsevierStylePara elsevierViewall">The level of risk was considered low if all quality parameters were met; it was considered moderate if one of the quality parameters was not met/or partially met and was considered high if one of the quality parameters was not met/or not included. A reexamination of the original article was addressed for any inconsistencies.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Eligibility criteria</span><p id="par0090" class="elsevierStylePara elsevierViewall">The main eligibility criteria concentrated on the effect of En-bloc transurethral-resection compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer. An evaluation of the influence of En-bloc transurethral-resection and conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer on the twelve-month recurrence, twenty-four-month recurrence, catheterization-time, catheterization-time, length-of-hospital-stay, postoperative bladder-irrigation-duration, operation-time, obturator-nerve-reflex, bladder-perforation, and urethral-stricture in primary non-muscle-invasive bladder-cancer was conducted and the data was extracted forming a summary.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Inclusion</span><p id="par0095" class="elsevierStylePara elsevierViewall">Studies reporting the effect of En-bloc transurethral-resection compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer were only included in the sensitivity analysis. In comparison, the impact of En-bloc transurethral-resection and conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer were considered as a subcategory of sensitivity analysis.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Statistical analysis</span><p id="par0100" class="elsevierStylePara elsevierViewall">The dichotomous or continuous-methods were used to compute the odds-ratio (OR) and mean-difference (MD) at a 95% confidence-interval (CI) on a fixed-influence or random-influence model. First, the I<span class="elsevierStyleSup">2</span> index range was established between 0%–100%, when the I<span class="elsevierStyleSup">2</span> index scale for heterogeneity was indicated as no, low, moderate, and high as 0%, 25%, 50%, and 75%, respectively. Random-influence was considered if I<span class="elsevierStyleSup">2</span> was >50%, and if <50%, as fixed-influence. The initial evaluation of the result was stratified, and in sub-group analysis a p-value <0.05 was reported statistically significant. Egger regression test was used quantitatively and qualitatively to assess the publication bias (if p ≥ 0.05) by inspecting funnel plots of the logarithm of odds-ratios compared with their standard errors. The entire p-values were two-tailed. The statistical analysis and graphs were done by “Reviewer manager version 5.3” (The Nordic Cochrane-Centre, The Cochrane-Collaboration, Copenhagen, Denmark).</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results</span><p id="par0105" class="elsevierStylePara elsevierViewall">A total of 1867 distinctive studies were found, of which 28 studies (between 2008 and 2022) satisfied the inclusion criteria and were comprised in the study.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–30</span></a> This meta-analysis study based on 28 studies included 3714 primary non-muscle-invasive bladder-cancer subjects at the start of the study; 1870 of them were En-bloc transurethral-resection, and 1844 were conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer. All studies evaluated the effect of En-bloc transurethral-resection compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer. Thirteen studies reported data stratified to the twelve-month recurrence, 15 studies reported data stratified to the twenty-four-month recurrence, 16 studies reported data stratified to the catheterization-time, 14 studies reported data stratified to the length-of-hospital-stay, 8 studies reported data stratified to the postoperative bladder-irrigation-duration, 17 studies reported data stratified to the operation-time, 10 studies reported data stratified to the obturator-nerve-reflex, 9 studies reported data stratified to the bladder-perforation, and 6 studies reported data stratified to the urethral-stricture. The study size ranged from 45 to 286 primary non-muscle-invasive bladder-cancer subjects at the beginning of the study. 3 studies used two techniques of En-bloc transurethral-resection compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer and were extracted separately.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,15,23</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Regarding the recurrence rate, En-bloc transurethral-resection had no significant difference in the twelve-month recurrence (OR, 0.79; 95% CI, 0.61–1.04, p = 0.09) with no heterogeneity (I<span class="elsevierStyleSup">2</span> = 0%) compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects as shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. However, En-bloc transurethral-resection had significantly lower twenty-four-month recurrence (OR, 0.63; 95%CI, 0.50–0.78, p < 0.001) with no heterogeneity (I<span class="elsevierStyleSup">2</span> = 0%) compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects as shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">En-bloc transurethral-resection had significantly lower catheterization-time (MD, −0.66; 95%CI, −1.02 to −0.29, p < 0.001) with high heterogeneity (I<span class="elsevierStyleSup">2</span> = 98%), shorter length-of-hospital-stay (MD, −0.95; 95%CI, −1.55 to −0.34, p = 0.002) with high heterogeneity (I<span class="elsevierStyleSup">2</span> = 98%), and lower postoperative bladder-irrigation-duration (MD, −6.06; 95%CI, −9.45 to −2.67, p < 0.001) with high heterogeneity (I<span