Factors That Would Affect Recurrence And Progression
Bladder cancer is associated with a high rate of recurrence among patients with NMIBC. A number of studies assessed the factors that might be associated with recurrence and progression of bladder cancer following TURBT. The majority of the studies were rated as low quality and no strong recommendations were made in the guidelines due to study heterogeneity and hence low grade evidence. Nevertheless, there were a number of factors that have been shown to significantly influence the outcomes.
The largest randomised controlled trial included 2,596 patients in seven European Organization for Research and Treatment of Cancer trials. It demonstrated recurrence rates ranging from 15% to 61% and progression rates of less than 1% to 17% at one year. At five years, the probabilities of recurrence and progression ranged from 31% to 78% and from less than 1% to 45%, respectively. The risk of recurrence was linked to a number of clinicopathologic factors including size, multifocality, prior recurrence, stage, CIS and grade . Based on these key factors the European Organization for Research and Treatment of Cancer scoring system and risk tables for recurrence and progression in patients with NMIBC have been developed as shown in Tables 1-31-3 .
Taking A Biopsy During A Turbt Procedure
When it is used to help diagnose bladder cancer, the TURBT procedure may involve taking small tissue samples from the area with abnormal cells or removing all of the tissue that contains abnormal cells. The urologist may also take samples from other parts of the bladder lining to check for cancer cells.
The biopsied tissue is then sent to the lab where it is analyzed to see if it contains cancer cells. Small samples of muscle from the walls of the bladder near the area of abnormal cells may also be taken for analysis, to see if it contains cancer cells that have grown into the muscle.
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Bladder Tumor: Cystoscopic Resection
The operation you have experienced is a “scraping” operation that is tosay, the bladder tumor or biopsy sample was “scraped” off the bladder wall.Bleeding was controlled with electrocautery which will produce a “scab” inthe inside bladder wall. About 1-2 weeks after the operation, pieces of thescab will fall off and come out with the urine. As this occurs, bleedingmay be noted which is normal. You should not worry about this. Simply liedown and increase your fluid intake for a few hours. In most cases, theurine will clear. Because of this tendency for bleeding, aspirin must be avoided for 2 weeks following your operation . Ifbleeding occurs or persists for more than 12 hours or if clots appearimpairing your stream, call your surgeon.
You will be given a prescription for antibiotics to be taken for about oneweek. This is to help prevent infection. If you develop a fever over 101°,or have chills, call your surgeon. Although not common, this may indicateinfection that has developed beyond the control of the antibiotics that youhave taken.
Finally, call our office one week after your surgery for the results ofyour biopsy and your next appointment.
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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.
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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What Is The Outlook For Someone Who Has Had Bladder Tumor Biopsy And Resection
Bladder tumor biopsy and resection is a successful treatment for early stage bladder cancer. It can prevent cancer from spreading into the bladder muscle wall. Invasive bladder cancers that spread require more extensive treatment.
However, bladder cancer often comes back . More TURBT procedures may be needed. Your doctor will do frequent follow-up checkups with you to look for signs that the cancer has returned. The risks of repeated TURBT procedures is small.
Some providers might choose to burn off smaller tumors rather than remove them.
If the TURBT shows that you have a more advanced bladder cancer, youll probably need further treatment. This could include:
- A more extensive TURBT.
- Surgery to remove the tumor.
- Surgery to remove the bladder.
- Bacillus Calmette-Guerin therapy or BCG. This is a type of therapy that uses the bodys own immune system to fight the cancer.
Your urologist and pathologist will determine the best course of treatment based on the staging of the tumor and your personal medical history. TURBT can help in staging the cancer by determining if the cancer has invaded the bladder wall. Staging refers to determining how serious the cancer is.
How Turbt Is Done
This surgery is done using an instrument put in through your urethra, so there’s no cutting into the abdomen . You’ll get either general anesthesia or regional anesthesia .
A type of thin, rigid cystoscope called a resectoscopeis put into your bladder through your urethra. The resectoscope has a wire loop at the end that’s used to remove any abnormal tissues or tumors. The removed tissue is sent to a lab for testing.
After the tumor is removed, more steps may be taken to try to ensure that the cancer has been completely destroyed. For instance, the tissue in the area where the tumor was may be burned while looking at it with the resectoscope. This is called fulguration. Cancer cells can also be destroyed using a high-energy laser through the resectoscope.
