Transurethral Resection of Bladder Tumors: Improving Quality Through New Techniques and Technologies: Beyond the Abstract

Transurethral resection of bladder tumors (TURBT) is a necessary component of the evaluation, diagnosis, and management of all stages of bladder cancer. This procedure demands visualization and careful resection of tumors within the bladder; an environment often complicated by irregularity, intravesical debris, and ongoing hematuria from friable tumors. Further, the often multifocal nature of cancer within the bladder demands careful inspection to identify what may be subtle tumors. Complete resections are important for appropriate diagnosis, clinical staging, and prevention of recurrent disease.

Several new technologies have emerged to facilitate improved resections. Bipolar electrocautery has been extensively used and demonstrated similar safety profile to monopolar cautery with potentially superior preservation of pathologic specimens.1,2 Most exciting is the addition of enhanced cystoscopy techniques to improve tumor visualization. Blue light cystoscopy following preoperative administration of hexyl-aminolevulinate HCL (Cysview®, Photocure ASA, Norway) has been demonstrated to result in better visualization of bladder tumors with subsequent decreased rates of recurrence 3-4 Narrow Band Imaging (NBI®, Olympus Medical, USA), though not as extensively studied or validated as blue light cystoscopy, has been demonstrated to also improve tumor detection.Capacity of these technologies to facilitate decreased rates of disease progression have not yet been well established and optimal application of these technologies continues to be explored at various stages of bladder cancer care. However, they represent tremendous advances over traditional resection techniques and provide direct benefits to patients. It is anticipated that continued research in this arena will lead to development of improved biomarkers, effective intravesical therapies, and novel technologies for bladder cancer management.

Beyond technologic considerations, clinical TURBT outcomes are highly dependent on surgeon factors such as experience and operative time.6,7 TURBT requires practiced awareness and technique for complete visualization and safe resection of all tumors. Training protocols and standardization of techniques are currently lacking. We recently described a resection technique especially applicable to a training environment but additional efforts towards validation and identification of optimal methods for training such as use of simulation tools are needed.8,9

Current guidelines recommend repeat TURBT for all patients with an incomplete initial resection or disease involving the lamina propria of the bladder as well as consideration for repeat resection in those patients with any high grade tumor.10 These guidelines reflect a failure of initial TURBT to consistently remove and stage bladder cancer adequately. It is hoped that improvements such as enhanced cystoscopy and standardized surgical training will one day obviate the need for repeated procedures, improving patient care and limiting costs. Though long established in the care of bladder cancer, TURBT continues to evolve to the benefit of bladder cancer patients.

Author: Daniel Zainfeld, MD, USC Norris Comprehensive Cancer Center, Los Angeles, CA; Siamak Daneshmand, MD, Keck Medical Center of USC, Los Angeles, CA
Twitter: @dzainfeld & @siadaneshmand

1. Xishuang, S. 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. 24, 69–73 (2010).
2. Venkatramani, V., Panda, A., Manojkumar, R. & Kekre, N. S. Monopolar versus bipolar transurethral resection of bladder tumors: a single center, parallel arm, randomized, controlled trial. J. Urol. 191, 1703–1707 (2014).
3. Daneshmand, S. et al. Hexaminolevulinate blue-light cystoscopy in non-muscle-invasive bladder cancer: review of the clinical evidence and consensus statement on appropriate use in the USA. Nat. Rev. Urol. 11, 589–596 (2014).
4. Burger, M. et al. Photodynamic diagnosis of non-muscle-invasive bladder cancer with hexaminolevulinate cystoscopy: a meta-analysis of detection and recurrence based on raw data. Eur. Urol. 64, 846–854 (2013).
5. Naselli, A., Introini, C., Bertolotto, F., Spina, B. & Puppo, P. Feasibility of transurethral resection of bladder lesion performed entirely by means of narrow-band imaging. J. Endourol. 24, 1131–1134 (2010).
6. Bos, D. et al. Impact of resident involvement in endoscopic bladder cancer surgery on pathological outcomes. Scand. J. Urol. 50, 234–238 (2016).
7. Matulewicz, R. S. et al. The effect of surgical duration of transurethral resection of bladder tumors on postoperative complications: An analysis of ACS NSQIP data. Urol. Oncol. 33, 338.e19-24 (2015).
8. Bazargani, S., Djaladat, H., Schuckman, A. K., Hugen, C. & Daneshmand, S. Blue Light Cystoscopy with Cysview: The USC Experience.
9. de Vries, A. H. et al. The Simbla TURBT Simulator in Urological Residency Training: From Needs Analysis to Validation. J. Endourol. 30, 580–587 (2015).
10. American Urological Association - Diagnosis and Treatment of Non-Muscle Invasive Bladder Cancer: AUA/SUO Joint Guideline. Available at: (Accessed: 18th May 2017)