What Is Transurethral Resection Of Bladder Tumor
TURBT is the procedure done to diagnose and to treat early stage bladder cancer at the same time. The initials stand for transurethral resection of a bladder tumor. This procedure is the first-line diagnostic test and treatment for bladder cancer. Men are almost four times more likely than women to be diagnosed with this type of cancer.
The majority of people have bladder cancer that hasnt invaded the muscle wall when first diagnosed. Almost everyone diagnosed with bladder cancer will undergo bladder tumor biopsy and resection.
A biopsy is a procedure in which a doctor takes a tissue sample from the area where cancer may exist. During the biopsy procedure, the doctor also will try to remove the cancerous growth. This is called resectioning. The entire procedure for bladder tumor biopsy and resection is known as transurethral resection of bladder tumor .
How Long Will It Take Me To Recover From A Turbt
The first 5-7 days after surgery are crucial for recovery. During this time, you should rest and refrain from strenuous activity and exercise. This time of rest allows your bladder to heal and decreases the risks associated with bleeding. Each person is different. You may require more or less recovery time than another person.
Tumor Involving The Ureteral Orifice
A tumor near or involving the ureteral orifice poses the challenge of obtaining complete resection and adequate hemostasis while preserving the caliber of the intramural ureter. Resecting with a purely cutting current and the judicious use of pinpoint cautery at the lowest effective setting for hemostasis make ureteral stricture unlikely. If postoperative flank pain develops, a renal ultrasound can be performed to evaluate for hydroureteronephrosis. If present, a percutaneous nephrostomy tube can be placed. Tumor location at the ureteral orifice should not deter appropriate endoscopic management.
Reflux of urine into the upper tracts, which may occur with ureteral stenting or via vesicoureteral reflux following resection of the ureteral orifice, has been shown to increase the risk of seeding and tumor occurrence in the ureter and renal pelvis in some retrospective studies. Conversely, Solsona and colleagues found no significant difference in upper tract recurrence patterns when refluxing and nonrefluxing patients were studied post-TURBT. Regardless, close follow-up and monitoring for bladder as well as upper tract recurrence are advisable. Patients who symptomatically reflux after TURBT have been successfully managed with the endoscopic injection of bulking agents. Surgical reimplantation of the refluxing ureter is also possible.
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Detecting Bladder Cancer With A Cystoscopy
Cystoscopy enables the inside of the urethra and bladder to be examined and sampled. Alongside urine testing and diagnostic imaging procedures, cystoscopy is used in both the initial diagnosis of bladder cancer and in ongoing surveillance for recurrence. In addition, cystoscopy-based procedures are commonly used to remove or treat small bladder tumors.
Preoperative Considerations History And Physical
As with any operation, the treatment begins in the outpatient setting. At this time, a full history is obtained, and a focused urological physical examination is performed. The history should include the patients age, sex, past medical history, smoking history, history of bladder cancer or other malignancies, previous surgical history including endoscopic treatment and any intravesical therapy following the diagnosis of bladder cancer . A review of the patients imaging studies is important to determine the status of the upper urinary tract.
On the day of the operation, the history and physical exam should be reviewed. The case should be discussed with the anesthesiologist. The type of anesthesia is important. The patient should be fully relaxed so that the bladder can be filled to the desired amount . General anesthesia with complete neuromuscular blockade is often preferred, as it allows the patient to be paralyzed as needed intraoperatively and to recover quickly postoperatively. Spinal anesthesia is also a reasonable option as it ensures the patient will not move during the procedure and maximizes bladder relaxation. Although we have never used this technique, transvesical injection of the obturator nerve has been reported to be an effective method to block the adductor or obturator reflex. Lastly, in addition to the routine preoperative lab values, the team should review any history of anticoagulant therapy, which is common in elderly patients.
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Transurethral Resection Of The Bladder Tumor: Standard Technique And New Advancements
Urology Times Urologists in Cancer Care
Improvement in imaging modalities may help in performance of transurethral resection of the bladder tumor.
Since it was first described in 1910, transurethral resection of bladder tumor has evolved into the cornerstone of bladder cancer diagnosis and staging, and is one of the most common surgeries urologists perform. Following the introduction of video endoscopy in the late 1970s, TURBT has been characterized as a relatively simple procedure, often performed by junior residents in the academic setting. More recent data emphasize the importance of high-quality TURBT by experienced surgeons in order to improve patient outcomes.1 Significant variation in recurrence rates among urologists has been described, supporting the assumption that experienced technical skill matters. At our institution, junior residents slowly gain more responsibility as their technical skills develop under the close supervision of an experienced surgeon with a low threshold to take over the case when accurate staging may be difficult to obtain. Below, we discuss our standard technique for TURBT and describe new advancements that may help standardize outcomes in a procedure that has experienced little evolution during the past century.
TURBT technique
Although postoperative continuous irrigation has been associated with lower recurrence rates, we typically avoid this in our patients because of concern for inducing or worsening bladder perforation.8
References
Guidelines For Use Of Turbt
The guidelines are in agreement that the final diagnosis of bladder cancer is based on cystoscopic examination and bladder tumor histology. The guidelines further agree that all visible lesions should be resected during TURBT with bimanual examination under anesthesia and that adequate sampling is required for proper tumor identification and staging. Lastly, imaging of the upper urinary tracts should be evaluated to assess for concomitant disease involvement.
The AUA/SUO recommendations for repeat TURBT are as follow :
- In patients with incomplete initial resection, repeat TURBT if technically feasible.
- For high-risk, high-grade Ta tumors, consider performing repeat TURBT of the primary tumor site within 6 weeks of initial TURBT.
- In T1 disease, repeat TURBT of the primary tumor site, including muscularis propria, within 6 weeks of initial TURBT.
EUA guidelines recommend performing a second TURBT 2-6 weeks after the initial resection in any of the following situations :
- After incomplete initial TURBT
- If there is no muscle in the specimen after initial resection, with exception of Ta low-grade tumors and, possibly, completely resected primary CIS
- In all T1 tumors
- In all high-grade tumors, except primary CIS however, it may be beneficial to attempt to resect all CIS lesions at repeat TURBT
The NCCN recommends TURBT as standard treatment for low-grade Ta NMIBC.
For treatment of T1 tumors NCCN recommends repeat TURBT.
- Smaller solitary tumors
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Tumor At The Lateral Wall
In addition to the anesthetic options discussed above, there are several techniques the surgeon can employ to lessen the likelihood of a complication stemming from the inadvertent stimulation of the obturator nerve during resection of a laterally located tumor. Preventing overdistention, decreasing the cutting/coagulation current settings, and the use of intermittent cautery can lessen the incidence of adductor contraction. The endoscopic injection of local anesthetic into the tumor base can also deliver an obturator nerve block if a percutaneous attempt was not made preoperatively. Lastly, use of a bipolar resecting system restricts the flow of current to between the two electrodes of the resecting loop thus decreasing stimulation of the obturator nerve.
What Happens During The Surgery
At the start of the procedure, you will be given a numbing drug . Generally, two options are available: general anesthesia where you take a nap for the entire procedure, or local anesthesia, where you remain awake, but are given a drug through a needle in your back to numb the lower half of your body.
During a TURBT procedure, the surgeon inserts a tool called a resectoscope through the urethra to reach the inside of your bladder. This tool has a surgical loop on it that resects or cuts off a sample of tumor tissue to be analyzed by a pathologist, or resects the entire tumor from your bladder . TURBT is used as a treatment for patients with early-stage bladder cancer, and is typically followed by intravesical therapy.
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When You Might Have A Turbt
TURBT is the main treatment for non muscle invasive bladder cancer. You usually have this operation as your first treatment.