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En Bloc Resection Of Bladder Tumour Technique
Typically a circumferential incision is made on the mucosa around the tumour with the tip of laser fibre maintaining a distance of 5Ã¢10 mm from tumour edge. The dissection is carried out in the macroscopically normal mucosa and extended through the submucosal and muscular layer. The muscular fibres are divided cautiously from the periphery to the centre of the tumour. The lesion is then detached and removed using various exit strategies . Alternatively, ERBT may be performed by undermining the tumour base via antegrade application of short energy impulses. In general 30% of patients might not be suitable for EBRT due to tumour size and location. Although successful resection of tumour up to 7.5 cm has been reported , it is often avoided if tumour is greater than 3 cm in size or arises from anterior or posterior bladder wall .
This can be performed using various types of energy source: laser , Hybrid-Knife, electrode .
KTP laser has been shown to be effective using 30 W but due to its side fire property and its wider penetration of tissue fulguration compared to Ho:YAG or Tm:YAG laser it could be associated with a greater risk of damage out of sight. This would make Ho:YAG and Tm:YAG more suitable form of laser for this procedure. The Tm:YAG laser mostly uses 30Ã¢50 W and is the most adopted technology to date .
An overview of ERBT studies is shown in Table 5.
Postoperative Details Of Turbt
Within the first 24 hours, a single intravesical instillation of mitomycin-C has been shown to reduce the frequency of tumor recurrence and should be considered the standard of care after TURBT or positive bladder biopsy findings. Gemcitabine has widely replaced mitomycin-C in this setting, due to its similar efficacy, lower adverse effect profile, and cost. It should be emphasized that while gemcitabine and mitomycin-C have established efficacy, there have been no studies comparing them head-to-head in this setting.
Postoperative intravesical chemotherapy is withheld if there is surgeon concern for bladder perforation extensive or deep resection or persistent hematuria, due to the possibility for systemic absorption.
Occasionally, a Foley catheter may need to be left in place for 1-3 days after TURBT. It is usually removed in the urology office.
Postoperatively, symptoms of intermittent dysuria, urinary frequency, urgency, and hematuria are anticipated.
The most common complications after TURBT are as follows :
A second TURBT should be performed 2-6 weeks after initial TURBT for several patient populations. Indications include the following:
- Incomplete initial resection
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What Are The Risks And Benefits Of A Turbt
As with any type of surgery, there are both risks and benefits to a TURBT procedure. Generally, bladder tumor biopsy and resection is considered a very safe procedure. Some of the possible risks during or after surgery include:
- Anesthesia-related complications
- Infections of the urinary tract
- Bleeding after surgery
- Perforation of the bladder
Despite these risks, TURBT procedures are typically a successful treatment for early-stage cancer of the bladder. Having a TURBT can prevent cancer from spreading into the muscle wall of the bladder.
Turbt Recovery & Complications
After the procedure, a flexible tube may be inserted into the bladder through the urethra to assist with draining urine from the bladder. The catheter will usually stay in place for 1 to 3 days. For a few days after the catheter is removed, the patient may have difficulty controlling their urine. This should improve on its own.
Although no incision is made in the belly, TURBT is still considered a major surgery. To speed up recovery, the patient should plan on resting for a few days after the procedure. This includes avoiding stressful physical activities.
Overexertion can cause bleeding inside the bladder. Some blood in the urine, however, is normal. If this does not clear up after several days, or if urination continues to be difficult or blood clots are present in the urine, a physician should be contacted immediately. It is also normal to notice a couple of days of bloody urine again 10 to 14 days after surgery.
Antibiotics may be prescribed to prevent infections, including those of the urinary tract. If so, it is important to take them as directed in order to prevent a recurrent infection.
Other complications of TURBT are:
- Perforation of the bladder wall
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Intraoperative Details Of Turbt
In most cases, general or regional anesthesia must be used to establish nerve paralysis, to minimize risk of obturator nerve reflex and subsequently, bladder perforation.
Complete eradication of tumor is the first step in TURBT. Most tumors are papillary and are easily removed by endoscopically transecting their narrow stalk or base. Following this, biopsy of the base or deeper resection is performed to ensure complete removal and the absence of invasion. The goal is that muscle tissue must is present in the base biopsy specimen to ensure accurate staging.
