Authors Reply Re: Maheshwari PN, Arora AM, Sane MS, Jadhao VG. Safety, feasibility, and quality of holmium laser en bloc resection of nonmuscle invasive bladder tumors: A single-center experience. Indian J Urol 2020;36:106-11

We thank the authors for taking an interest in our research and providing comments about the holmium laser en-bloc excision of nonmuscle-invasive bladder cancer. We do not agree with the author's premise that the Toomey syringe creates greater suction pressure than an Ellick's evacuator. Although there are no head-to-head comparisons in literature, few very old reports have suggested them to be comparable.[1,2] More importantly, the tumor evacuation would depend on the size of the sheath and the size of the tumor and not on the suction pressure. Regarding the question about the recurrence in the four patients who underwent cutting or morcellation of the large tumors, the follow-up has not been adequate to deduce this. Furthermore, the question about the difference in recurrence between conventional and en bloc resection remains unanswered yet, as no randomized controlled trials have been reported and the available prospective data is underpowered to assess this outcome.[3]

In contrast to the thermal damage caused by monopolar and bipolar conventional bladder tumor resection, the thermal damage by holmium laser is expected to be negligible as the coagulation thickness achieved by the holmium laser is only about 0.48 mm.[4] Regardless, the technique of en-bloc resection involves marking a circumferential resection margin 2–4 mm around the tumor and then lifting the entire tumor in one piece by working in the plane of the detrusor muscle. Thus, during en bloc resection, the energy source, whether monopolar, bipolar, or any kind of laser, would never come in direct contact with the actual tumor, avoiding any thermal damage. This particular feature of the en-bloc excision technique is a definite advantage over conventional resection.[5]

In one of the largest studies on en-bloc resection, Kramer et al. have compared laser (n = 65) and electrical (n = 156) en bloc resection of bladder tumor and found no difference in the presence of detrusor muscle between laser (100%) and electrical (96.2%) resections.[6] They too acknowledged that surgical experience is the most crucial factor influencing staging quality of en bloc resections.

We agree that bipolar electrosurgical equipment is cheaper than holmium laser and probably more readily available, but electrosurgery would have limitations of the increased possibility of obturator spasms and potential of bladder injury or perforation.[7] Furthermore, there is an increased risk of bleeding, especially in patients who cannot discontinue antiplatelet agents.

We propose that it is important to perform and offer en bloc excision as a treatment option to our patients with whatever energy source is available to us; surely, laser has some distinct advantages over electrosurgery.