Transurethral Resection of Bladder Tumor (TURBT)
About the Authors
Lee E. Ponsky, MD, FACS
Dr. Ponsky received his B.A. from University of Rochester and his Doctor of Medicine degree from Case Western Reserve University School of Medicine. He began his training in Urology at the Cleveland Clinic and completed his residency and extended his training to do a research fellowship in urologic oncology, followed by an additional fellowship in advanced urologic laparoscopy and endourology. In 2005, Dr. Ponsky joined the faculty at University Hospitals, Case Western Reserve University School of Medicine, and is currently an associate professor of Urology and holds the Leo and Charlotte Goldberg Chair in Advanced Surgical Therapies, he is the Director Urologic Oncology & Minimally Invasive Therapies Center and the Co-Director of the Institute for Surgery and Innovation. He has over 50 publications and has been invited as a faculty/visiting professor at numerous national and international conferences. He is the editor-in-Chief of a textbook on Robotic RadioSurgery and has authored more than 12 textbook chapters. He has received several research grants. One of his recent innovative ideas was awarded the highest ranking from Ohio Third Frontier and received $1 million dollar grant towards its development and is currently submitted to the US Patent office.
Dr. Ponsky has received numerous accolades for his medical contributions as well as his role and the founder of MedWish International, including U.S. Congressional Recognition, Crains Forty under Forty, as one of Northeast Ohio’s most influential people under the age of 40, Cleveland Upstander: Portraits of Courage, the recipient of the Golden Doc Award, from the Arnold P. Gold Foundation, and received the Rescuer of Humanity Award from Project Love, which recognizes and honors an individual or an organization of national or international stature, which has chosen to use their leadership beyond professional or institutional requirements to positively change the course of humanity. He has also been recognized by the Manhattan Institute in New York with the The Richard Cornuelle Award for Social Entrepreneurship, for originating and effectively implemented a new nonprofit organization providing direct services to those in need. In 2011, he was recognized by Smart Business as the nonprofit board executive of the year and also received the University Hospitals Case Medical Center, Urology Institute Faculty Teaching Award from his students and residents, for recognition of outstanding commitment and efforts to student and resident teaching. Dr. Ponsky also serves as a founding board member of the non-profit MedWorks, which provides free healthcare to the uninsured and underinsured.
Matthew J. Maurice, MD
Matt is a fourth-year Urology resident at University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, in Cleveland, Ohio. He was born and raised in Chicago, Illinois. He received his Bachelor of Science degree in Biology from Saint Louis University in 2005 and his medical degree from Northwestern University Feinberg School of Medicine in 2009. He is currently performing a year of dedicated research as part of his residency training. He anticipates completing residency in 2015, at which time, he plans to pursue further specialization in urologic surgery. His interests include: minimally-invasive surgery, oncology, reconstruction, and surgical innovation.
More than 70,000 new cases of bladder cancer (BC) are diagnosed in the United States (US) annually, making BC the ninth most common malignancy overall and the most common malignancy of the urinary tract (1,2). Furthermore, BC is responsible for 15,000 deaths in the US annually, making it the thirteenth most common cause of death overall and the second most common cause of death among genitourinary tumors (2,3).
In the US, 90% of BC is classified as urothelial carcinoma (UC) (4). UC behaves clinically like two separate diseases: innocuous, low-grade papillary tumors that tend to recur frequently but rarely invade or metastasize and life-threatening, high-grade lesions (papillary, nodular, or flat) that are prone to muscle invasion and cancer death (5-8). Non-muscle-invasive (NMI) BC constitutes 80% of initial UC diagnoses (9). Of these tumors, 80% are confined to the urothelium, 70% as stage Ta and 10% as carcinoma in situ (CIS), and 20% have invaded the submucosa (stage T1) (10). Once high-grade UC escapes the urothelium, it follows a natural course, sequentially invading the deeper layers, until ultimately progressing to lymph node involvement, metastases, and death (11,12). If muscle-invasive (MI) BC is untreated, 2-year survival is less than 15% (13). Radical cystectomy with bilateral pelvic lymph node dissection is potentially curative for MIBC but carries significant morbidity (14,15).
