Best Practices to Optimise Quality and Outcomes of Transurethral Resection of Bladder Tumours - Beyond the Abstract

One of the most underrated operations performed by urologists is transurethral resection of a bladder tumor (TURBT). There are a plethora of articles that highlight the fact that it is not always possible to look into the bladder of a patient with bladder cancer (BC) and remove, i.e. resect, all of the visible tumors and stage it accurately. We use a rigid instrument that is placed into a spherical organ, i.e. the bladder, with the objective of identifying the tumors and removing the tissue by cutting through the tissue with a one-centimeter loop while being careful not to perforate the bladder. Bladder tumors come in all shapes and sizes, some are quite large and many are very small. Some urothelial cancers (UC - previously termed transitional cell carcinoma) are flat while others are papillary. Some are firm or nodular. An experienced eye is pretty accurate at guessing the grade and depth of penetration of the tumor by its appearance. This is important, as it will guide the procedure of removing the tumor(s). Yet, this does not always assure a “complete” TURBT.

Although a TURBT is one of the most common operations performed by urologists there is a paucity of literature on how to improve one’s skills in performing this procedure. There are few articles on complications and not many on proper technique. A couple of years ago a Medline search of articles published over 3 years using the term “TURBT” yielded 71 articles (7 reviews). Entering “endoscopic resection” and “bladder cancer” provided just 30 articles of which 4 were reviews. In contrast, if one queries a far less common operation, radical prostatectomy, the numbers were 2595 and 211 (laparoscopic RP 456/41).

A couple of decades ago an endoscopic resection of the prostate (TURP) was one of the most common urologic procedures and thus a wonderful introduction for the training of future urologists. With the advent of oral medications for reducing prostate size and alpha-blocking agents which relax the smooth muscle of the bladder outlet, this procedure is less common. 

Following an initial diagnostic TURBT, the recurrence rate ranges from 30 – 80%. The reasons for this include the continued effect of the carcinogenic agent, e.g. cigarette smoking, implantation of viable tumor cells on the altered urothelium, and incomplete resection. In one report of patients referred after an initial TURBT for Ta/T1 BC, there was a 70% incidence of residual tumor when a second urologist performed a repeat TURBT within 4 weeks of the prior TURBT.1  Although there was a selection bias in this group of patients, it is reasonable to assume that the initial urologist’s goal was a “complete” TURBT. Thus their success rate was low. Most of the residual tumors were macroscopic. Others have emphasized the high incidence of tumors on a repeat TURBT.2-7 In another series of 50 consecutive TURBTs for Ta/T1 BC performed by a senior experienced urologist 28% had residual BC on a re-TURBT 4-6 weeks after the initial procedure, 67% were at the site of the prior tumor. Some authors suggest the experience of the surgeon is the deciding factor while others indicate that senior urologists do not perform much better than trainees. Many of these patients had a change in management based on the re-TURBT. 

The goal of this article is to outline the basics of cystoscopy and TURBT and describe how we perform this operation.8,9 A TURBT has two goals – establish a diagnosis and remove the entire tumor when possible. As we emphasize the importance of a “complete” TURBT we are referring to BCs that are either confined to the mucosa (Ta), lamina propria (T1) or minimally into the muscularis propria (T2). One cannot safely perform a complete TURBT when BC invades deeply into the bladder muscle (T3). This would risk perforation and would be unlikely to cure the patient.

Prior to embarking on a TURBT, the clinician should refer to a checklist which includes a detailed history and physical examination, the grade and stage of any previous bladder tumors as well as any prior treatment, other medical problems, and current medications. One should review prior imaging of the urinary tract. If this has not been done the urologist may want to perform a retrograde ureteropyelogram at the same time as the TURBT. The urologist should review the findings of flexible cystoscopy. Like a pilot about to fly an aircraft, we should use a checklist to ensure that the entire operating room team is prepared for “take-off.”

The urologist should decide whether the goal of the TURBT will be a “complete” resection or whether the purpose will be for staging only. The patient should be counseled about any additional procedures such as a prostate biopsy, upper tract imaging, or postoperative intravesical chemotherapy.

We should discuss the type of anesthesia with the anesthesiologist. The three common alternatives are general anesthesia with an endotracheal tube, general with a laryngeal mask airway (LMA), or spinal/epidural. A number of factors will enter into this decision and include the patient’s age and comorbidity as well as the urologist’s preference. Most of us prefer general anesthesia with paralysis as complete relaxation of the lower abdomen and bladder facilitates a successful TURBT.

