En bloc versus conventional transurethral resection for non-muscle-invasive bladder cancer: an expanded and updated systematic review and meta-analysis reconciling contemporary evidence on oncological, pathological, and safety outcomes

BACKGROUND: This systematic review and meta-analysis compares oncological outcomes, pathological quality, and safety profiles between en bloc (ERBT) and conventional transurethral resection (cTURBT) for non-muscle-invasive bladder cancer (NMIBC), incorporating the latest evidence from randomized trials and high-quality observational studies. METHODS: We systematically searched PubMed, Embase, Cochrane Library, and Web of Science (up to December, 2024) for studies comparing ERBT and cTURBT outcomes. Methodological quality was assessed using standardized tools, with statistical analysis performed using RevMan 5.3. RESULTS: Our meta-analysis incorporated 35 studies involving 6,013 patients with NMIBC. The overall methodological quality was high with a low risk of bias in most included trials; however, moderate to substantial heterogeneity was observed for several outcomes, and potential publication bias was detected for certain safety endpoints. The pooled results demonstrated statistically significant advantages for ERBT in reducing tumor recurrence at 12 months (OR = 0.56, 95% CI: 0.33–0.95; p = 0.03) and 24 months (OR = 0.70, 95% CI: 0.53–0.91; p = 0.009), though recurrence rates at 36 months showed no significant difference between techniques (p > 0.05). Similarly, progression risks did not differ significantly between groups at any time point (all p > 0.05). Pathological evaluation revealed superior outcomes with ERBT, including significantly higher detrusor muscle presence in specimens (OR = 2.60, 95% CI: 1.70–3.99; p < 0.0001) and lower residual tumor rates (OR = 0.60, 95% CI: 0.37–0.99; p = 0.05). However, mucosal muscle detection rates were comparable between techniques (p = 0.21). Regarding safety outcomes, ERBT demonstrated significantly lower risks of bladder perforation (OR = 0.36, 95% CI: 0.22–0.59; p < 0.0001), obturator nerve reflex (OR = 0.13, 95% CI: 0.06–0.29; p < 0.00001), and transfusion requirements (OR = 0.17, 95% CI: 0.04–0.80; p = 0.02). Perioperative metrics favored ERBT with shorter catheterization duration (p = 0.002), reduced hospital stay (p = 0.0002), faster resection time (p = 0.009), and better hemoglobin preservation (p = 0.006), while maintaining equivalent overall surgical times (p = 0.15). CONCLUSIONS: ERBT offers superior short-term oncological control, improved pathological assessment, and enhanced perioperative safety versus cTURBT, supporting its role as a preferred resection technique for NMIBC, despite equivalent long-term outcomes. Clinical implementation should consider individual tumor characteristics and surgeon expertise. TRIAL REGISTRATION: CRD420251032096.