Holmium laser treatment under local anaesthesia for recurrent non-muscle-invasive bladder cancer in patients at high perioperative risk

Repeated transurethral resection of bladder tumour (TURBT) can impose substantial procedural burden in recurrent non-muscle-invasive bladder cancer (NMIBC). We evaluated hospital-based holmium laser treatment under local anaesthesia in patients with comorbidity and high perioperative burden. This single-centre retrospective cohort included 155 of 326 patients assessed for local treatment (47.5%), within a screening population of 1,076 patients. Selection combined anaesthetic assessment, shared decision-making and endoscopic suitability, generally requiring no more than five lesions, maximum diameter ≤ 20 mm and cumulative diameter ≤ 40 mm. Follow-up began at the first laser procedure. The primary endpoint was subsequent TURBT under general or neuraxial anaesthesia; oncological outcomes were examined separately by pre-laser disease history. Median age was 76 years, and 94.2% were ASA III–IV. During median reverse Kaplan–Meier follow-up of 4.8 years (observed range 0.80–10.12), 314 laser procedures were recorded. Fifty patients subsequently underwent TURBT. The five-year probability without TURBT was 63.6% (95% CI 54.2–71.5), compared with 90.3% in the Ta low-grade history group and 32.2% in the T1 high-grade/carcinoma in situ group. Recurrence occurred in 94 patients; 47 (50.0%) had no subsequent TURBT. All eight muscle-invasive progressions occurred in the T1 high-grade/carcinoma in situ group. Median index procedure duration was 21 min. Thirty unplanned post-procedural events affected 29 patients, including 11 admissions. Local-anaesthetic holmium laser treatment provided a practical option for selected recurrent NMIBC in patients with substantial perioperative burden. Many patients had no subsequent anaesthetised TURBT during follow-up despite recurrence, particularly those with a Ta low-grade history. High-grade/T1/CIS disease followed a less favourable course and requires separate oncological assessment. The findings inform patient selection and counselling within this treatment pathway. Not applicable.