Medium and large tumors are resected in a controlled serial fashion prior to transection of the stalk. This ensures that large segments do not remain that might be too large to evacuate through the resectoscope.
Smaller and more friable tumors may be removed at least partially by knocking off fragments with the cutting loop of the resectoscope without the electricity turned on. This sometimes allows partial removal with less risk of bladder perforation.
Pulling the cutting loop away from the tumor is generally much safer than pushing it toward the tumor. Lifting the tumor away from the surrounding normal bladder tissue using the cutting loop is also advisable.
Transurethral resection syndrome, which results from absorption of electrolyte-free irrigating fluid, has become uncommon since the advent of bipolar resectoscopes, which utilize normal saline irrigation.
How Is A Turbt Performed
Before the TURBT, the care team will explain the procedure and answer any questions. To prepare for the procedure, patients receive general anesthesia or spinal anesthesia .
Once the anesthesia takes effect, the doctor inserts a long, thin tubecalled a resectoscopethrough the urethra and into the bladder. At the end of the resectoscope is a camera and wire loop. Using the camera to guide the instrument, the doctor uses the loop to scrape off amd remove the cancer cells from the bladder.
Doctors may also use a high-energy laser to kill remaining cancer cells or burn them off with a process called fulguration.
Because the procedure is performed in the urethra, it doesnt require incisions or stitches. The procedure typically takes about 15 to 90 minutes.
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Key Steps And Principles Of Turbt
After induction of anaesthesia patient is placed in the dorsal lithotomy position. The procedure can be performed either under spinal or general anaesthetics. General anaesthetics would be preferred if neuromuscular blockade is indicated to prevent stimulation of obturator nerve reflex during the resection of lateral wall tumours. Bimanual examination of the bladder under anaesthesia is performed before resection. The prostate should also be assessed for men. The TURBT is undertaken after a detailed pancystoscopic evaluation using both 30- and 70-degree lenses for optimal assessment of the urethra, prostate and bladder including the bladder neck. Alternatively, a retroflexion manoeuvre using a flexible cystoscope can also be utilized. The anterior wall and the dome of the bladder might require suprapubic pressure for better visualisation.
What Complications May Come With A Turbt
While TURBTs are generally considered low-risk procedures, patients may still experience some mild, short-term complications. These generally include:
- Bladder spasms and pain
- Need to urinate frequently
- Bruising and swelling
- Blood in the urine for up to two weeks after surgery
- Perforation, or a hole, in the bladder wall
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Sexual Effects Of Radical Cystectomy In Men
After surgery, many men have nerve damage that affects their ability to have erections. In some men this may improve over time. For the most part, the younger a man is, the more likely he is to regain the ability to have full erections. If this issue is important to you, discuss it with your doctor before surgery. Newer surgical techniques may help lower the chance of erection problems.
For more on sexual issues and ways to cope with them, see Sex and the Man With Cancer.
When Should I Seek Advice From My Physician
A patient should contact their physician if they run a 101 degree or greater fever or if they begin passing clots that are larger than 1 inch in diameter. Some will have cherry colored urine, but may also experience darker burgundy-colored urine and at times brown-colored urine. The color of urine typically is determined by how long a time has passed since the bleeding began. Drinking 48 ounces of water daily after TURBT can help avoid larger clots that may be problematic.
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What Happens After The Surgery
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.
After TURBT surgery, you may recover at home or spend a few days in the hospital. It is possible that you might have a catheter inserted into your urethra to help prevent blockage. The catheter tube is removed when the bleeding from surgery has stopped.
It is common to feel the need to urinate frequently after surgery. It may even burn or sting when you use the bathroom. These symptoms should become better with time. To improve these symptoms, stay hydrated by drinking fluids, it will help the healing process. Do not be alarmed if your urine appears pink. This is normal because there may be blood in your urine. Contact your doctor if these symptoms last for more than a few weeks.
Strenuous activity and heavy lifting should be avoided for around three weeks after your surgery. This means you should not lift grocery bags, children, pets or other things that cause you to strain until your doctor tells you that it is okay to. Speak to your medical team about any other recommendations they suggest.