A transurethral resection of the bladder is the initial treatment for all patients with urothelial cancer in the bladder, regardless of tumor stage.
For all primary and recurring tumors, a TUR-B should be performed with the goal of obtaining tumor tissue for a histopathological assessment to determine the grade of the tumor (WHO grade and pT classification). For this diagnostic/treatment procedure, it is a requirement that the underlying bladder musculature is included in the tissue specimen from the tumor area. All tumors will be removed, and all suspect areas of mucosa will be biopsied separately. The base ofthe resection wound with surrounding mucosa will be electrocoagulated. After all of the visible tumor tissue is resected and the margin biopsies are taken, it is normal to conclude the procedure with intillation of a cytotoxic substance (epirubicin, adriamycin) to reduce the chance of recurrence.
The pathologist who investigates the tumor specimen will describe the tumor type (WHO grade) and the depth of infiltration (pT stage). If the T stage ≤ 1, pT stage ≤ 1, WHO grade ≤ 2, then the primary surgical treatment is finished. If multiple tumors are found in the bladder, these must be removed and coagulated, if necessary. This type of patient has a high risk of recurrence, therefore, instillation of BCG should be considered.
Important factors of the procedure
- While under general anesthesia, a bimanual palpation will be performed. This can preferably be carried out both before and after, but should always be performed after the resection. The goal is to identify palpable masses in relation to the bladder, and to determine whether they are fixed or mobile relative to the pelvic wall. After the resection, finding a palpable tumor increases the probability that an infiltrating tumor (≥ T2) is present.
- The resection must be carried out in such a way that the relation of the tumor to the bladder can be judged, and that the tumor tissue can be preserved for a histological assessment. By taking large enough segments and minimalizing current for cutting, heat damage of representative tumor areas can be avoided. Superficial and deep parts of an infiltrating tumor should be resected individually and be sent to pathology as separate specimens.
In addition to the tumor resection, biopsies should be taken of suspect mucosal areas. If there is suspicion of infiltration into the bladder neck level and/or cancer in situ (Tis), a biopsy of the prostatic urethra down to the colliculus, preferably with the resection loop, is indicated. This type of biopsy should also be taken if a cystectomy is planned with construction of an orthotopic bladder substitute as additional treatment.
- It is contraindicated to take random bladder biopsies in patients with solitary papillomatous tumors, since such biopsies will not provide additional information. It is also a danger that biopsy lesions of mucosa may be locations for implantation of cells from the tumor.
- For superficial papillary tumors, a single instillation of chemotherapy is recommended immediately after a TUR-B.
- Treatment of superficial tumors (Tis, Ta, T1)
- Palliative treatment of T4b/metastatic tumors
- Curative treatment
- Palliative treatment