Transurethral resection of a bladder tumor needs to meet the following characteristics in order to achieve its diagnostic and therapeutic goal: Complete resection of all visible tumors, the presence of muscle in the specimen, and avoidance of complications that may affect the administration of intravesical therapy. At times, in order to accomplish the first two goals, complications do occur, which have an occurrence rate of ~ 5-10%. Several studies have assessed the risk factors associated with TURBT complications noting that surgeon experience, time of the resection and type pf power used as the most important factors. A study by Nieder et al. (J Urol 2005). showed that TURBT complications rates associated with resident involvement could be significantly reduced with the vigilant mentoring of an experienced surgeon, where complications rates were reduced from ~ 20% to 5.4%. A population analysis by Sugihara et al. (J Urol 2014), proved that bipolar energy was significantly safer than monopolar energy in regard to severe bladder injury (bleeding and perforation) mainly due to the decrease risk of an obturator reflex associated with bipolar resections. A NSQUIP review by Matulewicz et al ( Urol Onc 2015), aim to assess the risk factors associated with severe post-operative complications (Infection, DVT/PE, respiratory failure and MI), noted that time of resection was the only factor associated with a severe post-operative complications after controlling for known confounders. Moreover, they stated that a resection time greater than 90 minutes almost double the risk of a complication to occur.
The most common operative complications associated with TURBT are bleeding, bladder perforation and ureteral orifice stricture and these were the focus of the session. Bleeding complications have a reported occurrence rate of 1-4%. Interestingly, the risk of bleeding appears to be rising over time, and this may be due to the increased use of antiplatelet agents for prevention of cardiovascular events. Severe bleeding tends to be associated with larger tumors and early deep bladder perforations. The speaker, emphasizes the importance of appropriate visualization during bleeding control and recommends the use of large continuous flow resectoscopes. In cases where bleeding is hard to control Dr. Brausi recommends the use large surface area electrode (roller ball or bipolar button) to control the bleeding.
Bladder perforation (BP), is the second most common complication associated with TURBT. Risk factors associated bladder perforation are surgeon experience, bladder distention, tumor location and bladder wall thickness (female and low BMI). Early identification of a bladder perforation is the most important aspect of managing the complication, as to minimize the size of the perforation, the extravasation of fluid into the retroperitoneum/peritoneum, and prevention of tumor seeding. In the case of bladder perforation, if small and retroperitoneal, the resection can be completed if done in an expedited fashion. In cases where the perforation is large or an intraperitoneal perforation is suspected an immediate cystogram should be performed to characterize the perforation (retro vs. peritoneal). The mortality associated with an unrecognized intra-peritoneal perforation can be as high as 20% so timely recognition is essential. The management of intra-peritoneal perforation requires a formal bladder repair via an open or laparoscopic approach. Small retrospective studies have shown successful management of intra-peritoneal perforations with bladder catheter drainage and an intra-abdominal drain, but this has been performed in carefully selected cases.
Lastly, ureteral obstruction following TURBT is not an uncommon event with an occurrence rate of approximately 13%. Ureteral obstruction tends to occur due to ureteral orifice (UO) stenosis which is commonly found with resection of tumors in close proximity to the UO. In cases where resection of the UO is necessary, placement of a guidewire is useful for later identification and stenting. In cases were significant cautery is necessary near the UO, a prophylactic stent should be considered. A post-resection surveillance US should be considered in all these patients as early identification of obstruction may reduce the risk of long-term renal dysfunction.
In summary, complications associated with TURBT are common and at times can lead to significant morbidity and mortality. Experience, short resection times and use of bipolar technology have been shown to be modifiable factors aimed to prevent severe complications.
Presented by: Maurizio A. Brausi, Department of Urology, AUSL Modena, Modena, Italy
Written by: Andres F. Correa, Urologic Oncology Fellow, Fox Chase Cancer Center, Philadelphia, PA at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark