transurethral resection of bladder tumor ( turbt ) is well - established modality for treating non - muscle - invasive bladder cancer .
furthermore , it is essential for evaluating the pathological depth of bladder tumors in resected specimens . despite improvements in endoscopic instruments and imaging systems ,
there are well - recognized complications associated with turbt , such as bladder perforation , irrigation fluid absorption , bleeding , infection , damage to the ureteric orifices , obturator nerve stimulation , and tumor cell implantation . among these
, bladder perforation is one of the most frequent complications of turbt and is sometimes associated with obturator reflex .
several researchers have reported that the risk of obturator nerve stimulation is from 10.6% to 11% .
several advances in instruments and techniques , including modifications of resectoscope design and snare resection , have been proposed to remove pedunculated bladder tumors .
however , difficulties remain in safely collecting adequate specimens for flat tumors . we introduce an easy technique for superficial bladder cancer that uses a standard monopolar resectoscope loop . in this study
, we demonstrate the easy resection technique for superficial bladder tumors that we have termed the " grasp and bite " turbt technique and compare it with conventional turbt .
this was a retrospective study in the department of urology of chonnam national university hospital ( gwangju , korea ) between january 2012 and april 2013 .
this study included a total of 29 men and 6 women who had bladder tumors with superficial lesions and who underwent turbt .
patients with a huge unresectable mass , an invasive tumor shown during preoperative imaging , or an irradiated bladder were excluded .
group 1 patients were treated by use of the conventional turbt technique , and group 2 patients underwent the grasp and bite technique .
conventional turbt was performed in 2012 and grasp and bite turbt was performed in 2013 .
this study was approved by the institutional review board of chonnam national university hospital ( irb no .
transurethral resection was performed with a monopolar resectoscope system ( 24-fr karl storz , tuttlingen , germany ) . for the grasp and bite technique ,
the operator initially defined the tumor morphology and safe margin . in small and flat lesions
, the tumor and surrounding mucosal lesions were positioned between the resection loop and the end portion of the resectoscope sheath .
we call this the " grasp " step ( fig . 1 ; video clip , supplementary material ) . using the grasping technique , the tumor lesions were lifted up . in the " bite " step , the surgeon maintained a tight hold and resected the tumor while grasping . a cystoscopic view and schematic illustrations
1 . for resection during the bite step , the movement of the electrode loop was straight backward in a linear direction .
resection was performed carefully so as not to cause bladder perforation without excessive bladder wall distention .
the resection site was carefully inspected for bleeding and coagulation . in bulky or pedunculated tumors ,
after removal of the bulging mass , the base lesion and surrounding mucosa were resected carefully by using grasp and bite turbt as mentioned earlier .
specimens were measured by hematoxylin and eosin ( h&e ) staining and immunohistochemical smoothelin stain to determine the muscularis mucosae .
independent t - tests were used to compare the mean values of two independent parametric continuous variables .
the mann - whitney test was used to compare the median values of two nonparametric continuous variables .
this was a retrospective study in the department of urology of chonnam national university hospital ( gwangju , korea ) between january 2012 and april 2013 .
this study included a total of 29 men and 6 women who had bladder tumors with superficial lesions and who underwent turbt .
patients with a huge unresectable mass , an invasive tumor shown during preoperative imaging , or an irradiated bladder were excluded .
group 1 patients were treated by use of the conventional turbt technique , and group 2 patients underwent the grasp and bite technique .
conventional turbt was performed in 2012 and grasp and bite turbt was performed in 2013 .
this study was approved by the institutional review board of chonnam national university hospital ( irb no .
transurethral resection was performed with a monopolar resectoscope system ( 24-fr karl storz , tuttlingen , germany ) . for the grasp and bite technique ,
the operator initially defined the tumor morphology and safe margin . in small and flat lesions
, the tumor and surrounding mucosal lesions were positioned between the resection loop and the end portion of the resectoscope sheath .
we call this the " grasp " step ( fig . 1 ; video clip , supplementary material ) . using the grasping technique ,
the surgeon maintained a tight hold and resected the tumor while grasping . a cystoscopic view and schematic illustrations are shown in fig .
1 . for resection during the bite step , the movement of the electrode loop was straight backward in a linear direction .
resection was performed carefully so as not to cause bladder perforation without excessive bladder wall distention .
the resection site was carefully inspected for bleeding and coagulation . in bulky or pedunculated tumors ,
after removal of the bulging mass , the base lesion and surrounding mucosa were resected carefully by using grasp and bite turbt as mentioned earlier .
specimens were measured by hematoxylin and eosin ( h&e ) staining and immunohistochemical smoothelin stain to determine the muscularis mucosae .
independent t - tests were used to compare the mean values of two independent parametric continuous variables . the mann - whitney test was used to compare the median values of two nonparametric continuous variables .
statistical analyses were performed with ibm spss statistics ver . 20.0 ( ibm co. , armonk , ny , usa ) .
from january to april 2012 , 16 patients were enrolled who had undergone conventional turbt . from january to april 2013 , the grasp and bite technique was applied to 19 patients with superficial bladder tumors .
the two groups had comparable demographic and intraoperative data , including patient age , tumor size , patient gender , multiplicity , tumor morphology , and tumor location ( table 1 ) .
the mean operative time was similar in the conventional and grasp and bite groups ( 35 minutes vs. 35 minutes , respectively ) .
the mean duration of irrigation , duration of catheterization , and hospital stay were not significantly different between the groups .
there were no cases of bladder perforation , excessive obturator reflex , or persistent hematuria in either group .
