Bladder cancer begins in the innermost lining of the bladder wall and, on histological examination, is classified as one of two types: non-muscle-invasive bladder cancer (NMIBC) or muscle-invasive bladder cancer. Transurethral resection of bladder tumour (TURBT) is the standard treatment for people with NMIBC, but the high rate of cancer recurrence after first TURBT is a challenge that physicians and patients face. Tumours seen during follow-up may have been missed or incompletely resected during first TURBT. TURBT is conventionally performed using white light to see the tumours. However, small papillary or flat tumours may be missed with the use of white light alone. With the emergence of new technologies to improve visualization during TURBT, better diagnostic and patient outcomes may be expected. We conducted a health technology assessment of two enhanced visualization methods, both as an adjunct to white light to guide first TURBT for people with suspected NMIBC-hexaminolevulinate hydrochloride (HAL), a solution that is instilled into the bladder to make tumours fluoresce under blue-violet light, and narrow band imaging (NBI), a technology that filters light into wavelengths that can be absorbed by hemoglobin in the tumours, making them appear darker. Our assessment included an evaluation of effectiveness, safety, cost-effectiveness, and the budget impact of publicly funding these new technologies to improve patient outcomes following first TURBT. The use of NBI in diagnostic cystoscopy was out of scope for this health technology assessment.
We performed a systematic literature search of the clinical evidence from inception to April 15, 2020. We searched for randomized controlled trials (RCTs) that compared the outcomes of first TURBT with the use of HAL or NBI, both as an adjunct to white light, with the outcomes of first TURBT using white light alone, or studies that made such comparison between HAL and NBI. We conducted pairwise meta-analyses using a fixed effects model where head-to-head comparisons were available. In the absence of any published RCT for comparison between HAL and NBI, we indirectly compared the two technologies through indirect treatment comparison (ITC) analysis. We assessed the risk of bias of each included study using the Cochrane risk-of-bias tool. We assessed the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted a cost-utility analysis with a 15-year time horizon from a public payer perspective. We also analyzed the budget impact of publicly funding HAL and NBI as an adjunct to white light in people undergoing their first TURBT for suspected non-muscle-invasive bladder cancer in Ontario.
In the clinical evidence review, we identified 8 RCTs that used HAL or NBI as an adjunct to white light during first TURBT. Pairwise meta-analysis of HAL studies showed that HAL-guided TURBT as an adjunct to white light significantly reduces recurrence rate at 12 months compared with TURBT using white light alone (risk ratio 0.70, 95% confidence interval [CI] 0.51-0.95) (GRADE: Moderate). Five-year recurrence-free survival was significantly higher when HAL was used as an adjunct to white light than when white light was used alone (GRADE: Moderate). There was little to no difference in the tumour progression rate (GRADE: Moderate).Meta-analysis of NBI studies did not show a significant difference between NBI-guided TURBT as an adjunct to white light and TURBT using white light alone in reducing the rate of recurrence at 12 months (risk ratio 0.94, 95% CI 0.75-1.19) (GRADE: Moderate). No evidence on the effect on recurrence-free survival or tumour progression rate was identified for NBI-guided TURBT. The indirect estimate from the network analysis showed a trend toward a lower rate of recurrence after HAL-guided TURBT than after NBI-guided TURBT but the difference was not statistically significant (risk ratio 0.76, 95% CI 0.51-1.11) (GRADE: Low). Studies showed that use of HAL or NBI during TURBT was generally safe.The incremental cost-effectiveness ratio of HAL-guided TURBT compared with NBI-guided TURBT, both as an adjunct to white light, is $12,618 per quality-adjusted life-year (QALY) gained. Compared with TURBT using white light alone and using adjunct NBI, the probability of HAL-guided TURBT being cost-effective is 69.1% at a willingness-to-pay value of $50,000 per QALY gained and 74.6% at a willingness-to-pay of $100,000 per QALY gained. The annual budget impact of publicly funding HAL-guided TURBT in Ontario over the next 5 years ranges from an additional $0.6 million in year 1 to $2.5 million in year 5.
First TURBT guided by HAL as an adjunct to white light likely reduces the rate of recurrence at 12 months and increases 5-year recurrence-free survival when compared with first TURBT using white light alone. There is likely little to no difference in the tumour progression rate. First TURBT guided by NBI as an adjunct to white light likely results in little to no difference in the rate of recurrence at 12 months when compared with first TURBT using white light alone. Based on an indirect comparison, there may be little to no difference in cancer recurrence rate between HAL-guided and NBI-guided first TURBT. Use of HAL or NBI during first TURBT is generally safe. For people undergoing their first TURBT for suspected non-muscle-invasive bladder cancer, using HAL as an adjunct to white light is likely to be cost-effective compared with using white light alone or with using NBI as an adjunct to white light. We estimate that publicly funding HAL as an adjunct to white light to guide first TURBT for people in Ontario with suspected NMIBC would result in additional costs of between $0.6 million and $2.5 million per year over the next 5 years.