In 1910, Edwin Beer introduced the minimally invasive endoscopic treatment of papillary bladder tumors with electrocautery as an alternative to the open suprapubic approach (16). Later on, in 1931, the field of endourologic oncology was forever revolutionized when Stern and McCarthy debuted the first practical cutting loop resectoscope, permitting the endoscopic diagnosis and treatment of bladder tumors for the first time in history (17). Henceforth, transurethral resection (TUR), or transurethral resection of bladder tumor(s) (TURBT), has been the cornerstone of bladder tumor management. TUR is still the initial diagnostic and therapeutic modality of choice for BC. While small, low-risk (low grade, low stage) tumor recurrences can be safely and effectively managed by fulguration or laser ablation in the legacy of Beer, the initial retrieval of tissue by TUR for histologic evaluation is essential to the accurate staging and grading of BC (18,19).
While TUR is still regarded as the gold standard for the diagnosis and treatment of bladder tumors, its effectiveness is limited by the quality of the resection and by the intrinsic failings of the technique (20,21). TUR has three principal shortcomings: violation of en bloc resection, ineffectiveness against nonvisible lesions, and incomplete resection (20-24). Consequently, TUR is associated with high rates of tumor recurrence (50-70%) and understaging (34-62%) with detrusor muscle absent in, on average, 32% (as many as 51%) of specimens (25-28). Incomplete resection, tumor cell re-implantation, and to a lesser extent, the growth of subclinical tumors present, but non-visible, at the time of initial TUR are proposed to be the most important causes of early UC recurrence (29,30). Incomplete resection also most certainly contributes to understaging. Early repeat resection, new optical technologies, immediate post-TUR intravesical chemotherapy instillation, and new TUR techniques and technologies have been investigated to address these shortcomings and improve outcomes in BC treatment.
Repeat or restaging TUR (re-TUR), which is supported by both the American Urological Association (AUA) and European Urological Association (EUA), has been shown to clear residual tumor and correct clinical staging errors (22,31,32). New optical technologies, including photodynamic diagnosis (PDD), narrow band imaging (NBI), Raman spectroscopy, optical coherence tomography, virtual cystoscopy, and endoscopic microscopy, are being studied to improve the detection and resection of bladder tumors, which may further optimize traditional white light imaging (WLI) TUR (29). Intravesical chemotherapy decreases tumor cell implantation, and when given immediately after TUR, significantly reduces recurrence rates with the greatest impact on early recurrences (33-35). An immediate post-operative dose of intravesical chemotherapy is recommended by both the AUA and EUA for intermediate-to-high risk BC patients based on European Organization for Research and Treatment of Cancer (EORTC) risk stratification (31,32,36). En bloc resection techniques, including most recently the endoscopic snare resection of bladder tumors (ESRBT), have been advocated to decrease tumor cell dispersal and seeding at the time of TUR, potentially leading to decreased early recurrence rates (37-49).
TUR is the current standard of care for the initial diagnosis, staging, and grading of all bladder tumors regardless of tumor depth of invasion and for the primary treatment of visible, NMI tumors. Transurethral biopsy with a resection loop is an option for the evaluation of abnormal areas of the urothelium that may be concerning for CIS. While radical cystectomy with bilateral pelvic lymph node dissection (and neoadjuvant chemotherapy) is still the treatment of choice for MIBC, multimodal treatment with radical TUR and combined radiochemotherapy is considered an alternative to cystectomy that offers similar survival outcomes and the possibility of bladder preservation (50-52). In certain circumstances, radical TUR alone may be a definitive, bladder-sparing therapeutic strategy in selected patients with MIBC who have no residual disease on a re-TUR of the primary tumor site (53).
