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Transurethral resection of the bladder tumour (TURBT) for non-muscle invasive bladder cancer.
Its goal is to correctly identify the clinical stage and grade of disease while completely restricting or visible tumor.
It is the standard surgical procedure for non-muscle invasive bladder cancer.
The resectoscope, the instrument used to remove the tumor in the TURBT, is introduced through the urethra into the bladder.
An adequate biopsy includes bladder muscle should be obtained in the resection specimen, most notably in the setting of high grade disease.
With carcinoma in-situ biopsy sites adjacent to the tumor and multiple random biopsies may be performed to assess a field change.
MRI or CT of the abdomen and pelvis is recommended before TURBT, for a better anatomical characterization of a bladder lesion and possible delineation of its suspected depth of invasion.
Work up prior to TURBT includes urine cytology, evaluation of the upper urinary tract with imaging.
TURBT is bimanual examination under anesthesia to resect. the visible tumor and to sample underlying muscle to assess invasion.
An incision-less surgery usually performed as an outpatient procedure.
For non-muscle invasive bladder cancer: resection of all visible tumors; resection of apparently normal mucosa on the border of the tumor; resection of the muscle layer at the base of the tumor until normal muscle fibers are visible, and in applicable cases, random biopsy of apparently normal urothelium of the bladder wall and transurethral resection (TUR) biopsy of both sides of the prostatic urethra; and when possible, after these procedures are completed, a different operating surgeon should inspect the bladder lumen to confirm that there are no remaining tumors.
Resection should be implemented to achieve normal mucosa for approximately 1 cm around the tumor, and at the base of the tumor down to the superficial muscle layer.
Resected specimens are examined histopathologically to confirm the absence of malignant findings.
The goals of TURBT are used to correctly identify bladder cancer clinical stage, grade of disease, well completely restricting all visible tumor.
TURBT procedures include both one-stage and two-stage resections.
One-stage resection: used for relatively small tumors and involves a single procedure with simultaneous resection of both the tumor and the tissue at the tumor base down to the superficial muscle layer.
The two-stage resection, the first resection exposes the lower level of the mucosa and the second resection removes that lower mucosal layer in order to sample the superficial muscle layer for cancer staging.
“Blue light” cystoscopy uses an optical imaging agent is often used during this procedure at major medical centers.
Electrocauterization or fulguration is used to seal off bleeding vessels.
Can be performed repeatedly with minimal risk to the patient and with excellent results, and less than a 10% risk of infection or injury to the bladder.
Risks associated with TURBT
are: temporary bleeding, pain, and burning when urinating.
The urologist may choose to leave a catheter in the patient’s bladder for a day or two to minimize problems occurring from bleeding, clot formation in the bladder or expansion of the bladder due to possible storage of excess urine or blood.
It is essential to access tumor grade and stage to guide decisions about whether to perform deep resection with muscularis propria removed for high-grade tumors, or a less aggressive resection with cauterization of the tumor base for low-grade tumors.
TURBT may require hey decision on whether to instill perioperative adjuvant therapy with gemcitibine or mitomycin-C which has the most impact in low-grade tumors.
Single-dose intravesical gemcitabine or mitomycin within 24 hours of TURBT is recommended if non muscle invasive disease suspected: Gemcitabine being is preferred due to better tolerability.
The base of a large or T1 high-grade tumor should be biopsied and sent to pathological review so the depth of muscle invasion can be assessed.
En bloc resection also improves pathologic staging of smaller lesions, 3 cm or less.
En bloc resection may decrease tumor shedding and scattering of tumor cells, which may reduce the risk of early recurrence.
Anesthesia should allow complete paralysis of abdominal muscles to decrease movement, and facilitate resection of the lateral, posterior, and anterior bladder walls, and decrease the likelihood of obturator reflex jerk.
Bipolar electrictrocautery restricts electrical current enabling the current to bypass the patient and allows less charring of tissue.
Isotonic saline can be used decreasing the risk of complications such as hypotonic low sodium syndromes.
Bipolar electrocautery vs. monopolar electrocautery reduces hospital length of stay, blood loss, and rates of obturator nerve reflex and bladder perforation.
The immediate intravesical installation of chemotherapy may be given within 24 hours of TURBT to prevent to muscle implantation and early recurrence.
The delivery of immediate intravesical installation of chemotherapy decreases the risk of recurrence by 35% and a decrease five year recurrence rate from 58.8% to 44.8% when comparing immediate intravesical chemotherapy after TURBT toTURBT alone: agent used include gemcitabine or Mitomycin.
Intravesical. gemcitabine is preferred over mitomicin due to better tolerability and cost.
Studies show that BCG decreases the risk of bladder cancer recurrences after TURBT and analyses demonstrate that it is superior to chemotherapy in preventing recurrences when using BCG maintenance.