Overview
Definition:
Transurethral Resection of Bladder Tumor (TURBT) is a minimally invasive surgical procedure to diagnose and remove non-muscle-invasive bladder tumors
It involves using a resectoscope inserted through the urethra to excise the tumor and coagulate the base
Perioperative management encompasses the entire period from pre-assessment and preparation to immediate post-operative recovery.
Epidemiology:
Bladder cancer is the 10th most common cancer worldwide, with NMIBC accounting for approximately 70-80% of cases
TURBT is the cornerstone of initial management for these tumors
Incidence varies by geography and risk factors like smoking and occupational exposures.
Clinical Significance:
Effective perioperative management of TURBT is crucial for accurate staging, complete tumor resection, minimizing complications, and optimizing patient outcomes
It directly impacts recurrence rates, progression to muscle-invasive disease, and patient quality of life
This procedure is frequently encountered in surgical residency and is a key topic for DNB and NEET SS examinations.
Indications
Absolute Indications:
Diagnosis and treatment of suspected or confirmed urothelial carcinoma of the bladder
staging of bladder cancer
management of hematuria from bladder lesions.
Relative Indications:
Diagnostic confirmation of non-neoplastic bladder lesions
management of certain benign tumors like papillomas
recurrent NMIBC requiring re-resection.
Contraindications:
Unresectable muscle-invasive bladder cancer requiring radical cystectomy
severe coagulopathy
acute urinary tract infection
patient unfit for anesthesia or surgery.
Preoperative Preparation
Patient Assessment:
Detailed medical history including smoking status, occupational exposures, previous bladder cancer history, and previous treatments
Thorough physical examination including abdominal and rectal exams
Assessment of comorbidities and functional status (ECOG performance status).
Investigations:
Complete blood count (CBC), coagulation profile (PT/INR, aPTT), electrolytes, renal function tests (Urea, Creatinine), liver function tests (LFTs)
Urinalysis and urine cytology
Imaging: CT urography or MRI pelvis for staging and assessing muscle invasion, chest X-ray for metastatic workup.
Anesthesia Consultation:
Evaluation for general or spinal anesthesia
Discuss risks and benefits of anesthetic techniques with the patient
Ensure adequate fasting periods.
Informed Consent:
Discuss the procedure, its purpose, potential risks (bleeding, perforation, infection, stricture, recurrence, progression), benefits, alternatives, and expected outcomes
Obtain written informed consent.
Surgical Procedure And Intraoperative Management
Instrumentation:
Use of a resectoscope equipped with an active electrode loop (Monopolar or Bipolar)
Saline or glycine as irrigation fluid for Monopolar diathermy to avoid hyponatremia
Continuous bladder irrigation is essential.
Technique:
Insertion of resectoscope into the bladder
Identification of the tumor
Resection of the tumor piecemeal from periphery to center, including the submucosa to achieve adequate depth
Diathermy coagulation of the tumor base and any bleeding vessels
Careful inspection of the entire bladder mucosa for additional lesions
In certain cases, a "second-look" TURBT may be planned within 4-6 weeks for patients with high-risk tumors.
Hemostasis:
Achieving meticulous hemostasis using diathermy is critical to minimize postoperative bleeding
Close monitoring of irrigation fluid outflow for excessive blood loss.
Bladder Irrigation:
Maintaining clear vision by ensuring adequate inflow and outflow of irrigation fluid
Vigilance for signs of fluid absorption (hyponatremia, especially with Glycine irrigation in Monopolar TURBT).
Postoperative Care
Immediate Postoperative Period:
Monitoring vital signs, urine output, and fluid balance
Pain management with analgesics
Prophylactic antibiotics (e.g., fluoroquinolone or trimethoprim-sulfamethoxazole) typically for 3-7 days, depending on institutional protocol.
Urinary Catheterization:
Indwelling Foley catheter is typically left in place for 24-48 hours to ensure bladder drainage and facilitate hemostasis
Monitor for catheter patency and signs of infection.
Fluid Management:
Maintain adequate hydration
Monitor for signs of hyponatremia if non-electrolyte irrigation fluid was used, especially in prolonged procedures.
Discharge Instructions:
Instructions on wound care (if any), activity restrictions, diet, hydration, pain management, and signs/symptoms of complications (fever, severe pain, inability to void, heavy bleeding) requiring immediate medical attention
Follow-up appointment scheduling.
Complications
Early Complications:
Bleeding (immediate or delayed, up to 2 weeks post-op)
Bladder perforation (rare, usually managed conservatively with catheterization
requires open repair if severe)
Urinary tract infection (UTI)
Sepsis
Urethral stricture or meatal stenosis
Anesthesia-related complications.
Late Complications:
Recurrence of bladder tumor
Progression to muscle-invasive disease
Bladder neck contracture
Urethral stricture
Erectile dysfunction
Bladder stones
Increased risk of urothelial carcinoma in upper urinary tract.
Key Points
Exam Focus:
Understanding the indications for TURBT, the role of bladder biopsy vs
resection, importance of obtaining adequate tissue for staging, and management of post- TURBT bleeding
Know the typical irrigation fluid complications and their management.
Clinical Pearls:
Thorough bladder inspection is as important as resection
Always send tumor tissue for histopathology and staging
Consider intravesical chemotherapy (e.g., Mitomycin-C) immediately post-resection for high-risk tumors to reduce recurrence risk.
Common Mistakes:
Inadequate resection depth leading to understaging
Failure to inspect the entire bladder
Inadequate hemostasis
Mismanagement of post-op bleeding
Not suspecting hyponatremia with non-electrolyte irrigation fluids.