According to AUA, EUA, and international guidelines, re-TUR is indicated in the setting of: incomplete resection of the primary tumor, absence of muscle in the initial pathologic specimen, high-grade tumors, and pathologic stage T1 tumors (31,32,54). It also should be considered in referred patients. Based on expert opinion, re-TUR is recommended 2-6 weeks after the initial TUR.
Apart from untreated urinary tract infection, uncorrected coagulopathy or medical instability, there are no absolute contraindications to TURBT. It is important to remember, however, that for CIS, TUR serves only a diagnostic role as 71% of patients managed with TUR alone will progress to muscle invasive disease requiring cystectomy (55).
Special anatomic considerations
Five anatomic variants, which make TUR more challenging, deserve mention: morbid obesity, an enlarged prostate, a large capacity bladder, a thin-walled bladder, and tumor within a diverticulum. In the morbidly obese patient, a large subcutaneous pubic fat pad may impede passage of the scope, necessitating the use of an extra-long resectoscope setup. An enlarged prostate, especially with a significant median lobe, may restrict access to tumors arising from the bladder floor or may have a tendency to bleed and obscure visualization when downward pressure is applied with the resectoscope. Generally, TUR can be executed by favoring either side of the median lobe with the resectoscope, but if the prostate is extraordinarily large or is causing significant bleeding, a focused resection of the prostate can be performed in the same setting without increasing the risk of tumor recurrence or progression (56). Tumors arising from the dome of a large capacity bladder may be difficult to visualize and/or reach; however, this can be solved with bladder decompression and suprapubic pressure. Thin-walled bladders, common in the elderly, are more susceptible to perforation, making it very important to avoid bladder overdistention. Diverticula lack detrusor muscle; therefore, tumors arising from diverticula are very difficult to accurately stage and are at high risk for bladder wall perforation. Intradiverticular tumors are best managed in a staged fashion with cautious TUR and fulguration, followed by re-TUR or extirpative surgery as needed.
Patient positioning / Special instrumentation
Prior to the induction of anesthesia, compression stockings and/or intermittent pneumatic compression devices are placed on the patient’s legs to improve lower extremity circulation and to decrease the risk of deep venous thrombosis. Following the induction of regional anesthesia or general anesthesia with or without neuromuscular blockade and endotracheal intubation, the patient is re-positioned in dorsal lithotomy. With the patient supine, the buttocks are brought to the edge of the lower break in the table. The legs are raised slowly and simultaneously to avoid back strain and/or hip dislocation. The legs are placed in booted stirrups at an equal height and distance relative to the operating room table. The stirrups are well padded to prevent pressure ulcers and peripheral nerve injury. The legs are raised and abducted to provide adequate surgical exposure to the perineum, maintaining hip-knee-foot and hip-contralateral shoulder alignment so as to avoid over abduction of the knee or hip joints, respectively. When the patient is finally positioned, the bottom of the operating table is lowered or detached for access to the perineum.
A basic 21/22-French rigid cystoscopy set, including 30° and 70° lenses, and a video camera setup are opened for all cases. Occasionally, a flexible cystoscope is useful for visualizing anterior bladder neck tumors. A 24/26-French continuous-flow resectoscope and wire loop are appropriate for the resection of most tumors. The choice of irrigant depends on the resectoscope being used. Bipolar resectoscopes function in saline, while monopolar resectoscopes require water or glycine for conduction of electricity. The continuous-flow sheath facilitates irrigant flow and visualization and is thought to minimize the risk of bladder perforation due to overdistention. Urethral dilators and a guidewire should be readily available in case the urethra is too narrow to accommodate the resectoscope. An extra-long resectoscope may be required for obese patients or for males with long penile urethras. Alternatively, a cold cup biopsy forceps and Bugbee electrode, operated through the cystoscope sheath, may be sufficient for the resection of small tumors (<2 cm).
