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Transurethral Resection of Bladder Cancer and Its Applications

  • Stefania Zamboni
  • Marco Moschini
  • Atiqullah AzizEmail author
Living reference work entry

Abstract

Transurethral resection of bladder tumors (TURBT) is a procedure performed to diagnose and stage bladder cancer (BCa) and to resect all visible tumors. This chapter is focused on TURBT surgical technique, possible complications, and available tools which can improve the quality of resection to correctly stage the neoplasm and to reduce recurrences and progressions of non-muscle-invasive BCa.

Introduction

Transurethral resection of bladder tumors (TURBT) is a procedure which represents the initial treatment to diagnose, stage, and resect all visible tumors if technically possible and to perform biopsies of suspicious areas. TURBT is not only a diagnostic procedure but also a therapeutic procedure. In case of a suspicious bladder tumor, TURBT remains crucial in order to obtain a histopathological confirmed diagnosis of a bladder. Furthermore, TURBT is the essential procedure to decide whether an organ sparing approach in case of non-muscle-invasive disease is sufficient or a radical cystectomy is required in case of a muscle-invasive disease or high-risk non-muscle-invasive disease. Taking this all into consideration, TURBT is a key step in the treatment of bladder cancer.

Preoperative Diagnostics

The indication for a TURBT is a suspicious finding of bladder tumor via cystoscopy or imagings. Preoperative laboratory evaluation of coagulation and kidney parameters, respectively, should be performed. A preoperative ultrasound examination of the kidneys should be done in order to exclude hydronephrosis and if necessary to perform a urinary diversion via nephrostomy before TURBT. Further imagings via CT/MRI of the abdomen and chest should be performed after histopathological evaluation in case of a locally advanced disease to exclude an extraorgan extension and metastases, respectively.

Anesthesia

The aim of the anesthesia is to enable a safe resection with appropriate analgesia and relaxation of the pelvic floor, the abdominal wall, and the bladder. A general or a regional anesthesia or a combination between the two can be equally used. Regional anesthesia can be performed as an epidural or spinal blockade and they provide the advantage of an awake patient in case of intraperitoneal bladder perforation which can be identified by the appearance of abdominal pain. The stimulation of the obturator nerve, which is located close to the lateral wall of the bladder during the TURBT can provoke an obturator nerve-reflex with contraction of the adductor muscle of the leg, which consequently determines a sudden movement of the leg that can lead to a bladder perforation. Two options are available to prevent this phenomenon; one method consists of paralyzing the patient with a short-acting depolarizing drug that, however, can be only used only if the patient is in general anesthesia. The second method consists of the “obturator nerve block” which can be obtained with several techniques. One of them consist of the direct injection of Lidocain through a long needle, inserted 2 cm lateral and caudal to the pubic tubercle and the needle is walked off the inferior border of the superior ramus of the nerve and it enables to block the main trunk before it divides. Another technique consists on the transvesical block; after using a nerve stimulator to detect the nerve on the lateral bladder wall, 10 ml of 1% lidocaine are slowly injected through the working channel of a cystoscope. According to own clinical experience, a semi-filled bladder reduces the risk of an obturator nerve reflex during resection of the tumor at the lateral walls of the bladder.

Antibiotic Prophylaxis

Intravenous antibiotic prophylaxis at the time of anesthesia is recommended for this surgery to prevent infectious complications. The type of antibiotic prophylaxis should be decided on the base of the resistance profile within the region of the treating hospital. A preoperative urine culture should be performed in case of suspicious urine assessed via dip-stick, and any detected infection should be treated before the procedure according to the pathogen spectrum.