TURBT can also diagnose bladder cancer and find out whether the cancer has spread into the muscle layer of the bladder wall. The surgeon removes the tumour . They send the tissue they remove to the laboratory. This tells them:
- how far the cancer has grown through the bladder wall
- how abnormal the cancer cells look under the microscope
You sometimes have a second TURBT operation within 6 weeks of the first. You usually have this if you have a high risk non muscle invasive bladder cancer. This is to make sure the surgeon has removed all the cancer. And to double check how far your cancer has grown.
Are There Any Risks Associated With Cystoscopy
Cystoscopy is usually a safe procedure and serious complications are uncommon. The most frequent complication is urinary tract infection . UTIs may require antibiotic treatment, so it is important to seek medical help if urinary symptoms persist for longer than expected following a cystoscopy or if other UTI symptoms develop . Less commonly, patients may be temporarily unable to pass urine after a cystoscopy and it may be necessary for a catheter to be inserted into the bladder to enable emptying. There is also a small risk that the urethra or bladder may be damaged by the cystoscope and subsequently require remedial surgery.
In patients who undergo rigid cystoscopy, side effects associated with anesthesia may be experienced. Common side effects of general anesthesia include nausea, vomiting, sore throat, muscle aches, itching, shivering, and sleepiness side effects most frequently associated with spinal anesthesia include itchiness, a drop in blood pressure, and temporary difficulty passing urine .
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A Single Immediate Postoperative Intravesical Instillation Of Chemotherapy
All participants will undergo IPIC unless bladder perforation occurs or is suspected during TUR. Within 24h postoperatively, one intravesical instillation of 60mg of epirubicin in 30ml of saline will be administered. The catheter will be clamped and left for 1h, and subsequently unclamped. The patients who do not undergo IPIC will be excluded from the analysis of primary endpoint, but included in the analysis of secondary endpoints.
Chemotherapy Into Your Bladder
You usually have a single dose of chemotherapy into the bladder at the end of your operation. Or you may have it when you return to the ward. You have it within 6 hours of having the operation.
This is to help stop the bladder cancer from coming back and get rid of any cancer cells that may have been left behind.
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Outcomes And Complications Of Bipolar Vs Monopolar Energy For Transurethral Resection Of Bladder Tumors: A Systematic Review And Meta
- 1Department of Urology, Affiliated Hospital of Qingdao University, Qingdao, China
- 2Department of Urology, Beijing TianTan Hospital, Capital Medical University, Beijing, China
- 3Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
- 4Department of Urology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
Background: Bipolar and monopolar transurethral resections have a stable status for non-muscle invasive bladder cancer . We conducted a meta-analysis to analyze the outcomes and complications of bipolar vs. monopolar energy for transurethral resection of bladder tumors .
Methods: The Preferred Reporting Items for Systematic Reviews and Meta-analyses was followed. Based on the Population, Intervention, Comparator, Outcomes, and Study Designs strategy, randomized controlled trials were searched in MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. The reference lists of the associated articles were also retrieved. The data were calculated by Rev Man v5.3.0.
B-TURB was more effective than m-TURB in minimizing intraoperative or postoperative bleeding with the smaller loss of hemoglobin and the shorter hospitalization time for patients with NMIBC.
What Happens To The Tumor After The Procedure
All the tumor specimens from the TURBT will be sent to a pathologist for review. The pathologist will confirm the type of bladder cancer and the depth of invasion into the bladder wall, if any. This will help the pathologist and your medical team determine the stage and grade of your bladder cancer. These findings, along with results from imaging such as CT scans, will determine the type and duration of further treatment if necessary.
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How Is Bladder Tumor Biopsy And Resection Performed
You may have general anesthesia for this procedure, which means youll be asleep for it. Some providers might use regional anesthesia, which means youll be awake. However, you wont feel any pain.
Bladder tumor biopsy and resection is performed when a doctor inserts a rigid instrument called a resectoscope into the bladder through the urethra. Inserting the resectoscope in this way means that no incisions are necessary.
