Optimal energy source selection strategies for en bloc resection in non-muscle invasive bladder cancer: a systematic review and network meta-analysis.

Objective: This research aimed to identify the most effective energy source for en bloc resection of non-muscle-invasive bladder cancer (NMIBC) by a systematic review and network meta-analysis of randomized controlled trials (RCTs) and observational studies. We assessed and contrasted the effectiveness and safety of various energy modalities used in en bloc resection (ERBT) with those employed in conventional transurethral resection of bladder tumor (cTURBT).

Methods: A thorough search was conducted in PubMed, EMBASE, Cochrane, and Web of Science (WOS) to discover relevant articles published till August 29, 2024. Research comparing en bloc resection using various energy sources (such as hybrid knife, holmium laser, thulium laser, green-light laser, monopolar, and bipolar devices) to conventional transurethral resection of bladder tumor (cTURBT) was included. A network meta-analysis was performed using Stata/MP 18.0. Standardized mean differences (SMD) were computed for continuous outcomes, whilst relative risks (RR) were used for dichotomous outcomes. Nine clinical outcomes were assessed: duration of surgery, length of hospital stay, catheterization duration, irrigation duration, volume of intraoperative blood transfusion, 12-month recurrence rate, bladder perforation rate, incidence of obturator nerve reflex, and presence of detrusor muscle in the resected specimen. (PROSPERO ID: CRD42024623881).

Results: The study included 37 research, including 8 randomized controlled trials (RCTs) and 29 high-quality non-randomized controlled trials (NRCTs), with a total of 4973 patients involved. The network meta-analysis revealed that ERBT was much better than cTURBT in the majority of outcomes. Hybrid knife and laser technologies (holmium, thulium, and green-light lasers) shown superior efficacy regarding decreased surgical length, diminished 12-month recurrence rates, and fewer problems. Hybridknife proved to be the most advantageous energy source for various results, while cTURBT consistently exhibited the least effective performance across all metrics.

Conclusion: En bloc resection surpasses traditional TURBT in the management of NMIBC, with various energy modalities exhibiting distinct benefits. Among the assessed energy sources, laser technologies and hybrid knives regularly surpassed monopolar and bipolar devices. These findings provide critical direction for urologists in selecting the most suitable energy source for en bloc resection in NMIBC, emphasizing the need for individualized decision-making based on the patient's distinct variables and tumor attributes.