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Transurethral resection of the bladder (TUR-B)


Medical editor Bjørn Brennhovd MD
Urologist
Oslo University Hospital

General

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. 

Indications

  • Treatment of superficial tumors (Tis, Ta, T1)
  • Palliative treatment of T4b/metastatic tumors

Goal

  • Curative treatment
  • Palliative treatment

Equipment

  • Cystoscopy set
  • Resectoscope number 24 or 27  
  • Optic 30¤
  • Evacuator
  • 3-way catheter nr 20
  • Light source
  • Light cable
  • Diathermy cable
  • Diathermy
  • Diathermy pad with cable

 


Preparation

  • The patient should be informed that presence of some blood and blood clots in urine is normal and will disappear during the first days after the procedure.
  • Urine stick - If positive, antibiotic prophylaxis will be given.  
  • Pretreatment according to schedule
  • The patient will lie with their legs in leg supports.
  • A diathermy pad will be applied to the thigh.
  • Sterile wash and draping 

Implementation

  • Place Xylocaine® gel in the urethra
  • Insert the resectoscope via the urethra and into the bladder 
  • Inspect the bladder for pathological findings 
  • Resect tissue/superficial tumors in the bladder using an electrical loop . The pieces of tissue will remain in the bladder and the wound surfaces will bleed, therefore, it is important to flush the area. When the bladder is full of flushing fluid, the resection instrument should be pulled out of the resectoscope to drain the fluid. Alternatively, a suprapubic catheter can be used to provide continual drainage. 
  • