Editing Transurethral Resection of Bladder Tumour (section)

== Adverse Events ==

=== Intra-operative ===
* '''<span style="color:#ff0000">Bladder perforation</span>'''
** Occurs in <5% of cases
** '''Risk of tumor seeding from perforation appears to be low'''
** '''<span style="color:#ff0000">Vast majority of perforations are extraperitoneal</span>'''
*** '''<span style="color:#ff0000">Intraperitoneal perforation associated with posterior and dome tumors</span>'''
****'''<span style="color:#ff0000">Resections elsewhere in the bladder are more likely to result in an extraperitoneal perforation</span>'''
** '''<span style="color:#ff0000">Diagnosis and Evaluation</span>'''
*** '''<span style="color:#ff0000">History and Physical Exam</span>'''
**** '''<span style="color:#ff0000">Physical Exam</span>'''
***** '''<span style="color:#ff0000">Findings during resection suggestive of an intraperitoneal rupture (3):</span>'''
*****# '''<span style="color:#ff0000">Loss of bladder distention</span>'''
*****# '''<span style="color:#ff0000">Visualization of a defect posteriorly or at the dome</span>'''
*****# '''<span style="color:#ff0000">Palpable distention of the abdomen; an increase in abdominal girth or fullness</span>'''
*** '''<span style="color:#ff0000">Labs</span>'''
**** '''<span style="color:#ff0000">Intraperitoneal extravasation of glycine (monopolar) can lead to hyponatremia</span>'''
***** '''Glycine is quickly metabolized in the liver after absorption and is unlikely to be detected in the serum.''' However, the remaining extravesical fluid is free water and will cause acute dilutional hyponatremia as it is absorbed.
***** Serum BUN only goes up over a longer period of time if there is extravasation of urine with secondary resorption from exposed tissues.
*** '''Imaging'''
**** '''When suspected, confirmation can be obtained with an intraoperative cystogram'''
** '''<span style="color:#ff0000">Management</span>'''
*** '''<span style="color:#ff0000">Extraperitoneal: Foley catheter drainage and observation</span>'''
*** '''<span style="color:#ff0000">Intraperitoneal:</span>'''
***# '''<span style="color:#ff0000">Abdominal exploration</span>'''
***# '''<span style="color:#ff0000">Meticulous inspection of the bowel</span>'''
***# '''<span style="color:#ff0000">Repair of the injury with both a Foley catheter and abdominal drainage</span>'''
*** Decisions for surgical correction should be made based on the extent of the perforation and the clinical status of the patient.
* '''Injury to ureteric orifice'''
** If resection of the ureteral orifice is performed with pure cutting current, scarring is minimal and obstruction unlikely.
** Cystoscopy to visualize efflux, which is occasionally aided by intravenous administration of indigo carmine or methylene blue or retrograde ureteropyelography, can determine presence or absence of obstruction
* Bleeding
* Obturator reflex
* Urethral false passages/trauma
*If using laser for resection, the most significant complication is forward scatter of laser energy to adjacent structures, resulting in perforation of a hollow, viscous organ such as overlying bowel.

=== Early post-operative ===
* '''<span style="color:#ff0000">Irritative symptoms'''
** Common
* '''<span style="color:#ff0000">Bleeding'''
** Minor bleeding is common; uncontrolled hematuria occurs in <5% of cases
* '''TUR syndrome'''
** Managed in the same manner as during TURP
** '''Risk factors for TUR syndrome (3):'''
*** '''Long resection time >90 mins'''
*** '''Increased pressure of irrigation fluid'''
***'''With TURP: large glands >45g''' 
* <span style="color:#ff0000">'''Sepsis'''
* <span style="color:#ff0000">'''Foot drop (common peroneal nerve)'''

=== Late post-operative ===
* '''<span style="color:#ff0000">Urethral stricture disease'''
* Ureteral orifice scarring/obstruction