Since its introduction, video TURBT has been universally accepted, improving surgeon comfort, tumor visualization, and trainee teaching. When available, newer optical technologies, especially PDD and NBI, offer diagnostic advantages over standard WLI cystoscopy and may improve the completeness of TURBT (57).
According to current guidelines from the AUA and EUA, bimanual examination is recommended as an integral component of a complete clinical staging evaluation for bladder cancer, especially for patients with muscle-invasive disease (50,58). However, recent evidence suggesting that bimanual examination provides accurate staging in only 57.6% of cases has called its utility into question (59).
Prior to prepping and draping the patient, bimanual examination of the bladder should be performed under anesthesia before prepping and draping unless the tumor is clearly small and noninvasive, and it should be repeated after resection. Fixation or persistence of a palpable mass after resection suggests locally advanced disease. An increase in abdominal girth or fullness after resection indicates intraperitoneal perforation.
The cystoscope is inserted transurethrally into the bladder, inspecting the urethra on entry. Once the bladder is entered, a thorough cystoscopy is performed, first with the 30° lens and then with the 70° lens. Suprapubic pressure and minimal bladder filling may assist with visualization of the anterior bladder wall. The locations of tumors and erythematous lesions are identified, and their relation to bladder landmarks, especially the bilateral ureteral orifices or possible diverticula, is noted. The cystoscope is removed without emptying the bladder.
A continuous-flow resectoscope sheath is inserted into the bladder under direct vision using the visual obturator and a 30-degree lens. Once the bladder is entered, the visual obturator is exchanged for the resectoscope loop. For monopolar TURBT, the cutting and coagulation currents are set at 120 W and 60 W, respectively. For bipolar TURBT, the cutting and coagulation currents are set at 160 W and 80 W, respectively. Throughout resection, the bladder is kept half-full.
Tumor Resection and Specimen Retrieval
Tumors are resected in a systematic, piecemeal fashion. For tumors oriented parallel to the resectoscope (i.e. tumors arising from the trigone, floor, lateral walls, or dome), the resectoscope is maintained in a fixed position with the tumor in full view. The loop is extended beyond the tumor, and the tumor is engaged as evidenced by resistance to withdrawal of the loop and slight movement of the tumor toward the scope. While maintaining contact with the tumor, the cutting current is applied, and the loop is gradually swept through the tumor. Periodically, the entire resectoscope may need to be re-positioned to gain better exposure to the resection bed; however, the scope should not be moved while taking a swipe as this predisposes to deeper bites and possible bladder perforation. On the contrary, for tumors oriented perpendicular to the resectoscope (i.e. tumors arising from the posterior wall), moving the resectoscope during tumor resection is necessary. For these tumors, the wire loop is extended to a fixed length, and the resectoscope is maintained at a fixed insertion depth. Tumors are resected by moving the entire resectoscope in the vertical plane from dome-to-floor (painting the posterior wall), and the resectoscope insertion depth controls the depth of resection. For tumors arising from the dome, anterior bladder wall and bladder neck, minimal bladder filling and suprapubic pressure may be required in order to bring the tumor within the field of vision and within reach of the resectoscope. Anterior bladder wall and bladder neck tumors, which are usually oriented perpendicular to the resectoscope, assume a more parallel orientation with suprapubic pressure, facilitating resection.
For medium-to-large tumors (2 cm and greater), resection begins at the periphery and proceeds centrally. The bulky papillary portion is resected first before addressing the pedunculated or sessile base. Depending on its size, the tumor may require multiple swipes before its base is exposed. Long swipes through the tumor improve the efficiency of the resection. The loop, which often retains the resected tumor chip, should be cleared of the chip prior to proceeding onto the next cut in order to avoid excessive electrocautery artifact on the pathologic specimen. The chip can be cleared from the loop in one of two ways: 1) the loop is brushed over the tumor in the opposite direction of the prior cut thus dislodging the chip, or 2) the loop is extended and retracted rapidly at a safe distance away from the tumor and bladder wall thus expelling the chip. The brushing technique is efficient and conserves resection strokes by freeing the chip and getting the loop into position for the next swipe simultaneously. Tumor chips are allowed to fall the bladder floor away from the resection bed. After a substantial amount of chips have accumulated, they may be collected an Ellik evacuator and sent to pathology for analysis.
