Thesis (Ph.D)-Cairo University, 2025.

Bibliography: pages 57-65.

Introduction
Non-muscle invasive bladder cancers (NMIBCs) are commonly managed with endoscopic resection and risk-based intravesical therapy (bladder instillation). With the advent of en-bloc resection of urinary bladder tumors, lasers have become a focal point in bladder tumor management. The two most commonly used lasers are thulium and holmium. This study aimed to assess the safety and efficacy of thulium laser enucleation of bladder tumors (Tm-LRBT). Safety will be evaluated based on intraoperative complications such as obturator reflex and bladder perforation. Efficacy will be assessed by the presence of detrusor muscle in the specimen, specimen quality, the need for second-look cystoscopy, and recurrence rates, in comparison with conventional monopolar TURBT
Patients & Methods
This prospective randomized clinical comparative study was conducted between October 2021 and August 2023, involving 100 patients. Each patient signed an informed consent after being informed about the procedure, risks, and potential benefits.
Inclusion Criteria: Patients with NMIBC, tumor size less than 5 cm, and fewer than three tumors. Exclusion Criteria: Tumors larger than 5 cm, more than three tumors, invasive and upper tract cancers, hydronephrosis, metastases on imaging, and history of TURBT.
Demographic data collected included age, sex, medical history, mass localization, and size. A detailed history was obtained, focusing on presenting complaints, symptom duration, and comorbid conditions.
Surgical Technique: TmLRBT was performed with the patient in a lithotomy position under spinal anesthesia, using 0.9% sodium chloride for continuous irrigation. TmLRBT was conducted through a 550-μm optical laser fiber (RigiFibTM, LISA, Katlenburg, Germany) introduced into a 26F continuous- flow resectoscope (Karl Storz, GmbH, Tuttlingen, Germany). The fiber was connected to the Tm: YAG laser (RevolixR, LISA, Katlenburg, Germany) in continuous-wave mode at 30 W, with parameters set to 1.5 J energy, 20 Hz

pulses, and 30 W power. The distal tip of the laser fiber and the aiming beam spot were visible.
A circumferential incision was marked around the stalk at a margin of 2–5 mm for small villous tumors. For non-pedunculated tumors, the incision was marked around the visible margin. A vertical incision was made from the mucosa into the deep detrusor muscle layer by layer. The resectoscope sheath tip and thulium laser vaporization were used to push the tumor base until the submucosa was exposed, identifying the fibrous connective tissue between the mucosal layer and the detrusor muscle. Using a layer-by-layer resection procedure, the detrusor muscle fibers were removed. At the end of the procedure, the tumor base was adequately coagulated using the thulium laser in pulsed-wave mode at 20 W. The tumor was removed in one piece through the instrument with the help of the resectoscope's cold loop or cut into pieces by the laser fiber for extraction in case of large masses. A three-way 24 Fr catheter was inserted post-procedure and irrigated with normal saline in cases of hematuria.
Postoperative intravesical chemotherapy was considered according to EAU recommendations.
Data Collection: Perioperative data included cystoscopy report, operation duration, number, size, and site of lesions, complications (perforation and obturator reflex), irrigation duration if needed, postoperative hemoglobin, urethral catheter removal timing, hospital stay duration, type of anesthesia, and adjuvant therapy. Re-staging cystoscopy was performed in each group 2-6 weeks after the first cystoscopy. Follow-up cystoscopy was conducted according to EAU guidelines risk stratification.
Adjuvant Chemotherapy: Immediate intravesical chemotherapy (40 mg of mitomycin) was administered to all patients except in cases of perforation, within the first two hours after surgery.
Intravesical BCG was administered according to EAU risk stratification for high-risk tumors while intravesical chemotherapy was administrated for intermediate risk group.
Results
The mean tumor diameter in Group A was 2.3 ± 0.74 cm. The mean operative time was 45.4 ± 13.48 minutes. Re-resection of the tumor base within 90 days was negative for bladder cancer in all Group A patients, raising the possibility

of eliminating the need for second-look cystoscopy. In Group B, three patients had persistent disease. Seven cases in Group B had no muscle in the specimen, while only three in Group A did. Significant intraoperative bleeding occurred in four cases in Group A and five cases in Group B. During the 12-month follow- up, all patients adhered to the surveillance regimen according to EAU guidelines. Tumor recurrence was observed in two cases (4%) in Group A (one at six months and the other at nine months) and seven cases (14%) in Group B (three at three months, one at six months, and three at nine months) which was clinically but not statistically significant.
Conclusion
TmLRBT represents a potential alternative to TURBT. In our study, TmLRBT allowed accurate reporting of neoplastic depth invasion. Tumors in any bladder wall can be enucleated with thulium laser, offering advantages over TURBT, especially for tumors located in the lateral wall, dome of the bladder, or perimeatal zone.

يعد سرطان المثانة البولية من أكثر الأمراض انتشاراً وعنفاً و هو من أشهر أنواع السرطان شيوعاً في مصر.
ينقسم سرطان المثانة إلي نوعين: سرطان سطحي و سرطان متوغل في عضلات المثانة البولية بناء علي تحليل الأنسجة.
يتميز سرطان المثانة بالقابلية الكبيرة للارتجاع بعد الاستئصال بالمناظير وهذا في حالة الأورام السطحية ؛أما في حالة الأورام المتوغلة لعضلات المثانة فيكون العلاج بالا ستئصال الجذرى للمثانة البولية.
منظار المثانة يستخدم لتشخيص و علاج أورام المثانة وأخذ العينات المناسبة بناء علي مكان وشكل الورم.
ما زال الاستئصال التقليدي لأورام المثانة باستخدام حلقة تقطع الورم إلي إجزاء عن طريق التيار الكهربيأحادي القطب لكن يحمل عديد من السلبيات ولهذا ظهرت بعض التقنيات الحديثة مثل التيار ثنائي القطب أو الليزر بأنواعه المختلفه كالهوليوم أو الثوليوم.
استخدام الليزر لاستئصال الورم ككتلة واحده ظهر مع بداية الألفية الجديدة ويحمل ميزه مهمه وهي منع انتشار الورم في المثانة وبالتالي تقليل فرص الا رتجاع.
في هذا البحث عملنا علي مقارنة ليزر الثوليوم مع الاستئصال التقليدي باستعمال الحلقة القاطعه بواسطة التيار أحادي القطب.
قمنا بعمل هذا البحث في الفترة من أكتوبر 2021 إلي أغسطس 2023 علي 100 مريض داخل مستشفيالقصر العيني قاموا بالتردد علي عيادة القصر العيني للمسالك البولية يشكون من نزيف بولي أو أعراض تهيجية بالمثانة البولية.
البحث يهدف إلي مقارنة الاستئصال ككتلة واحدة باستخدام ليزر الثوليوم مقارنة بالاستئصال التقليدي بالتيارأحادي القطب بالحلقة القاطعة من حيث فترة بقاء المريض و فترة بقاء القسطرة ومدي الأمان للمريض أثناء وبعد المنظار ونسبة ارتجاع الورم و تحليل

Issues also as CD.

Text in English and abstract in Arabic & English.