Sometimes, the small but subtle difference in the reception of ancient phrases of wisdom lies in the process of coining slogans that suit the author more than the fineness of human thought and action. The famous verse of Titus Maccius Plautus in his comedy Truculentus [1] is most often referred to as “Seeing is believing.” However, this was true for my name patron Saint Thomas the Apostle and for the impromptu convert to en bloc resection of bladder tumors (ERBT), Marek Babjuk, visiting me at Hanover Medical School (MHH) 2013  being exposed to ERBT surgery for the first time. However, the topos of cognition and action has been the subject of epistemology since Platon and Aristotelis. This is why Plautus originally more precisely phrased: One eye-witness is of more weight than ten hearsays. Those who hear, speak of what they have heard; those who see, know beyond mistake. This is more or less the definition of the passion with which key opinion leaders as surgeon scientist driving the field of technical innovations forward. For me, personally, by the experience acquired in endoscopic enucleation of the prostate [2, 3], it was a small step to venture for ERBT in the shape of Tm:YAG laser en bloc mucosectomy for accurate staging of primary bladder cancer in 2010 [4]. To reach a sound base for the future one needs to look back. The first stocktaking of the already published studies set the agenda for the coming years [5]. It was puzzling from the start that a treatment with such great potential was not used sooner, had not taken off earlier. The march of ERBT started with a “sling polypectomy of bladder tumors” by Kitamura in 1980 [6] and as a circumferential incisive technique using current by Kawada [7] and using Holmium laser by Das and Gilling [8] in 1997. The spread of the technique came to a halt as did the proliferation for endoscopic enucleation of the prostate in the shape of HoLEP in the early 2000s [9].

With the advent of new lasers, namely, the continuous wave Thulium:YAG and Thulium fiber laser in 2005 [10, 11], that in the end led to a more conceptual way of understanding of surgical principles of anatomical enucleation of the prostate [3], a renaissance of reception of the “antique” en bloc resection technique of bladder tumors was about to start in 2011 [4]. Acteurs in the field of transurethral enucleation of the prostate, now familiar and embracing the concept of dissection along anatomical landmarks turned their focus on this technique. From the start of this renaissance the European Society for Uro-Technlogy (ESUT), with its chair Jens Rassweiler proved to be a sounding board for innovation. At the expert meeting of the ESUT and Section for Uro-Oncology (ESOU) on 2nd February, 2013 in Davos, Switzerland, ERBT data until 2013 were introduced to the uro-oncological peers [12]. ESUT could transfer a lot of enthusiasm in the meeting summary paper titling Technical solutions to improve the management of non-muscle-invasive transitional cell carcinoma: summary of a European Association of Urology Section for Uro-Technology (ESUT) and Section for Uro-Oncology (ESOU) expert meeting and current and future perspectives [13]. The results were certainly an imposition to the traditional TURB scene for two reasons: already having overseen the potential of early ERBT and probably having settled in an endoscopic therapy with known shortcomings and now being challenged. The beaming delta of lamina muscularis propria presentation (LMP) between ERBT and TURB of almost 25% coding for lower local recurrence and lower inter surgeon variance first need digesting [14]. The figures for LMP presentation in TURB specimens have just been reproduced by a current multicenter study with 71.1% in the TURB, and 80.7%, suprisingly low but still significantly better in the ERBT arm [15].

Maurizio Brausi as the author of EORTC studies [16] at that meeting wanted to send Udo Nagele and myself straight to Askaban when we topped the introduction of ERBT by suggesting vaporizing of the vast exophytic portion of the tumor and focus on the contact surface to the bladder wall. As good catholics Udo and I certainly deserve purgatory for something, but not for this push in solving the most urging inherent problem of the size limitation of specimen retrieval by sheath and in the end urethra. The “limitations” were clearly described at that time and approached ([17], Table 1).

Table 1 Exit strategies for tumor retrieval
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The time was not right for this imposition by the power of two, although Bogdan Geavelete had tested this in a randomized controlled trial for TURB, published in 2012 [19]. It is good to see how the “overcoming the one piece extraction dilemma” debate is moving on [22]. For myself, from the beginning, neither “one piece” nor “negative margins” were the direction but anatomical dissection and thereby accurate staging that would make the difference.

Udo Nagele and I also did not deserve purgatory for exploring endoscopic submucosal hydro-dissection (ESD), a technique from gastroenterology in ERBT and presented it in that same meeting. Adding of another modality, referred to as ERBT plus to distinguish from ERBT “only,” seemed to be feasible but not superior and brought another variability to the dissection plane by injecting saline [23, 24]. Unlike ERBT only in other studies, the Hybrid blue study, ESD finished with a LMP presentation of 86% in the ERBT arm, which might enlighten this fact [25].

Not only urologists headed in that direction, but also pathologists immediately were fond of ERBT and wanted the “TURBO,” as they concluded in 2013 that ERBT had the potential to overcome inherent problems of TURB specimen presenting cautery and crush artifacts as well as tangential rather than vertical sections allowing for spatial orientation in embedded tissue [26]. Furthermore, oncological principles known from other surgical fields seemed to be met in the principles that Ukai laid down 12 years before in 2000 with his publication of TransUrethral Resection of Bladder tumors in One piece (TURBO) [27].