Once the tumor base is encountered, a swipe is taken from its edge at a depth that achieves good sampling of detrusor muscle without causing perforation. Bladder overdistention thins the bladder wall, increasing the difficulty of detrusor sampling and the risk of bladder perforation. Using the previous depth as a guide, the resection is continued across the entire base. Specimens sampled from the base can be captured individually with the resectoscope loop and sent to pathology separately to facilitate identification of muscle invasion.
Small tumors (<2 cm) may be best managed with a single swipe of the resectoscope or with a cold-cup biopsy forceps.
For tumors arising near or from the ureteral orifice, pure cutting current should be used to minimize the risk of ureterovesical obstruction secondary to ureteral orifice stenosis.
Throughout the resection, discrete bleeding vessels should be controlled with spot coagulation current via the cutting loop. After completing resection and retrieving all tumor specimens, the resection bed should be inspected thoroughly for hemostasis. Any bleeding areas are fulgurated. The entire resection bed and a surrounding edge (~0.5 cm) of normal-appearing mucosa should be cauterized, ensuring hemostasis of delayed bleeders and destruction of occult disease. The bladder is emptied and then re-inspected under minimal bladder filling to ensure complete hemostasis.
Procedure Completion and Recovery
Prior to completion, the decision is made whether or not to leave a urethral catheter. A catheter may be indicated for a variety of reasons, especially for bladder decompression in the setting of a perforation (absolute) or a large, extensive resection (optional); it also may be required for the instillation of intravesical chemotherapy or the initiation of continuous bladder irrigation (CBI) with saline. If a catheter is not needed, the bladder is drained, and the cystoscope is removed. Prior to discharge, bladder drainage is ensured by verifying successful voiding or patency of homegoing catheters for each patient.
In the absence of perforation, an immediate dose of intravesical chemotherapy can be instilled in the operating room and allowed to dwell for approximately one hour in the recovery room prior to drainage. Hemostasis is essential prior to the post-operative instillation of intravesical chemotherapy, as active bleeding while the catheter is clamped can result in increased absorption of the chemotherapeutic agent through open venous channels and clot retention due to urinary stasis. Patients still require a trial of void after catheter removal. Patients are instructed to wash their hands and genitals after their first void to reduce local toxicity from residual chemotherapy. Alternatively, CBI may be delivered following resection to thoroughly wash out the bladder of residual tumor cells (60-62). Following CBI, the catheter is discontinued, and the patient is given a trial of void.
Bleeding, depending on the source (prostate vs. bladder) and severity, usually can be managed with catheter drainage and observation. Occasionally, bleeding may require temporary catheter placement on gentle traction with or without CBI and potentially overnight observation. Rarely, bleeding may require re-operation for clot evacuation and fulguration.
Historically, before the introduction of modern resectoscopes and video-endoscopy, TURBT was a fairly morbid procedure with an approximately 45% overall complication rate (63). In a review of TURBTs performed between 1931 to 1971, complications included: infection (24%), hemorrhage requiring transfusion (13%), bladder perforation (5.1%), and postoperative mortality (1.3%) (63).
In modern series, TURBT is associated with a low (5%) overall complication rate (64). In a review of over 2,800 TURBTs performed between 1979 to 1996, Collado et al. reported the following intraoperative and immediate complications: bleeding (2.8%), bladder perforation (1.3%), medical (0.14%), reabsorption syndrome (0.07%), urethral lesion or false passage (0.07%), sepsis (0.03%), and skin burn or plaque (0.03%). Likewise, in the academic setting, urologists in training also display a low (5.8%) overall complication rate, including hematuria requiring blood transfusion (2.3%) and bladder perforation (3.5%) (65). In the modern era, the occurrence of any symptomatic urinary tract infection following TURBT, historically the most common complication, is infrequent (2-3%), and this rate appears to be independent of preoperative antibiotic usage (66).
