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• W4321166836 abstract "Dear Editor, We recently read with great enthusiasm the article by Li et al1. We sincerely congratulate the authors for publishing an excellent systematic review and meta-analysis of randomized controlled trials (RCTs) on transurethral en-bloc resection versus conventional transurethral resection for patients with nonmuscle-invasive bladder cancer. Transurethral resection of bladder tumor (TURBT) is considered the ‘gold standard’ of treatment for nonmuscle-invasive bladder cancer2. However, its fractional resection increases the potential for residual and disseminated tumors and also leads to deviations in pathological staging, with approximately one-third of patients having underestimated tumor staging, which undoubtedly increases the rate of recurrence3. En-bloc resection of bladder tumor (ERBT) was first described by Kawada et al4 in 1997 and was defined as marking the extent of enucleation at ~1 cm from the base of the tumor and then gradually removing the tumor and detrusor muscle along the marker. It prevents morphological destruction of tumor tissue and provides more accurate staging, allowing for a more precise treatment for patients5. The authors concluded that ERBT is more feasible and safer than TURBT. Namely, ERBT was associated with a significantly lower risk of bladder perforation and significantly better rates of detection of the detrusor muscle, muscular mucosae, and surgical margins. Finally, re-resection ERBT had significantly lower rates of residual disease. While the present study was well designed and conducted with high quality, there are a few points of concern that we would like to raise. First, RCTs represent the gold standard and offer a high level of evidence when comparing treatment options. Whenever data from RCTs exist, systematic reviews or meta-analyses should be conducted based on a pooled analysis of these specific data. However, we retrieved four additional RCTs from the databases, which are Bălan et al., Lu et al., Razzaghi et al., and Cheng et al. 6–9. Through a careful reading of the literature, we found that all of them met the inclusion criteria for the article, and the authors should have incorporated them into the present study for analysis. Second, assessing the rate of muscular mucosae detection and concomitant carcinoma in situ (CIS) are significant clinical questions. We found that two of these studies, including 670 patients, provided data on the rate of detectable MM. We carried out an analysis and concluded that ERBT was significantly associated with a higher rate of detectable MM than TURBT (relative risk: 2.69, 95% CI: 1.81–3.97, z=4.94; Fig. 1). In addition, three RCTs, including 906 patients, provided data on the rate of concomitant CIS as detected by ERBT compared to TURBT. However, the results revealed no statistically significant difference in the rate of concomitant CIS between ERBT and TURBT (relative risk: 1.02, 95% CI: 0.64–1.64, z=0.11; Fig. 2).Figure 1: Forest plot of muscular mucosae between ERBT and TURBT.Figure 2: Forest plot of concomitant carcinoma in situ between ERBT and TURBT.Finally, heterogeneity was observed in some of the group analyses. For example, a heterogeneity of 97 and 96% on the I2 statistic was found in Figures 3A and B, which is a high number for heterogeneity. Where there is evidence of high heterogeneity, it is not sufficient to resolve it by using a random-effects meta-analysis. The authors should attempt to determine the reasons for heterogeneity. Please see the statistical guidelines for clinical research in urology at https://www.auajournals.org/doi/10.1097/JU.0000000000000001 # 4.10.Figure 3: (A) Forest plot of catheter time between ERBT and TURBT. (B) Forest plot of hospital stay between ERBT and TURBT.Overall, we thank Li and colleagues from the bottom of our hearts for their concerted efforts in investigating the therapeutic efficiency of ERBT in bladder cancer, this paper provides the most compelling evidence data in favor of ERBT. It is well designed, thorough, and complete. But we just point out our concerns, which might help the authors re-analyze their data to increase the reliability of this study. We believe that solving the above problems would make the authors’ findings clearer. Ethical approval Not applicable. Sources of funding None. Author contribution Z.T.: writing. H.W.: data collections and data analysis. J.W.: study design. Conflicts of interest disclosure The authors declare that they have no conflict of interest. Research registration unique identifying number (UIN) 1. Name of the registry: none. 2. Unique identifying number or registration ID: none. 3. Hyperlink to your specific registration (must be publicly accessible and will be checked): none Guarantor Jiansong Wang. Provenance and peer review Commentary, internally reviewed." @default.
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• W4321166836 date "2023-01-24" @default.
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• W4321166836 title "A commentary on ‘systematic review and meta-analysis of randomized controlled trials of perioperative outcomes and prognosis of transurethral en-bloc resection versus conventional transurethral resection for nonmuscle-invasive bladder cancer’ (Int J Surg 2022; 104:106777)" @default.
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• W4321166836 doi "https://doi.org/10.1097/js9.0000000000000097" @default.
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