The urologist should survey the operating room to ensure that the required instruments are readily available. This includes endoscopic lenses, camera, light source, cystoscope sheath and optical dilator, resectoscope, cautery unit, lubricant, specimen container, strainer for the specimen, irrigation system, foot pedal, etc. The choices for lenses are 0, 12, 30, 70, and rarely 120 degrees. The zero or 12-degree lens is placed inside either a cystoscopy or resectoscope sheath. Once the cystoscopic sheath or resectoscope is positioned in the bladder one can use a 30 or 70-degree lens to survey the entire bladder. Most of us prefer a 70-degree lens for the initial overview. If available, some may use a 120 lens to provide a retrograde view of the anterior bladder neck (most patients have had a flexible cystoscopy prior to the TURBT and the anterior bladder will have been adequately visualized prior to the TURBT). When performing the TURBT some urologists prefer to use a 12-degree lens if the tumor is located at the trigone or anterior bladder. The 30-degree lens is useful if the tumor is posterior or on the lateral walls. Following the TURBT a 70-degree lens should be used to ensure all tumors have been removed as this provides the most comprehensive view of the bladder. These lenses are delicate and one should avoid placing heavy objects on top of them.

The patient is positioned in the dorsal lithotomy position with the buttocks at the edge of the table. A bimanual examination should be performed noting any mass in the bladder or pelvis. In men the prostate is palpated to note its size and any firm areas that might suggest prostate cancer. The patient is prepped and draped. The various cables and irrigation tubing are arranged in an orderly manner so as not to put traction on the endoscopic instruments. The surgeon white balances the optical system. The cautery is set to minimize the coagulation artifact during the TUR BT. The urologist introduces a cystoscope or resectoscope into the urethra. If the latter is used it should have an insert to protect the urethra from trauma.10 The goal is to ensure that the resectoscope is positioned in the bladder as atraumatically as possible. The object is to have a 26 or 28 French (Fr) continuous flow resectoscope sheath in the bladder without traumatizing the urethra. 

We prefer a continuous flow resectoscope and this requires a sheath greater than 24 Fr. If the male urethra is narrow one can use a 24 Fr sheath without continuous flow. This is satisfactory for removing small tumors by resection or fulguration. If the urologist is confident the tumors are low grade and Ta they can be removed with a biopsy forceps followed by cautery or laser for hemostasis. For the TURBT the urologist can choose to use a monopolar or bipolar resectoscope and water/glycine or saline for the irrigant depending on the energy source. The surgeon decides on the height of the irrigant. The goal is to maintain a bladder capacity of approximately 50%. Over -distention may cause bleeding and risks perforation during resection as the bladder wall is thinner. In addition, it is more difficult to detect carcinoma in situ (CIS) and small papillary tumors when the bladder is distended. 

When the urologist first enters the bladder it is useful to collect the urine. He/she may elect to send the urine for cytology and/or culture depending on the clinical scenario. If urine cytology is particularly important a saline barbotage of the bladder will obtain more and better-preserved cells.11,12 It is preferable to perform the barbotage after the initial cystoscopy since the irrigation may cause erythema which can mimic CIS.

The initial overview of the bladder should begin optimally with a 70-degree lens. The urologist inspects the bladder in a systematic fashion - trigone, bladder neck, lateral, posterior, and anterior walls. In overweight patients, this can be a challenge. It requires relaxation of the abdominal wall and is aided by one hand pressing down on the lower abdomen. The location, configuration, and the number of tumors are documented. A photograph is useful. “A picture is worth many words” and the urologist can refer to photos when discussing the results with a patient. 

Following review of the bladder and urethra, the urologist will remove any tumors and biopsy areas suspicious for CIS. A cold cup biopsy of a tumor is useful as it provides a sample devoid of cautery. This will help the pathologist who will determine the tumor grade and depth of invasion. If a tumor is small and appears to be low grade and confined to the urothelium, Ta, removal with the biopsy forceps and fulguration is safe and effective. Most of us do not feel there is a reason to obtain muscle for such tumors. If a tumor appears to be high grade, lamina propria and muscle should be part of the specimen to determine whether the stage is Ta (confined to the urothelium), T1 (lamina propria invasion), or T2 (invasion of the muscularis propria).2 Obtaining muscle in the specimen is not always simple as indicated by literature indicating the understaging of Ta/T1 tumors as revealed by the discordance of the depth of invasion when comparing the result of the initial and second resection.13 This has led to guidelines stipulating that following resection of a T1 tumor (and some advocate for high-grade Ta) one should return the patient to the operating room for a second resection 2-4 weeks following the initial TURBT to determine if there is a residual tumor.14-16 Proper staging is the basis for the treatment of bladder cancer.

