Transurethral Resection of Bladder Tumour

2021 CUA NMIBC Guidelines: Checklist for high-quality TURBT§

• Cystoscopy (3):
  1. Provide detailed description of urethra, bladder walls, and lesions (number, size, appearance, suspicion for concurrent / primary CIS)
  2. Report visual impression of clinical stage and grade
  3. Collect washing or voided urine cytology if not previously obtained.
• TURBT (10):
  1. Completely resect all visible tumours and suspicious areas;
  2. Send labeled tumour specimens separately;
  3. Avoid excessive fulguration;
  4. Use enhanced visualization techniques when available;
  5. Use bipolar energy when indicated and available;
  6. Deep resection of the detrusor muscle – send deep specimens separately.
  7. Random biopsies (bladder and prostatic urethra) if indicated.
  8. Ensure adequate hemostasis.
  9. Assess bladder wall integrity after resection (evaluate for perforation).
  10. Perform bimanual exam under anesthesia.

Bimanual examination under anesthesia prior to resection

• Bimanual examination of the bladder with the patient under anesthesia is done before preparation and draping (unless the tumor is clearly small and noninvasive), and repeated after resection
• The dominant hand is placed on the suprapubic region and one or two fingers from the nondominant hand in the rectum (males) or vagina (females).
• Fixation or persistence of a palpable mass after resection suggests locally advanced disease
• The additional value of this maneuver in the era of modern imaging appears limited and may even be misleading
  • 11% clinical overstaging and a 31% clinical understaging rate
• Staging based on bimanual examination (as per EAU Guidelines)
  • cT2a: nonpalpable
  • cT2b: induration but no 3D mass
  • cT3: 3D mass that is mobile
  • cT4a: invading adjacent structures such as the prostate, vagina, or rectum
  • cT4b: fixed to pelvic sidewall and not mobile
• Guideline perspective on role of bimanual examination:
  • 2015 CUA NMIBC guidelines: a valuable staging component of the TURBT procedure (Level of Evidence 3)
  • 2016 AUA NMIBC guidelines: can assist with clinical staging

Antibiotic prophylaxis

• CUA/AUA Guidelines recommend prophylaxis for all patients undergoing TUR of bladder tumors, and it should be administered within 1 hour of the procedure

Principles of adequate resection

• Full cystoscopic assessment first
  • At the time of TURBT, a thorough cystoscopic examination of a patient’s entire urethra and bladder should be performed that evaluates tumor size, location, configuration, number, and mucosal abnormalities
• Complete resection (wide resection)
• Fulguration alone insufficient for primary tumours
• Sample muscularis
• No perforation
• Paralysis for lateral tumours

En-bloc TURBT§

• Aims for complete removal of the bladder tumour with the adjacent bladder tissue and muscularis propria in one single specimen
• Potential advantages (4):
  1. Better quality specimens (less fulguration)
  2. Improved accuracy of pathology diagnosis
  3. Reduced number of floating tumour cells
  4. Lower risk of bladder perforation during TURBT
• Benefit on disease recurrence has not been established

Lens

• A thorough visual inspection involves using the 30° lens to examine the urethra and then to perform a preliminary evaluation of the bladder mucosa and ureteral orifices. A 70° lens should then be used to completely evaluate the bladder again with particular attention to the bladder neck, dome, and anterior wall.
  • The most common lenses used during a typical rigid cystourethroscopy are the 30° and 70° lens.
  • The urethra is best visualized using the 0 to 12° lens.
  • A 30° lens is most often used for therapeutic purposes.
  • Resection is performed using a 12- or 30° lens because this deflection allows visualization of the cutting loop.
  • The 70° or 120° lens are often required to inspect the anterior and inferolateral walls, dome, and neck of the bladder.

Irrigation fluid

• Traditionally, TUR has been performed in sterile water because saline solutions conduct electricity and disperse energy from the monopolar cautery cutting loop
• 1.5% glycine is more expensive, and there is no evidence of its benefit in this setting compared with water

Obturator nerve reflex

• When tumors are encountered on the lateral wall, there is the risk of an obturator reflex whereby the cautery current stimulates the obturator nerve, causing the ipsilateral leg to aDDuct
• This can lead to inadvertent deflection of the instrument laterally and can cause perforation.
• Techniques to reduce the risk of an obturator reflex (5):
  1. Minimize distention of the bladder
     • Continuous irrigation with the bladder filled only enough to visualize its contents minimizes bladder wall movement and lessens thinning of the detrusor through overdistention, which should reduce the risk of perforation
  2. Using bipolar over monopolar cautery
  3. If the patient is under a general anesthetic, administer a general muscle relaxant
  4. Direct injection of local anesthetic (20-30 mL lidocaine) into the obturator nerve and its canal
  5. Tapping the peddle during resection

Advantages of bipolar TURP (compared to monopolar)

1. Reduced risk of postoperative electrolyte abnormalities since bipolar uses 0.9% NS as irrigation
2. Reduced risk of triggering an obturator reflex for tumours overlying the lateral walls of the bladder.
3. [Reduced bleeding, increased resection time]

Resection

• See BJUI Surgical Atlas for details and figures
• Performed piecemeal, delaying transection of any stalk until most tumor has been resected, to maintain countertraction. Friable, low-grade tumors can often be removed without the use of electrical energy because the nonpowered cutting loop will break off many low-grade tumors. This minimizes the chance of bladder perforation and unnecessary cautery damage or loss of specimens. Higher-grade, more solid tumors and the base of all tumors require the use of cutting current; cautery yields hemostasis once the entire tumor has been resected. Lifting the tumor edge away from detrusor lessens the chance of perforation
• Histologically, bladder tumors frequently exhibit growth beyond the visible edge and, as such, resection should include an approximate 2-cm margin of normal-appearing tissue.
• For tumours overlying a ureteral orifice, only cutting current should be used and resection strokes should be as quick as possible to minimize the possibility of cauterizing the ureteral orifice closed. Data suggest routine stenting is not necessary following ureteral orifice resection.
• 2016 AUA NMIBC Guidelines: During resection, tumors of significant size should be resected and labeled
• 2015 CUA NMIBC Guidelines: Complete resection of all visible tumours with adequate depth to include muscularis propria should be performed, when feasible
  • Campbell’s: The necessity of obtaining detrusor muscle in the surgical specimen is widely taught but not established in benefit. For example, the potential for muscle invasion for low-grade disease is essentially nonexistent, so a transmural biopsy offers little potential benefit compared with the risk of bladder perforation incurred
• Small tumors may be resected using the cold-cup biopsy forceps alone. This is especially helpful in elderly women, who are predisposed to perforation owing to their thin-walled bladders. If perforation occurs, the cup causes a smaller hole than does the cutting loop. A Bugbee electrode facilitates hemostasis.
• In a patient with a history of TaLG disease and a noted sub-centimeter papillary tumor(s), a clinician may consider in-office fulguration as an alternative to resection under anesthesia.
  • A fulguration approach that does not obtain tissue for pathologic evaluation should not be utilized unless a diagnosis of TaLG disease or PUNLMP has been previously established and should be restricted to those patients in whom the lesion is papillary in appearance, rather than sessile or flat, and ≤ 1 cm in size. Furthermore, patients in whom a urinary cytology is suspicious for urothelial carcinoma are at higher risk for harboring occult high-grade disease and warrant pathologic evaluation of any visible lesion.
• Many small, low-grade tumors can be safely observed until they exhibit significant growth because of the minimal risk of progression

Diverticular tumours

• Because the underlying detrusor is absent, accurate staging is difficult and increased risk of bladder wall perforation
• Invasion beyond the diverticular lamina propria immediately involves perivesical fat (stage T3a by definition)
• Treatment
  • Low-grade diverticular tumors are best treated with a combination of resection and fulguration of the base. Conservative resection can be followed with subsequent repeat resection if the final pathologic interpretation is high grade.
  • High-grade tumors require adequate sampling of the tumor base, often including perivesical fat, despite the near certainty of bladder perforation. An indwelling catheter usually allows healing within a few days. Partial or radical cystectomy should be strongly considered for high-grade diverticular lesions

Anterior wall tumors and tumors at the dome

• Can be difficult to reach in patients with large bladders
• Minimal bladder filling combined with manual compression of the lower abdominal wall to bring the tumor toward the resectoscope facilitates removal. Digital manipulation through the rectum or vagina can occasionally facilitate resection
• Modern resectoscopes are long enough to reach the entirety of most bladders; creation of a temporary perineal urethrostomy offers deeper access but is rarely necessary except in the obese patient with an inaccessible tumor

Post-operative Instillation

• Consider post-operative instillation of intravesical chemotherapy, if appropriate
• Continuous bladder irrigation (CBI) may be of benefit
  • Systematic review of CBI following TURBT for non-muscle invasive bladder cancer
    • 6 studies meeting inclusion criteria
      • 2 studies (without peer-reviewed publication) compared CBI vs. no CBI and found that CBI reduced risk of at 2 years
      • 4 studies from 3 randomized trials compared CBI vs. intravesical chemotherapy and found similar recurrence rates at 1 year (odds ratio 1.29, 95% confidence interval 0.78-2.13) but a lower risk of adverse events (6-34% versus 27-48%)
    • Li, Mo, et al. "Continuous bladder irrigation after transurethral resection of non‐muscle invasive bladder cancer for prevention of tumour recurrence: a systematic review." ANZ Journal of Surgery 91.12 (2021): 2592-2598.

Complications

• Intra-operative
  • Perforation
    • Occurs in <5% of cases
    • The risk of tumor seeding from perforation appears to be low
    • The vast majority of perforations are extraperitoneal
      • Intraperitoneal perforation associated with posterior and dome tumors; resections elsewhere in the bladder are more likely to result in an extraperitoneal perforation
    • Diagnosis and Evaluation
      • History and Physical Exam
        • Physical Exam
          • Findings during resection suggestive of an intraperitoneal rupture:
            1. Loss of bladder distention
            2. Visualization of a defect posteriorly or at the dome
            3. Palpable distention of the abdomen; an increase in abdominal girth or fullness
      • Labs
        • Intraperitoneal extravasation of glycine can lead to hyponatremia
          • 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 a cystogram at the same setting
    • Management
      • Extraperitoneal: Foley catheter drainage and observation
      • Intraperitoneal:
        1. Abdominal exploration
        2. Meticulous inspection of the bowel
        3. Repair of the injury with both a Foley catheter and abdominal drainage
      • 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
    • As long as 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
• Early post-operative
  • Irritative symptoms
    • Common
  • 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:
      • Long resection time >90 mins
      • Large glands >45g
      • Increased pressure of irrigation fluid
  • Sepsis
  • Foot drop (common peroneal nerve)
• Late post-operative
  • Urethral stricture disease
  • Ureteral orifice scarring/obstruction

• Tumour resection can also be done with laser therapy.
  • The most significant complication of laser therapy is forward scatter of laser energy to adjacent structures, resulting in perforation of a hollow, viscous organ such as overlying bowel.
  • Because there is no tissue available for pathologic inspection, the optimal candidate for laser therapy is the patient with recurrent, low-grade lesions whose biology is already known
  • The optimal laser for fulguration of bladder tumors is Neodymium-doped yttrium aluminium garnet (Nd:YAG)
• In the presence of a bladder tumor, selective upper tract cytology may be falsely positive and is not recommended for most patients
• The use of random biopsies to identify CIS in otherwise normal-appearing mucosa remains controversial. The current consensus is that random biopsies are not indicated in low-risk patients (i.e., those with low-grade papillary tumors and negative cytology), but there remains no consensus with regard to patients with high-grade disease, and most urologists perform random biopsies in this setting.
• Prostatic urethral biopsy using the cutting loop may be performed at the time of TURBT, especially if neobladder creation is anticipated for high-risk disease, but bleeding may be more common
• Traditional teaching is that TURP and TURBT of a low-grade bladder tumor may be performed at the same setting but that resection of a high-grade bladder tumor should not be performed coincident to TURP to avoid tumor seeding and possible intravasation of tumor cells

References

• Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 95
• Bhindi, Bimal, et al. "Canadian Urological Association guideline on the management of non-muscle invasive bladder cancer." Canadian Urological Association Journal 15.8 (2021).