Surgical Technique

The position is the same adopted for a classic cystoscopy. The patient is placed supine in a low lithotomy position: the knees should be separated enough to allow a comfortable manipulation of the instruments. Before the surgical procedure, a bimanual examination should be performed unless the tumor is clearly small and noninvasive: the bladder should be palpated bimanually between a finger in the rectum or vagina and the other surgeon’s hand, which is applied over the abdomen in the lower part. Usually, the presence of a palpable disease indicates the invasion of the muscle, either within or through the bladder wall. The bimanual palpation should be repeated at the end of the TURBT. A 24 Fr resectoscope has to be lubricated and inserted into the urethra. An accurate visual inspection of both anterior and posterior urethra with a 0° lens attached to a camera should be carried out. In case of resistance during the urethral passage, any forcing should be avoided. The procedure is pursued with the aid of irrigation either of sterile water or glycine 1.5%. Once the bladder is reached, all its surface should be accurately examined to establish a plan for the sequence of resection with a 30° lens (authors’ preference), alternatively with 12°, 70°, or 120° lens. The urine ejaculation from both ureteric orifices should be observed searching for possible hematuria from the upper tract; in case of its detection, a separate urine sample should be collected for a cytologic evaluation. The bladder capacity should be evaluated, which is important in cases of a repeat resection. TURBT is best performed with the bladder half full since an empty bladder increases the risk of bladder perforation and a full bladder of overdistention. Each visible tumor should be resected systematically and completely if possible and submitted separately for histopathologic evaluation. The presence of detrusor muscle in the specimen is required. The resection is performed with a resectoscope equipped with a cutting monopolar or bipolar loop, similar to the one used for transurethral resection of prostate. The cutting mode should be activated before the contact between the loop and the tissue; this seems to be the only way to ensure a visually controlled penetration. There are two basic approaches to perform a TURBT: staged resection and en-bloc resection. A staged TURBT is performed in several phases (Fig. 1). First, the exophytic portion of the tumor is resected. Then, the next layers of tissue are resected in a similar fashion until the base of the tumor is reached. Finally, the base of the tumor is resected. En-bloc resection may be used for small tumors, generally those <3 cm in the greatest dimension (Fig. 2). The advantages of an en-bloc resection include more accurate pathologic assessment due to the decreased cautery artifact, the avoidance of tumor fragmentation, and the preservation of the spatial orientation of the tumor relative to the bladder wall. However, no study found superiority of en bloc resection, but available evidences suggest safety and its oncologic equivalence compared to the staged TURBT (Kramer et al. 2017). A separate sample of the ground of the resection including the muscle should be performed in order to avoid an understaging. Since the coagulation of neoplastic tissue is very difficult, the coagulation of the wound should be performed after the cut on the healthy tissue, from the margins to the inner area. As already before mentioned, at the end of the TURBT, the bimanual examination should be repeated before the insertion of the catheter. The bladder should be emptied, and any possible residual tumor has to be carefully palpated to determine the depth of the invasion, the eventual invasion of adjacent organs, and the potential fixation to the pelvic wall. In case of non-muscle-invasive bladder cancer, the probability to palpate a lesion bimanually is low. At the end of the procedure, a three-way transurethral catheter (at least 20 Charrier) should be inserted; continuous irrigation with sodium chloride 0.9% is recommended to clear and prevent clots. The catheter should be maintained for 24 h in case of superficial resections and more (at least 2–3 days) in case of deep or extended resection.
Fig. 1

Antegrade staged transurethral resection

Fig. 2

Retrograde “en bloc” transurethral resection

Special Conditions

Tumors in Bladder Diverticulum

By definition, tumors in bladder diverticulum do not have a muscular layer between themselves and the serosa. This feature makes the resection of this type of tumors challenging due to the high risk of bladder perforation. In general, small lesions with the appearance of low-grade tumors can be treated safely with a combination of resection and fulguration whereas large or high-grade tumors should be treated with diverticulectomy, partial or radical cystectomy.

Involvement of the Ureteral Orifices

Resection can be safely performed to remove tumors located close to the ureteral orifices, whereas cautery should be used as little as possible, given the high risk of subsequent stenosis.

Tumors in Bladder Dome

Resection of these tumors can be very challenging because of the difficulty in reaching the tumor and the high risk of intraperitoneal perforation if the resection is too deep especially in older women who have thin bladder walls. To help the resection, the surgeon or an assistant can applicate a pressure just above the pubic symphysis (Fig. 3) and the patient can be placed in the Trendelenburg position.
Fig. 3

Resection of tumors in bladder dome

Biopsies During TURBT

Biopsies are recommended for all suspicious areas detected during a TURBT. Moreover, random biopsies of a unsuspicious bladder urothelium should be performed especially in patients with previous or suspected CIS (van der Meijden et al. 1999) since it can be present also in a normal-looking mucosa or in case of discordance between cytology and cystoscopy. Biopsies of the prostatic urethra should be taken in case of known or suspected CIS, tumors located on the bladder neck, positive cytology with macroscopic negative bladder (Mungan et al. 2005), or when are alterations of urethral mucosa are visible.

Complications of TURBT

The overall rate of complications of TURBT is low. The most frequent minor complications are development of irritative symptoms and minor bleeding which can occur in the immediate postoperative period. Major complications are rarer and consist mainly of uncontrolled hematuria and bladder wall perforations which are more frequently extraperitoneal, treated with a prolonged maintenance of the transurethral catheter. On the contrary, intraperitoneal perforations require a surgical repair.

Photodynamic Diagnosis (PDD) and Narrow Band Imaging (NBI)

Conventionally, cystoscopy and TURBT are performed with a white light. Given the high rates of residual or recurrent tumors after a white light cystoscopy, new technologies have been developed to improve the visualization and the detection of bladder diseases.

PDD

PDD consists of preoperative intravesical instillation of a fluorophore that is a precursor in the heme biosynthesis pathway. Hexylaminolevulinate (HAL) and 5-aminolevulinic acid (5-ALA) have been used for this technique. The 5-ALA is converted in all nucleated cells into an active fluorescent molecule, the protoporphyrin IX (PPIX), which in normal conditions is rapidly converted to heme. Tumor cells have a different metabolism compared to those of a normal urothelium, and these differences lead to a selective accumulation of PPIX which is about five times higher in neoplastic cells (Krieg et al. 2000). The fluorescence of PPIX is achieved by the presence of pyrol rings, and PPIX emits red light (635 nm) when exposed to a blue light (around 400 nm). About 1 h before the planned TURBT, 50 ml of solution of a fluorophore is instilled into the bladder through a transurethral catheter. The fluorescent cystoscopy is performed with a rigid cystoscope combined with a light source called D-light and should be done with an empty bladder. PDD showed a higher sensitivity and a lower specificity compared to white light endoscopy in detection of BCa, with a high rate of false-positive (Mowatt et al. 2011) even if artifact fluorescence is usually less intense than the one determined by a tumor. Moreover, a recent meta-analysis demonstrated a reduced recurrence rate in patients who underwent PDD-guided TURBT (Chou et al. 2017) compared to those treated with the white light endoscopy. The use of PDD is currently recommended in several cases. Firstly, in every patient with a new presentation of non-muscle-invasive BCa. Therefore, tumor detection is higher in patients evaluated with white light plus PDD compared to those evaluated with the white light alone (Mowatt et al. 2011), and as already mentioned, recurrence and progression rates are significantly lower (Chou et al. 2017; Gakis and Fahmy 2016). Moreover, PDD is particularly helpful in detection of CIS (Daneshmand et al. 2018) and improves quality of resection (Geavlete et al. 2010). Secondly, in patients with positive cytology and negative white light cystoscopy since it has been shown that PDD detect tumors in approximately 30% of patients with this condition. And finally, PDD is indicated for the treatment of multifocal recurrent tumors.

NBI

NBI takes advantage of the hypervascular nature of bladder cancer to enhance the contrast with the normal urothelium. It consists of modified optical filters applied to the light source of a video endoscope system which filter the light into two bandwidths of 415 and 540 nm. The intensities of blue and green light are increased, and these two narrow bandwidths are strongly absorbed by hemoglobin in hypervascular neoplastic tissues. Several studies reported the advantage of NBI in detection of non-muscle-invasive BCa compared to white light endoscopy and in recurrence especially in patients with low-risk tumors (pTa low grade, <30 mm, no CIS) (Naito et al. 2016).

Role of re-TURBT

It is not always possible to achieve a complete resection of the tumors since often the lesions are too big or located in areas difficult to reach with the resectoscope. Sometimes the incompleteness of the TURBT is caused by the necessity of a limited anesthesiologic time due to patient’s comorbidity or to the need to interrupt the procedure for the occurrence of intraoperative complications. In any case, the rates of residual tumors after the initial TURBT are high and variable according to grade of the lesions (higher for T1 high grade tumors) (Gontero et al. 2016). Moreover, several studies have demonstrated that the understaging of tumors during the initial TURBT is common and the probability increases when the muscle is absent in the pathologic specimen (Herr 1999). A re-TURBT is recommended in all cases of macroscopic incomplete initial resection, when the muscle is not present at pathologic evaluation and in all T1 and high-grade tumors, because in these cases, a re-TURBT decreases rates of recurrences and progressions (Gontero et al. 2016). When indicated, the second TURBT should be performed 2–6 weeks after the first operation.

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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Stefania Zamboni
    • 1
  • Marco Moschini
    • 1
  • Atiqullah Aziz
    • 2
    Email author
  1. 1.Klinik für UrologieLuzerner KantonsspitalLucerneSwitzerland
  2. 2.Department of UrologyUniversity Medical Center RostockRostockGermany

Section editors and affiliations

  • Wolfgang Otto
    • 1
  • Shahrokh F. Shariat
    • 2
  1. 1.Department of UrologyCaritas St. Josef Medical Centre, University of RegensburgRegensburgGermany
  2. 2.Departement of UrologyWeill Cornell Medical CenterNew YorkUSA

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