Mariappan et al17 reviewed 398 TURBTs for Ta/T1 bladder cancers and analyzed the difference in the recurrence rate depending on whether muscle was in the specimen. When muscle was present the 3-month recurrence rate was 22% and if it was not the rate was 44%. Having a TURBT by a more senior surgeon was also a predictor for muscle in the initial specimen and a lower 3-month recurrence rate. Only 67% of all patients had muscle in the specimen which highlights the fact that it is not easy to ensure this occurs even when the policy was to obtain muscle in all TURBTs.

Just as in sports there isn’t one perfect way to swing and hit a ball so too there may be different maneuvers that facilitate a TURBT. Most of us prefer to sit during endoscopy and tumor resection. A light-weight camera is preferable. If it can rotate easily this will eliminate the need to rest one hand on the camera. The urologist might select a right angle or 90-degree loop for resection of tumors at the bladder neck and trigone and a bladder wall or angled loop for other locations. The angled loop conforms to the walls of the bladder. We do not believe that it is acceptable to perforate the bladder in an attempt to completely resect a tumor. If a tumor extends through the entire thickness of the bladder it is unlikely a TURBT will cure the patient.

The surgeon should ensure that the cautery pedal is positioned as to be comfortably within reach. We recommend that the urologist practice stepping on the pedal prior to engaging the tissue with the activated loop. We liken this to a golfer or baseball player taking a practice swing. The tumor resection should be performed in an orderly fashion beginning at one end of the tumor and resecting with slow steady motion at a depth designed to safely remove all tumor and obtain muscle when necessary. It is useful to initiate the resection in normal urothelium and continue into the tumor. This is particularly important for a repeat TURBT. Some clinicians advocate that one should take a separate specimen from the depth of the resection which is sent separately.18 More recently an en bloc resection technique has been advocated. The goal is to remove the entire tumor in one piece. This might benefit the pathologist as it minimizes cautery damage and helps with orientation.

One can consider obtaining cold cup biopsies from normal-appearing urothelium. The likelihood that normal-appearing urothelium contains CIS is low and thus in the absence of a specific indication for the sampling of “normal” bladder, e.g. partial cystectomy candidate, positive cytology without evident tumor, we do not advocate performing selected site or random biopsies.19,20

There are some patients at increased risk for urothelial cancer in the prostatic urethra. If tissue from the prostatic urethra is important it should be optimally obtained with the resectoscope and not with cold cup biopsies.21-24 The urologist should obtain a sample of the prostatic ducts as well as the urothelium. If the ducts are invaded by a high-grade UC then stroma must also be present to evaluate whether there is stromal invasion. Patients more likely to have UC in the prostate are those with high-grade UC at the bladder neck, multifocal CIS, multifocal high-grade UC, and a patient with a positive cytology and no visible bladder cancer.23,24 

Many TURBTs do not remove all tumors. Fluorescence endoscopy (FE) was developed to improve the ability to identify neoplastic urothelium.25-27 FE requires instillation of an exogenous photosensitizer into the bladder one hour prior to endoscopy. The agent is hex aminolevulinic acid (Cysview®) and a specific light source is required. The urologist examines the bladder first with conventional white light and then switches to blue light. Tumors appear red and are highlighted against the darker background. The TURBT can be performed with white or blue light. One can switch to the blue light to ensure all tumor has been removed. A number of trials have indicated an improved detection rate of Ta and to a lesser extent T1 tumors with the addition of blue light FE. The nine-month recurrence rate was lower in patients who had both blue and white light endoscopy compared to only white light. A systematic review of clinical trials has shown a reduction in the recurrence rate of bladder tumors when FE was used as an adjunct to white light resection of bladder tumors.28 

Like FE, narrow-band imaging (NBI) aims to improve the ability to discriminate malignant from normal mucosa.29-32 NBI requires a specially designed camera and light source. Tumors appear red when the filter length is changed. It identifies papillary tumors that might otherwise be overlooked with white light endoscopy.  Studies suggest an improvement in tumor detection and a reduction in recurrence rate with NBI.32 

The bipolar resectoscope was developed to reduce the side effects associated with a TURBT.33,34 This technique was initially introduced to improve the safety of a TUR of the prostate. It has been extensively evaluated in bladder tumor resection and reduces the extent of any cautery artifact as well as reducing the stimulation of the obturator nerve during resection of a tumor located on the lateral wall.