class="elsevierStyleSup">2</span> = 98%) compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects as shown in <a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3–6</a>. However, En-bloc transurethral-resection had no significant difference in the operation-time (MD, 0.67; 95%CI, −1.92 to −3.25, p = 0.61) with high heterogeneity (I<span class="elsevierStyleSup">2</span> = 87%) compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Regarding the complication, En-bloc transurethral-resection had significantly lower obturator-nerve-reflex (OR, 0.08; 95%CI, 0.02–0.34, p = 0.03) with moderate heterogeneity (I<span class="elsevierStyleSup">2</span> = 71%), and lower bladder-perforation (OR, 0.14; 95%CI, 0.06–0.36, p < 0.001) with no heterogeneity (I<span class="elsevierStyleSup">2</span> = 0%) compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects. However, En-bloc transurethral-resection had no significant difference in the urethral-stricture (OR, 0.46; 95%CI, 0.14–1.47, p = 0.0.19) with no heterogeneity (I<span class="elsevierStyleSup">2</span> = 0%) compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The stratified data did not examine the factors like age, gender, and ethnicity between the two groups because no studies adjusted or outlined these factors. No publication bias (p = 0.87) was detected when the quantitative measurement was conducted using the Egger regression test and examination of the funnel plot. However, low methodological quality was observed in selected randomized conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer trials. No articles had selective reporting or incomplete data, which proved that selected articles devoid of selective reporting bias.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">This meta-analysis study based on 28 studies included 3714 primary non-muscle-invasive bladder-cancer subjects at the start of the study; 1870 of them were En-bloc transurethral-resection, and 1844 were conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–30</span></a> En-bloc transurethral-resection had no significant difference in the twelve-month recurrence compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects. However, En-bloc transurethral-resection had significantly lower twenty-four-month recurrence compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects. This was similar to most of the previous meta-analyses. However the p-value of the twelve-month recurrence comparison was very low in favor of En-bloc transurethral-resection suggesting a relatively low twelve-month recurrence En-bloc transurethral-resection. En-bloc transurethral-resection had significantly lower catheterization-time, shorter length-of-hospital-stay, and lower postoperative bladder-irrigation-duration compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects. However, En-bloc transurethral-resection had no significant difference in the operation-time compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects. En-bloc transurethral-resection had significantly lower obturator-nerve-reflex, and lower bladder-perforation compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects. However, En-bloc transurethral-resection had no significant difference in the urethral-stricture compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects. However, the analysis of outcomes should be performed with consideration because of the low sample size of half of the selected studies found for the meta-analysis, 14 out of 28 studies with ≤100 subjects as sample size; recommending the need for other studies to confirm these findings or perhaps to significantly impact confidence in the influence evaluation.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Meta-analysis is a methodology adapted to statistically pool and study the findings from several independent randomized control-trials.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> As technology develops, conventional-transurethral-resection of bladder-tumors is extensively used in the management of non-muscle-invasive bladder-cancer. Though, there are still some limits needing to be overcome. Primarily, it is unavoidable for a tumor with a diameter of above 3 cm to be resected piece-by-piece and then the parts of it would be naturally washed out through the cystoscope sheath, which is inconsistent with the tumor-free standard. Moreover, detrusor muscle is one of the criteria to evaluate the extensiveness of resection. The eschar in the specimen produced by electric coagulation would influence the correctness of tumor penetration for its depth, grading, and staging. Also, there is an opportunity for problems such as obturator-nerve-reflex and bladder-perforation to happen through the resection of lateral wall tumors. En-bloc transurethral-resection of bladder-tumor is an adjusted method for non-muscle-invasive bladder-cancer. According to EAU guidelines, it is capable of giving high-quality specimens comprising muscle layer in almost 100% of the current cases. En-bloc transurethral-resection of a bladder-tumor can help decrease different problems e.g. obturator-nerve-reflex, bladder-perforation, bladder irritation, and urethral-stricture. Also, En-bloc transurethral-resection of bladder-tumor showed a lower residual tumor on the base (0.53% vs. 1.55%) and same site recurrence rate (3.74% vs. 8.69%). En-bloc transurethral-resection of bladder-tumor showed a shorter length-of-hospital-stay, catheterization-time, fewer problems, and lower 24-month recurrence rate than conventional-transurethral-resection of bladder-tumor in the management of non-muscle-invasive bladder-cancer. This favors its use in place of conventional-transurethral-resection. This meta-analysis showed the relationship between the influences of En-bloc transurethral-resection compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects. However, further studies are needed to validate these potential associations. Also, further studies are needed to deliver a clinically meaningful difference in the results. This was suggested in other meta-analyses which showed similar effects. This needs additional examination and clarification because no clear reasoning was found to clarify these outcomes. Well-designed clinical trials are also required to evaluate these factors with the blend of diverse ages, gender, and ethnicity; as our meta-analysis study could not answer whether these factors are related to the outcomes.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Limitations</span><p id="par0140" class="elsevierStylePara elsevierViewall">There may be a collection bias in this meta-analysis since several studies found were excluded from the meta-analysis. Though, the studies excluded did not satisfy the inclusion criteria of the meta-analysis. Furthermore, we could not decide if the results were linked to age, gender, and ethnicity or not. The study was designed to assess the relationship between the influence of En-bloc transurethral-resection and conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer on the outcomes of primary non-muscle-invasive bladder-cancer subjects was depending on data from former studies, which may result in bias brought by incomplete details. The meta-analysis was depending on 28 studies; 14 studies of them were small, ≤100. Features comprising the age, gender, obedience, nutritional status, and ethnicity of subjects were also likely bias-encouraging features.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusions</span><p id="par0145" class="elsevierStylePara elsevierViewall">En-bloc transurethral-resection had a significantly lower twenty-four-month recurrence, catheterization-time, length-of-hospital-stay, postoperative bladder-irrigation-duration, obturator-nerve-reflex, and bladder-perforation and no significant difference in the twelve-month recurrence, operation-time, and urethral-stricture compared with conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects. However, the analysis of outcomes should be done with consideration because of the low sample size of half of the selected studies found for the meta-analysis; recommending the need for added studies to confirm these results or perhaps to significantly influence confidence in the effect evaluation. More studies are essential to confirm these outcomes.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1908046" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1648304" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1908047" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1648305" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study selection" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Identification" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Screening" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "The level of risk of bias is counted in the assessment criteria" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Eligibility criteria" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Inclusion" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Limitations" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Conclusions" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-03-08" "fechaAceptado" => "2022-04-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1648304" "palabras" => array:6 [ 0 => "En-bloc transurethral resection" 1 => "Conventional transurethral resection" 2 => "Primary non-muscle invasive bladder cancer" 3 => "Recurrence" 4 => "Catheterization time" 5 => "Length of hospital stay" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1648305" "palabras" => array:6 [ 0 => "Resección transuretral en bloque" 1 => "Resección transuretral convencional" 2 => "Cáncer vesical primario no músculo-infltrante" 3 => "Recurrencia" 4 => "Tiempo de sondaje" 5 => "Duración de la estancia hospitalaria" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">We performed a meta-analysis to evaluate the effect of en-bloc transurethral resection vs. conventional transurethral resection for primary non-muscle invasive bladder cancer.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A systematic literature search up to January 2022 was done and 28 studies included 3714 primary non-muscle invasive bladder cancer subjects at the start of the study; 1870 of them were en-bloc transurethral resection, and 1844 were conventional transurethral resection for primary non-muscle invasive bladder cancer. We calculated the odds-ratio (OR) and mean-difference (MD) with 95% confidence-intervals (CIs) to evaluate the effect of en-bloc transurethral resection compared with conventional transurethral resection for primary non-muscle invasive bladder cancer by the dichotomous or continuous methods with random or fixed-effects models.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">En-bloc transurethral resection had significantly lower twenty-four-month recurrence (OR: 0.63; 95%CI: 0.50–0.78; <span class="elsevierStyleItalic">p</span> < 0.001), catheterization-time (MD: –0.66; 95%CI: –1.02–[–0.29]; <span class="elsevierStyleItalic">p</span> < 0.001), length of hospital stay (MD: –0.95; 95%CI: –1.55–[–0.34]; <span class="elsevierStyleItalic">p</span> = 0.002), postoperative bladder irrigation duration (MD: –6.06; 95%CI: –9.45–[–2.67]; <span class="elsevierStyleItalic">p</span> < 0.001), obturator nerve reflex (OR: 0.08; 95%CI: 0.02–0.34; <span class="elsevierStyleItalic">p</span> = 0.03), and bladder perforation (OR: 0.14; 95%CI: 0.06–0.36: <span class="elsevierStyleItalic">p</span> < 0.001) and no significant difference in the 12-month-recurrence (OR: 0.79; 95%CI: 0.61–1.04; <span class="elsevierStyleItalic">p</span> = 0.09), the operation time (MD: 0.67; 95%CI: –1.92 to 3.25; <span class="elsevierStyleItalic">p</span> = 0.61), and urethral stricture (OR: 0.46; 95%CI: 0.14–1.47; <span class="elsevierStyleItalic">p</span> = 0.0.19) compared with conventional transurethral resection for primary non-muscle invasive bladder cancer subjects.