Laser surgery for transitional-cell carcinoma. Technique, advantages, and limitations.

Lasers generate a unique form of energy with specific tissue effects different from those of either unipolar or bipolar electrocautery. A noncontact coagulation necrosis of superficial transitional-cell carcinoma of the bladder can be achieved. There are insufficient data to support the contention that the recurrence rate of transitional-cell carcinoma is decreased by laser therapy. However, there is abundant evidence that laser treatment of superficial bladder cancer is effective in eradicating grossly visible tumors. Bleeding does not occur during laser application, a clear advantage over electrocautery resection. Additionally, the treatment can sometimes be performed without anesthesia, and the energy can be transmitted via flexible fibers, facilitating the use of flexible cystoscopes. Bladder perforation is unlikely, obturator nerve stimulation does not occur, and postoperative Foley catheter drainage of the bladder is unnecessary. Tumors within bladder diverticula can be treated endoscopically with lasers, and stenosis of the ureteral orifice is rare. There is experimental evidence that laser treatment does not increase the absorption of intravesical chemotherapy, possibly allowing earlier adjuvant use of intravesical treatment postoperatively. On the other hand, there are limitations of laser treatment. Lasers are less familiar to both surgeons and operating room personnel. Appropriate eye protection during treatment is mandatory. Tumor staging is suboptimal, because tissue from the base of the lesion is not routinely available for histologic examination. Accordingly, appropriate patient selection is a paramount consideration. Finally, bowel injury without bladder perforation is a unique, though rare, complication of laser surgery. Simultaneous laparoscopy may be of benefit in some patients but is not indicated routinely. Although laser treatment has not revolutionized the management of superficial bladder cancer, it has an established and enduring role. Future changes in surgical instruments seem likely to increase the usefulness of lasers in managing patients with transitional-cell carcinoma of the bladder.