Materials and Methods
We designed a retrospective cross-sectional observational study that was
conducted between January 2015 and March 2020. A total of 315 patients
with the diagnosis of NMIBC localized on lateral wall of the bladder
were analysed at Izmir Bakircay University Cigli Training and Research
Hospital Urology Department and Recep Tayyip Erdogan University Urology
Department. Patients with a history of previous TUR-BT, diagnosis of
non-urothelial carcinoma, coagulopathy, history of allergic reaction to
the local anaesthetic agent, presence of muscle invasive bladder cancer,
history of chemotherapy or radiotherapy before TUR-BT, presence of
variant histopathology, use of bipolar energy for the resection of
bladder tumour, presence of concomitant upper urothelial tract
urothelial carcinoma, neuromuscular disease, pregnancy or history of
medication affecting the immune system were excluded. Of the initial 315
patients, 209 were excluded from the study, and the remaining 106
patients were included (Fig. 1). After local ethical committee
permission was received (local ethical committee number 2020/131), data
from the patients with the diagnosis of NMIBC were recorded
retrospectively from the hospital patient record system. Patients’
demographic characteristics, localization, largest tumour size,
histopathological type of tumour, presence of recurrence and/or
progression, time to recurrence from initial TUR-BT, presence of muscle
tissue in the surgical specimen, inability to complete resection, death
from cancer and both perioperative and postoperative complications were
recorded for further statistical analyses. All TUR-BT procedures were
performed using monopolar energy for the resection of the tumour with a
26 Fr Karl-Storz resectoscope under 30 degree optical vision with
adjustment to 120 joules for cutting and 80 joules for coagulation. One
surgeon performed the TUR-BT procedure on the patients in group 1 in
Recep Tayyip Erdogan University, Urology department and one surgeon
performed the TUR-BT procedure on the patients in group 2 in Izmir
Bakircay University Cigli Training and Research Hospital, Urology
Department. All obturator block decisions were made by the
anesthesiologist when the suggestion of surgeon according to the
localization of tumor. Spinal anaesthesia was performed in the operating
room in a sitting position at the level of the L3–4 or L4–5
intervertebral space with a 25 gauge Quincke needle, and 10–15 mg of
2–3 ml 0.5% hyperbaric bupivacaine was administered through the needle
into the subarachnoid space before the patient was repositioned to a
supine position. After waiting for 10 min, and when sensorial blockade
up to T10 dermatome was observed, a lithotomy position was performed.
Additional obturator nerve blockade with ultrasound guidance was
performed according to the localization of the tumour. First, the
antero-medial side of the femur was demonstrated by a two-dimensional
38 mm, 6–13 MHz ultrasound probe (Mindray, M7, Biomedical Electronics
Co., Shenzhen, China). Afterward, a high-frequency probe was placed
proximal to the adductor longus muscle to determine the adductor longus,
brevis and magnus muscles. When the obturator nerve was demonstrated
between the muscle groups, the position of the nerve was confirmed by
setting the current of the stimulator (Braun Stimuplex HNS11, B. Braun,
Melsungen, Germany) to 1.5–2 mA and the duration to 0.1 ms. Under
ultrasound vision, a 50 mm needle (21 gauge, 50 mm Stimuplex A, B.
Braun, Melsungen, Germany) was inserted parallel to the long axis of the
probe and guided to the anterior branch of the obturator nerve. After
adductor contractions were observed at 0.3–0.5 mA, a maximum of 10 mL
2% lidocaine was injected through the needle. Surgery started after
10 min had passed. During the surgery, patients were monitored with
non-invasive blood pressure, pulse, sPO2 intraoperative
electrocardiography.
In our study, all patients underwent monopolar TUR-BT due to the
presence of controversial results regarding bipolar versus monopolar
techniques and strong advice to use monopolar TUR-BT in current urology
guidelines (12). Patients were divided into two groups according to the
anaesthesia used. While only spinal anaesthesia was performed in Group
1, spinal anaesthesia combined with ultrasound-guided obturator nerve
blockade according to the localization of the tumour was performed in
Group 2. The groups were compared statistically in terms of oncological
outcomes. In patients with an incomplete resection, re-TUR-BT was
performed 4–6 weeks after the first TUR-BT. The first follow-up was
performed with all patients the third month after the initial TUR-BT,
and subsequent follow-ups were performed every 3 months up to 2 years,
then every 6 months up to 5 years and 1 per year after 5 years. A
detailed history, physical examination, cystoscopic examination and
urinary cytology were collected at each follow-up (12).
All statistical analyses were conducted using the SPSS Statistics 26.0
(IBM Inc., Armonk, NY, US) software package. Categorical variables were
described by frequencies and percentages; continuous variables were
described by means and standard deviations. The Kolmogorov–Smirnov test
was used to evaluate the normality of the distributions, and the
Mann–Whitney U test was used to compare groups and quantitative
independent data. The chi-square test was used for qualitative
independent data. Spearman’s correlation analysis was applied for
correlation, and the Kaplan–Meier test was used to calculate survival
statistics. A p -value less than 0.05 was chosen as the criterion
for statistical significance.