Bleeding, the most frequent complication, is usually minor. Delayed bleeding can be largely avoided with meticulous hemostasis, which is ensured by the return of clear irrigant on post-operative bladder irrigation. If brisk bleeding causing clot retention or requiring transfusion is encountered post-operatively, while rare, it should be managed surgically with clot evacuation and fulguration.
Bladder perforation, the most serious complication, may occur in as many as 58% of cases based on cystographic evidence of contrast extravasation; however, the majority of these are probably clinically silent (67). Most recognized perforations are small and extravesical and can be managed by catheter drainage. Intraperitoneal perforations are rare (0.2%) but may require open surgical repair when catheter drainage alone is inadequate (67). Extravesical tumor seeding secondary to perforation is exceedingly rare (67,68). While the obturator nerve reflex, itself, is not a complication, it does increase the risk of bladder perforation (69-71).
TUR syndrome due to endoscopic bladder cancer surgery is very rare (72-74). In TURBT syndrome, fluid absorption occurs exclusively via either an intraperitoneal or extraperitoneal bladder perforation, in contrast to the direct intravascular fluid absorption that occurs with TUR syndrome secondary to prostate resection.
Late complications following TURBT are not well reported but may include: complications related to urethral manipulation and/or dilation (e.g. meatal stenosis, urethral stenosis, or urethral stricture) and complications related to resection or fulguration of the ureteral orifice (e.g. ureteral stenosis, or de novo vesicoureteral reflux). Fortunately, when iatrogenic injury occurs to the distal ureter during radical TURBT, it is not associated with long-term distal ureteral sequelae (75).
UC is a heterogeneous disease. The EUA and EORTC have formulated risk stratification tables in order to predict a NMIBC patient’s short- and long-term risks of recurrence and progression after TUR (36). Intermediate-to-high risk BC meets one or more of the following criteria: intermediate or high grade (G2/3), pathologic stage T1, presence of CIS, multifocality, tumor size >3 cm, and history of recurrence. The most important prognostic factors for recurrence are multifocality, tumor size, and prior recurrence rate, while the most important prognostic factors for progression are T stage, grade, and the presence of CIS. Since these risk factors are inconsistently reported in the literature, outcomes data with regards to recurrence rates (RR) and progression rates (PR) are difficult to compare. Furthermore, the use of adjuvant of intravesical chemotherapy or Bacillus Calmette-Guérin (BCG) immunotherapy, which have been shown to reduce recurrence and/or progression rates, further complicates outcomes analyses (34,76,77). In an attempt to provide an accurate assessment of outcomes, data presented in Tables 1 and 2 is organized by tumor stage and grade and BCG usage (when available).
Final thoughts/Surgical Pearls
- Always perform a careful, thorough cystoscopy prior to TUR. Tumor number and location may be different from what you remember from the office cystoscopy. An overlooked tumor is certain to become an early “recurrence”.
- Pay close attention to bladder filling throughout the procedure and maintain the bladder at half-capacity.
- Make contact with the tumor prior to cutting.
- Plan the course of the cut; stabilize the resectoscope; and take a long swipe. This technique greatly reduces the risk of perforation.
- Improve the efficiency of your resection by conserving movements; brush off the resected tissue while setting up for the next swipe.
- Avoid excessive cauterization during TUR to preserve integrity of the pathologic specimen.
- Send tissue specimens from the tumor body and base to pathology separately to ensure detrusor muscle sampling and to accurately assess the depth of tumor invasion.
- Judiciously cauterize the base of the resection bed and re-evaluate the base for bleeding under minimal bladder filling to avoid delayed bleeding complications.
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