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TURBT

Goals of the procedure:

  • Complete safe resection of tumour
  • Accurate pathological staging and grading
  • Clinical staging with bimanual examination under anaesthesia
  • Symptom relief (bleeding and irritation)

 

Steps:

  • GA or spinal with antibiotic prophylaxis
    • GA with neuromuscular blockade preferred if lateral wall tumour
  • EUA
  • Rigid cystoscopy with 30 and 70 degree lens
  • Resection of tumour – complete visual resection with margin, ideally to muscular fibres
    • Start from superficial and work deep
    • I take a separate specimen from the base
  • Haemostasis
  • 3-way catheter with irrigation if needed
  • EUA with empty bladder

 

Problems:

  • Obturator nerve reflex – causing thigh adduction rapidly and risking perforation
    • Muscle paralysis (? Consider obturator nerve block)
    • Empty bladder
    • ?Bipolar reduces risk
    • Staccato technique
    • Reduce cutting current
  • Anterior or dome tumours (especially difficult in obese)
    • Beware intraperitoneal perforation
    • Modulate bladder volume
    • Assistant’s hand for suprapubic pressure
    • Longer resectoscope available
  • Tumour over ureteric orifice
    • Cut current only – less heat and minimises risk of obstruction
    • Pinpoint haemostasis
    • Consider need for ureteroscopy if concerns for ureteric disease
    • Consider need for stent – risk of obstruction balanced with need for removal and theoretical risk of seeding/reflux up the ureter
  • Tumour in diverticulum
    • No muscle layer – can go from T1 straight to T3, be aware of perforation risk
    • Consider sampling only with view to diverticulectomy vs aiming for complete resection

 

Complications of TURBT:

Perforation

  • Consider if input ≠ output, suprapubic distension intra-operatively or in recovery, difficulty filling bladder, respiratory compromise
  • On table cystogram or CT can diagnose and see if extraperitoneal or intraperitoneal
  • Extraperitoneal can be managed with IDC for 10 days and repeat cystogram prior to removal
  • Intraperitoneal should probably be managed with formal repair via laparotomy (and removal of urinoma, wash ++ of abdomen)
  • Higher risk of extravesical malignancy
  • Also risks TUR syndrome, infection

 

Bleeding

  • May need to continue resecting to get to base of vessels and allow for haemostasis
  • Ensure adequate irrigation, taps on etc
  • If post-operative clot retention and bleeding – best managed back in theatre

 

Infection 3 – 5 %

Urinary retention, especially for bladder neck tumours

 

 

En-bloc resection is emerging as a technique for suitable exophytic tumours:

  • Use Collin’s knife or laser to resect tumour in one piece, aiming for better and more accurate pathological assessment

 

Bipolar vs monopolar

  • Suggestion of reduced obturator kick although this has not been proven in the literature.
  • Systematic review failed to show difference in efficacy or safety

 

Presence of detrusor muscle in the specimen is considered a surrogate of resection quality.

 

Prostatic urethral biopsies recommended if:

  • Bladder neck tumours
  • Positive cytology without bladder tumour
  • Suspicion of CIS
  • Abnormalities visible