A properly performed endoscopic tumor resection should have a low rate of complications.35,36 There are few articles which detail this information but those that do indicate that bleeding and bladder perforation are the major concerns. For the most part, they can be avoided by following the principles of technique.

Written by: Mark S. Soloway1, Hugh Mostafid2, Ashish M. Kamat3, Siamak Daneshmand4, Joan Palou5, John A. Taylor III6, James McKiernan7, James Catto8, Marko Babjuk9

  1. Division of Urology, Memorial Hospital, Hollywood, FL, USA
  2. Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK;
  3. Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
  4. Department of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA, USA
  5. Department of Urology, Fundacio Puigvert, Universidad Autonoma de Barcelona, Barcelona, Spain
  6. 6.Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA
  7. Department of Urology, New York Presbyterian Hospital/Columbia University Medical Center, New York City, NY, USA
  8. Academic Urology Unit, University of Sheffield, Sheffield, UK
  9. Department of Urology, Hospital Motol, Second Faculty of Medicine, Charles University, Prague, Czech Republic

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  11. Matzkin H, Moinuddin SM, Soloway MS. Value of urine cytology versus bladder washing in bladder cancer. Urology. 1992;39:201-3.
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  15. Kirkali Z, Chan T, Manoharan M, Algaba F, Busch C, Cheng L, et al. Bladder cancer: epidemiology, staging and grading, and diagnosis. First International Consultation on Bladder Tumors. In: Soloway MS, Carmack A, Khoury S, editors. Bladder Tumors: Health Publications Ltd 2006. p. 13-64.
  16. Soloway MS, Hegarty P, Amin M, Shariat SF, Oosterlinck W, Hautmann RE, et al. ICUD/EAU International Consultation on Bladder Cancer. 2011.,17971#
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  22. Solsona E, Iborra I, Ricos JV, Monros JL, Dumont R, Casanova J, et al. Recurrence of superficial bladder tumors in prostatic urethra. Eur Urol. 1991;19:89-92.
  23. Ayyathurai R, Gomez P, Luongo T, Soloway MS, Manoharan M. Prostatic involvement by urothelial carcinoma of the bladder: clinicopathological features and outcome after radical cystectomy. BJU Int. 2007;100:1021-5.
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  25. Daniltchenko DI, Riedl CR, Sachs MD, Koenig F, Daha KL, Pflueger H, et al. Long-term benefit of 5-aminolevulinic acid fluorescence assisted transurethral resection of superficial bladder cancer: 5-year results of a prospective randomized study. J Urol. 2005;174:2129-33, discussion 33.
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  27. Kausch I, Sommerauer M, Montorsi F, Stenzl A, Jacqmin D, Jichlinski P, et al. Photodynamic diagnosis in non-muscle-invasive bladder cancer: a systematic review and cumulative analysis of prospective studies. Eur Urol. 2010;57:595-606.
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  29. Bryan RT, Billingham LJ, Wallace DM. Narrow-band imaging flexible cystoscopy in the detection of recurrent urothelial cancer of the bladder. BJU Int. 2008;101:702-5; discussion 5-6.
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  31. Cauberg EC, Kloen S, Visser M, de la Rosette JJ, Babjuk M, Soukup V, et al. Narrow band imaging cystoscopy improves the detection of non-muscle-invasive bladder cancer. Urology. 2010;76:658-63.
  32. Herr HW, Donat SM. Reduced bladder tumour recurrence rate associated with narrow-band imaging surveillance cystoscopy. BJU Int. 2011;107:396-8.
  33. Geavlete B, Multescu R, Georgescu D, Jecu M, Dragutescu M, Geavlete P. Innovative technique in nonmuscle invasive bladder cancer-bipolar plasma vaporization. Urology. 2011;77:849-54.
  34. Xishuang S, Deyong Y, Xiangyu C, Tao J, Quanlin L, Hongwei G, et al. Comparing the safety and efficiency of conventional monopolar, plasmakinetic, and holmium laser transurethral resection of primary non-muscle invasive bladder cancer. J Endourol. 2010;24:69-73.
  35. Nieder AM, Meinbach DS, Kim SS, Soloway MS. Transurethral bladder tumor resection: intraoperative and postoperative complications in a residency setting. J Urol. 2005;174:2307-9.
  36. Collado A, Chechile GE, Salvador J, Vicente J. Early complications of endoscopic treatment for superficial bladder tumors. J Urol. 2000;164:1529-32.
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