Enhanced Visualization Methods for First Transurethral Resection of Bladder Tumour in Suspected Non-muscle-invasive Bladder Cancer: A Health Technology Assessment.

Multiple treatments for early-moderate grade symptomatic haemorrhoids currently exist, each associated with their respective efficacy, complications, and risks. The aim of this study was to compare the relative clinical outcomes and effectiveness of interventional treatments for grade II-III haemorrhoids.
A systematic review was conducted according to PRISMA criteria for all the RCTs published between 1980 and 2020; manuscripts were identified using the MEDLINE, Embase, and CENTRAL databases. Inclusion criteria were RCTs comparing procedural interventions for grade II-III haemorrhoids. Primary outcomes of interest were: symptom recurrence at a minimum follow-up of 6 weeks, postprocedural pain measured on a visual analogue scale (VAS) on day 1, and postprocedural complications (bleeding, urinary retention, and bowel incontinence). After bias assessment and heterogeneity analysis, a Bayesian network meta-analysis was performed.
Seventy-nine RCTs were identified, including 9232 patients. Fourteen different treatments were analysed in the network meta-analysis. Overall, there were 59 RCTs (73 per cent) judged as being at high risk of bias, and the greatest risk was in the domain measurement of outcome. Variable amounts of heterogeneity were detected in direct treatment comparisons, in particular for symptom recurrence and postprocedural pain. Recurrence of haemorrhoidal symptoms was reported by 54 studies, involving 7026 patients and 14 treatments. Closed haemorrhoidectomy had the lowest recurrence risk, followed by open haemorrhoidectomy, suture ligation with mucopexy, stapled haemorrhoidopexy, and Doppler-guided haemorrhoid artery ligation (DG-HAL) with mucopexy. Pain was reported in 34 studies involving 3812 patients and 11 treatments. Direct current electrotherapy, DG-HAL with mucopexy, and infrared coagulation yielded the lowest pain scores. Postprocedural bleeding was recorded in 46 studies involving 5696 patients and 14 treatments. Open haemorrhoidectomy had the greatest risk of postprocedural bleeding, followed by stapled haemorrhoidopexy and closed haemorrhoidectomy. Urinary retention was reported in 30 studies comparing 10 treatments involving 3116 participants. Open haemorrhoidectomy and stapled haemorrhoidopexy had significantly higher odds of urinary retention than rubber band ligation and DG-HAL with mucopexy. Nine studies reported bowel incontinence comparing five treatments involving 1269 participants. Open haemorrhoidectomy and stapled haemorrhoidopexy had the highest probability of bowel incontinence.
Open and closed haemorrhoidectomy, and stapled haemorrhoidopexy were associated with worse pain, and more postprocedural bleeding, urinary retention, and bowel incontinence, but had the lowest rates of symptom recurrence. The risks and benefits of each treatment should be discussed with patients before a decision is made.

Interventional treatments for prolapsing haemorrhoids: network meta-analysis.

Popliteal artery aneurysms (PAA) were traditionally treated by open repair (OR). Endovascular repair (ER) has become a new treatment strategy. The aim of this systemic review and meta-analysis was to evaluate and compare the current outcomes of OR and ER in the emergency treatment of PAA.
A systematic literature search of the PubMed/Medline database was carried out. Outcomes were 30-day mortality, morbidity, major amputation rate (30 days), major amputation rate (1 year), 1-year primary patency rate, 1-year secondary patency rate and 1-year survival. Additionally, we included clinical data of patients with popliteal aneurysms treated between 2009 and 2021 at the Martin-Luther University Halle-Wittenberg.
We identified two cohort studies from 2014 and 2015 with a total of 199 patients that underwent emergent surgery (39 ER and 160 OR). We also included 26 patients from our institution. For emergency treatment, 30-day major amputation rates (18% vs 3%, Odds Ratio 5.82, 95% CI [1.75; 19.30], 
Endovascular repair represents an alternative approach for the emergency treatment of PAA. Limited evidence from the available non-randomized studies shows unfavorable outcomes for patients undergoing ER. However, the results are prone to selection bias, and only randomized trials comparing ER to OR might reveal whether a subgroup of patients would benefit from ER as primary treatment of PAA in an emergency setting.

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