title: Flexible cystoscopy and Holmium:Yttrium aluminum garnet laser ablation for recurrent nonmuscle invasive bladder carcinoma under local anesthesia.
abstract: OBJECTIVE
  The management of recurrent nonmuscle invasive bladder cancer (NMIBC) post-transurethral resection has been based around electrocautery techniques, either under local or general anesthetic. We determine the long-term outcome of the management of NMIBC recurrences treated with Holmium:Yttrium Aluminum Garnet (Ho:YAG) laser ablation under local anesthetic with a flexible cystoscope.
  
  
  METHODS
  We performed a prospective analysis of 151 consecutive patients, undergoing treatment of 444 tumors, between 2006 and 2011 in a University Teaching Hospital. Median follow-up was 24 months (0-58 months). The primary outcome was local, on-site recurrence rates of NMIBC. The secondary outcome measure included off-site recurrence rates, complications, pain perception, and patient satisfaction.
  
  
  RESULTS
  Local, on-site recurrence rates after first treatment for all NMIBC disease were 10%. In patients with low risk NMIBC (G1/2, Ta), this reduced to around 4% post laser treatment. Higher recurrence rates (14%) were seen in those with high-grade (G3, T1) disease. Treatment was more successful with disease around the trigone, posterior and lateral bladder walls, with a significantly higher risk of recurrence for tumor around the ureteric orifice. The median time to local recurrence was 12 months and off-site recurrence was 25 months. Complication rates were low: dysuria (4.2%), frequency (1.5%), and hematuria (1.9%), with no episodes of bladder perforation. Visual analog pain scores were low, mean score 1 (range 0-7). The overall patient satisfaction was 100%.
  
  
  CONCLUSIONS
  Flexible cystoscopy and Ho:YAG laser therapy should be considered as a first line treatment option for the management of recurrence in low-grade NMIBC (G1/2, Ta/1) throughout the bladder, except around the ureteric orifices. For those with high-grade disease (G3), the recurrences rates are increased, but the procedure still offers an acceptable recurrence rate. It provides good local disease control, low complications, patient acceptability and tolerance.
authors.affiliation: Department of Urology, Good Hope Hospital, Sutton Coldfield, United Kingdom. haider.syed@heartofengland.nhs.uk
authors.forename: Haider A
authors.initials: HA
authors.lastname: Syed
authors.forename: Nicholas
authors.initials: N
authors.lastname: Talbot
authors.forename: Ahmed
authors.initials: A
authors.lastname: Abbas
authors.forename: Donald
authors.initials: D
authors.lastname: MacDonald
authors.forename: Robert
authors.initials: R
authors.lastname: Jones
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: Marr
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Rukin
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000772:Anesthesia, Local / Q000379:methods; D002295:Carcinoma, Transitional Cell / Q000473:pathology / Q000601:surgery*; D003558:Cystoscopy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053685:Laser Therapy / Q000379:methods*; D053844:Lasers, Solid-State / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009364:Neoplasm Recurrence, Local / Q000601:surgery*; D017060:Patient Satisfaction; D011446:Prospective Studies; D001749:Urinary Bladder Neoplasms / Q000473:pathology / Q000601:surgery*