ERBT coined as an acronym in 2014 would be general practice if [24] “Seeing is believing” would be true. The field of uro-oncological endoscopic surgery seems to be different and for good reasons asks for more evidence to arrive on the table of the debate than was available from 2011 till 2018. Reviewing the summaries of that time [17, 28,29,30] gaps were obvious. If it was not for the first larger multi-institutional publication of the experience of the EBRUC consortium (En Bloc Resection of Urothelial Cancer) formed by the ad hoc working group after the ESUT / ESOU meeting published in 2015 [31] proving what structured reviews before had produced. The key messages were as follows: The representation of the lamina muscularis propria in the pathology report was as high as 97.3% in all groups; excellent specimen quality; and low procedural associated morbidity, when compared to contemporary series of TURB covered in the EAU Guidelines on NMIBC, who introduced a dedicated section almost in textbook fashion on how to perform TURB in 2015 [32]. However, with growing evidence ERBT made an entry into the EAU Guidelines on NMIB in 2017 [33], an important year not only for ERBT but also for myself deciding to leave Hanover Medical School and joining the Urological community in Switzerland (SGU). At this point I would like to sincerely thank Mario Kramer who was and still is a great collaborator not only because he largely composed our manuscripts, but he also aimed for the next level: a large multicenter randomized controlled trial. However, some gaps were closed in between by Rodolfo Hurle and Lukas Lusuardi [34] when it came to technical aspects of the feasibility of TURB after ERBT. The international consensus in ERBT meeting in Hong Kong hosted by Jeremy Teoh [35] in 2020 defined the gap of knowledge, already tangible beforehand in earlier reviews and meta-analysis, to be filled.

After 2020, these high-quality randomized controlled trials arrived that were urged for in the past in the beginning of the renaissance. Almost all of my collaborators are displayed in the authors list of this special issue. I would like to personally thank those people that caught fire and marvelously conducted studies. All of them became passionate fellow campaigners not only for ERBT but also for improved training of residents and better surgery and outcomes for our patients: the study groups of Alberto Breda [36, 37], Jeremy Teoh [[22], and Dimitry Enikeev [38] as well as the ESUT led by Ali Serdar Goezen [39] did a wonderful job for the delight of the reader and sake of the subject.

Jeremy Teoh who is the head of a global registry database [22] will deliver the evidence requirement of what we defined in the EUA guideline panel of Male LUTS as required certainty of evidence to implement ERBT as a first-line treatment option supported by the guidelines reaching the top of the evidence pyramid [48].

The efforts the urological community undertook in the last 15 years to get on top of uro-oncology and medical therapy of malignant disease are remarkable. However, even in 2023, I still sense at the same time disengagement of venturing for new surgical techniques. The problems of filter bubbles and echo chambers in knowledge societies are subjects [40, 41] of the contemporary version of the epistemology debate. These bubbles between endourology and uro-oncology do not seem to communicate well. A look in a different context is useful to enlighten this.

Platon would let Sokrates ask a person of the uro-oncology bubble in the fashion of hermeneutics, why the community was easily jumping for Abiraterone after data from Cougar 301 study presented by Johann S de Bono et al. in [43] showing a difference in OS in mCRPC of 3.9 months (14.8 vs. 10.9 months) or embracing of Docetaxel after Ian Tannock presenting data of TAX 327 [44] study showing a difference of median survival of 2.4 months (18.9 vs. was 16.5 months) and not immediately embracing ERBT by pointing the uro-oncology bubble member toward the “red” line in MIBC of 3 months. The EAU guidelines on muscular invasive bladder cancer (MIBC) refer to a meta-analysis including 19 studies concluding that a delay of > 3 months has a negative effect on OS. Although the authors highlighted the lack of standardization regarding the definition of delays, overall conclusion was that patients scheduled for radical cystectomy should be treated without delays to maximize survival [42].

However, every thought experiment lags behind but if you ask your colleague from the uro-pediatric surgeon bubble, who also will tell you about his appreciation of submucosal dissection for ureteral reimplantation, that it is a great deal to tackle problems right at the beginning to avoid further damage. A delay in definite treatment is potentially a lethal damage, and probably we can save a proportion of our patients from requiring (cost intensive) adjuvant treatment after definite treatment, when we do it right from the beginning. Can one believe that when f.e. Manni Mennon or Inderbir Gil had called for a surgical procedure with the robot that would have delivered an improvement of 25% in the pathological review of the surgical specimen in the 2000s, that the uro-oncological surgeons would have ignored that (like they did for ERBT)? I can hardly believe that. Be it cognitive bias or dissonance, or simply decision fatigue [45, 46]. We have to move on.

Concluding, on the footstep of the perron to the portal of a better staging and management of bladder cancer, where ERBT in my perception has arrived today, I want to approach the informed surgeon scientist with what large language models like ChatGPT already “know” about ERBT [47], and most probably all of your patients will most probably find out, supporting surgeons to venture for ERBT for various reasons (Table 2).

Table 2 What ChatGPT “knows” on ERBT [47]
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I hope that the readers of this Special Issue with the data of 2023 will enjoy reading it and that it will give them an impulse to actively turn to ERBT.