Your provider will use the resectoscope to remove the tumor, which will be sent to a pathology lab for testing. Once the tumor is removed, your doctor will attempt to destroy any remaining cancer cells by burning the area using electric current by a process called fulguration or cauterization.
Your provider may decide to insert some type of chemotherapy medicine into the bladder using the scope. This is called intravesical chemotherapy. Your provider might suggest that you have maintenance intravesical chemotherapy for a period of time, meaning that you’ll have regular treatments.
What Is The Recovery Time From Bladder Tumor Biopsy And Resection
Following the procedure, youll have a catheter inserted into the bladder to drain urine. It is normal for there to be blood in the urine at first. Drinking liquids will help flush out your bladder and help prevent infections. Your catheter will be removed when there is no more blood visible in the urine or when you go home.
Most people can have a simple bladder tumor biopsy and resection done as an outpatient procedure. However, your provider might suggest you stay overnight if you have other medical concerns or if you have had a large amount of tissue removed.
You should be able to drink and eat the way you normally do. Youll probably be told to make sure you drink adequate amounts of fluids.
You might have some discomfort when you urinate.
You should be able to return to normal activity in a few days.
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Surgical Procedure And Device For Pdd
Approximately 3h before surgery, patients orally received a water-dissolved 5-ALA solution at a dose of 20mg/kg . The PDD-EBTUR will be performed by a single surgeon with substantial experience in this surgical technique , while the PDD-cTURBT will be performed by one of the following experienced urologists: M. Miyake, S. Hori, Y. Nakai, S. Anai, K. Torimoto, N. Tanaka, and K.Fujimoto. The surgical procedures and devices for PDD-EBTUR and PDD-cTURBT are described in our previous report .
Bladder Neck And Prostate Biopsy
The biopsy of the bladder neck and the prostatic urethra with there is an evidence of disease is not questioned. However, in some cases, the involvement is not visible. The risk of involvement is higher in case of carcinoma in situ , high-grade tumor, and positive cytology without evidence of the disease in the bladder .
When indicated, the biopsy from abnormal areas in the prostatic urethra and from the precollicular area are performed using a resection loop or cold-cup biopsy when stromal invasion is not suspected .
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Damage To The Bladder
There is a small risk of a hole being made in the bladder during surgery. If this happens, the catheter is left in the bladder to allow the hole to heal. The catheter will be removed when the hole has healed. Rarely, you may have an operation to close the hole.
The nurse or doctor may ask you for a sample of your urine to check for any infection. If you have a urine infection, your doctor will give you antibiotics to treat it before surgery.
You will see a member of the surgical team and a specialist nurse who will talk to you about the operation. This is a good time to ask any questions, or to talk about any worries you may have.
You usually go into hospital on the day of your operation. You usually have a general anaesthetic. But you may have the operation done under a spinal anaesthetic. For a spinal anaesthetic, the doctor injects a drug through a needle into your back. This numbs the nerves from the waist down. You will be awake during the operation, but you will not feel anything. If you are having a spinal anaesthetic, you may also have another drug to help you relax.
You will see the doctor who gives you the anaesthetic either at a pre-assessment clinic, or when you are admitted to hospital.
The nurse will talk to you about what you should do before the operation. This can include instructions about medications or eating and drinking.
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Monopolar Versus Bipolar Electrocautery
Both bipolar and monopolar electrocautery can be used for transurethral resection of bladder tumors. A recent study retroactively compared monopolar versus bipolar TURBT. The study examined perioperative complications in monopolar versus bipolar TURBT. They found that bipolar TURBT was associated with a lower incidence of bladder injury, with slightly shorter postoperative length of hospitalization and lower costs. In contrast, Venkatramani and colleagues found that bipolar transurethral resection was not superior to monopolar with regard to obturator reflex, bladder perforation, or hemostasis. However, other authors have reached the opposite conclusion.
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