2 ) . there was no significant difference in recurrence rates between the conventional and grasp and bite turbt groups during the 14-month follow - up ( 43.8% vs. 31.6% , p=0.458 ) .
the purpose of turbt is complete removal of all visible tumors for curative intent and acquisition of adequate tissue for pathologic evaluation .
also , tumor recurrence after turbt is relatively high . for non - muscle - invasive bladder cancer , the probability of recurrence after 1 year ranges from 15% to 70% .
many obstacles can arise during the procedure , such as bladder perforation , bleeding , obturator reflex , and damage to the ureteral orifices . to overcome these difficulties , many surgical techniques and innovative devices
for example , endoscopic snare resection of a bladder tumor can be used to remove pedunculated tumors .
although the snare method offers the advantage of en block resection , smaller and sessile tumors are not suitable for this technique .
new devices such as water jet hydrodissection and the thulium : yttrium aluminium garnet laser may be applicable for en block resection of superficial tumors . however , further studies and development of these techniques are necessary to determine efficacy and oncologic outcomes . variable methods of tumor resection have been developed and used in association with tumor size and location .
the side - to - side bidirectional lateral rotating handgrip and loop allows excellent precision and control over the loop under direct vision .
loop modification , the so - called " runner , " can push the bladder wall away during resection , thereby widening the view and decreasing the risk of perforation .
we wanted a technique in which we could use a conventional resectoscope and loop without accessory equipment .
when using a wire - loop resectoscope , the tumor must be resected thoroughly to obtain adequate muscle tissue .
the movement of the loop is somewhat fast and deep to avoid charring of the surrounding mucosa and bladder perforation .
direct pressure to the bladder wall may allow deeper tissue to protrude into the bladder wall and then be easily removed by use of the resectoscope . instead of the curvilinear movement of the resectoscope end
according to the curved bladder surface , the easy linear motion can make a curved resection with grasping . using our " grasp and bite " technique
, beginners can easily perform turbt safely . often , small and sessile tumors are missed and severely damaged during resection and cauterization . the grasp and bite technique
, the protruding tumor can be removed f irst by the conventional method , and then the stalk and base lesion can be removed by the grasp and bite technique .
, the grasp and bite technique could have difficulties in a posterior or posterolateral located tumor because of its moving mechanism . in our series , two posterior and four posterolateral tumors were successfully accessed by use of suprapubic pressure and nearly emptying the bladder .
similar to conventional turbt , it was also difficult to access posterior tumors with the grasp and bite method . in our consecutive cases ,
general anesthesia was preferred in the conventional and grasp and bite groups ( 81.3% vs 57.3% , p=0.138 ) .
also , tumor locations did not differ significantly between the two groups ( p=0.253 ) .
we postulated that the grasping method , which lifts the tissue away from the obturator nerve and tightly holds the grasped tissue , may eventually weaken the reflex . considering this small population , however ,
thus , there could have been a selection bias . also , the study population was small , and thus we were unable to perform statistical analysis of the oncologic outcome as recurrence - free survival .
this was a preliminary study to develop a surgical technique performed by an experienced surgeon .
larger prospective studies with a long follow - up period will be necessary to show the oncologic advantage of this technique . to determine the feasibility of the technique for inexperienced surgeons ,
future study will address a teaching protocol comparing the conventional and grasp and bite methods .
investigation of tissue adequacy of proper muscle and effect of coagulation will be our next subject of study .
our study demonstrated that grasp and bite turbt is a safe and effective method for removing superficial bladder tumors .
this technique has merit for flat tumors and can also be used for pedunculated and poorly accessible tumors .
the grasp and bite method may be a shortcut for overcoming the difficulties of turbt .
an accompanying video can be found in the ' urology in motion ' section of the journal homepage ( www.kjurology.org ) .
the supplementary data can also be accessed by scanning a qr code located on the fig . 1 of this article , or be available on youtube ( http://youtu.be/2xjdgspzvy4 ) .
 purposetransurethral resection of bladder tumor ( turbt ) can be a challenging procedure for an inexperienced surgeon . 
 we suggest an easy technique for turbt , which we have named the " grasp and bite " technique . 
 we describe this technique and compare its effectiveness and safety with that of conventional turbt.materials and methodsmonopolar turbt ( 24-fr karl storz ) was performed in 35 patients who had superficial bladder tumors . after defining the tumor margin , the tumor and surrounding mucosa were grasped by use of a loop electrode and resectoscope sheath . with tight grasping , 
 linear moving resection was performed . 
 the patients ' demographic , intraoperative , and postoperative data were analyzed between the conventional and grasp and bite turbt groups.resultsof 35 patients , 16 patients underwent conventional turbt ( group 1 ) , and the other 19 patients underwent grasp and bite turbt ( group 2 ) . 
 both groups were similar in age , tumor multiplicity , size , anesthesia method , and location . 
 grasp and bite turbt could be performed as safely and effectively as conventional turbt . 
 there were no significant differences in irrigation duration , urethral catheterization , postoperative hemoglobin drop , or length of hospital stay . 
 no significant side effects such as bladder perforation , severe obturator reflex , or persistent bleeding occurred . 
 there were no significant pathological differences between specimens according to the type of resection technique.conclusionsthe grasp and bite turbt technique was feasible for superficial bladder tumors . 
 it may be a good tool for inexperienced surgeons owing to its convenient and easy manner . 