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">En-bloc transurethral resection had a significantly lower twenty-four-month recurrence, catheterization time, length of hospital stay, postoperative bladder irrigation duration, obturator nerve reflex, bladder perforation, and no significant difference in the twelve-month recurrence, operation time, and urethral stricture compared with conventional transurethral resection for primary non-muscle invasive bladder cancer subjects. Further studies are required.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se realizó un metaanálisis para evaluar el efecto de la resección transuretral en bloque en comparación con la resección transuretral convencional para el cáncer de vejiga primario no músculo-infltrante.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se realizó una búsqueda sistemática en la literatura hasta enero de 2022 y se incluyeron 28 estudios con 3.714 sujetos con cáncer de vejiga primario no músculo-infltrante al inicio del estudio; a 1.870 de ellos se les efectuó una resección transuretral en bloque y a 1.844 una resección transuretral convencional para el cáncer de vejiga primario no músculo-infltrante. Se calculó la <span class="elsevierStyleItalic">odds-ratio</span> (OR) y la diferencia de medias (DM) con intervalos de confianza (IC) del 95% para evaluar el efecto de una y otra en el cáncer primario de vejiga no invasivo por métodos dicotómicos o continuos con un modelo de efectos aleatorios o fijos.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">La resección transuretral en bloque obtuvo valores significativamente menores en términos de recurrencia a los 24 meses (OR: 0,63; IC 95%: 0,50-0,78; <span class="elsevierStyleItalic">p</span> < 0,001), tiempo de sondaje (DM: –0,66; IC 95%: –1,02-[–0,29]; <span class="elsevierStyleItalic">p</span> < 0,001); duración de la estancia hospitalaria (DM: –0,95; IC 95%: –1,55-[–0,34]; <span class="elsevierStyleItalic">p</span> = 0,002), tiempo de irrigación vesical postoperatoria (DM: –6,06; IC 95%: –9,45-[–2,67]; <span class="elsevierStyleItalic">p</span> < 0,001), contracción del nervio obturador (OR: 0,08; IC 95%: 0,02–0,34; <span class="elsevierStyleItalic">p</span> = 0,03) y perforación de la vejiga (OR: 0,14; IC?95%: 0,06–0,36; <span class="elsevierStyleItalic">p</span> < 0,001) y no hubo diferencias significativas en cuanto a la recurrencia a los 12 meses (OR: 0,79; IC?95%: 0,61–1,04: <span class="elsevierStyleItalic">p</span> = 0,09), tiempo quirúrgico (DM: 0,67; IC?95%: –1,92–3,25; <span class="elsevierStyleItalic">p</span> = 0,61) y estenosis uretral (OR: 0,46; IC 95%: 0,14–1,47; <span class="elsevierStyleItalic">p</span> = 0,0,19) en comparación con la resección transuretral convencional para sujetos con cáncer de vejiga primario no invasivo.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La resección transuretral en bloque tuvo resultados significativamente menores en recurrencia a los 24 meses, tiempo de sondaje, duración de la estancia hospitalaria, duración de la irrigación vesical postoperatoria, reflejo del nervio obturador y perforación de la vejiga y no tuvo ninguna diferencia significativa en la recurrencia a los 12 meses, el tiempo quirúrgico y la restricción uretral respecto a la resección transuretral convencional para sujetos con cáncer de vejiga primario no invasivo. Se necesitan más estudios.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2238 "Ancho" => 2508 "Tamanyo" => 332917 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Schematic illustration of the study method.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 958 "Ancho" => 2925 "Tamanyo" => 299274 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A forest plot of the twelve-month recurrence of the En-bloc transurethral-resection compared with the conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1298 "Ancho" => 3341 "Tamanyo" => 412979 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A forest plot of the twenty-four-month recurrence of the En-bloc transurethral-resection compared with the conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1163 "Ancho" => 3341 "Tamanyo" => 442980 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A forest plot of the catheterization-time of the En-bloc transurethral-resection compared with the conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects.</p>" ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1065 "Ancho" => 3341 "Tamanyo" => 401845 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A forest plot of the length-of-hospital-stay of the En-bloc transurethral-resection compared with the conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects.</p>" ] ] 5 => array:8 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 701 "Ancho" => 3341 "Tamanyo" => 273748 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A forest plot of the postoperative bladder-irrigation-duration of the En-bloc transurethral-resection compared with the conventional-transurethral-resection for primary non-muscle-invasive bladder-cancer subjects.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cancer statistics, 2019" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.L. 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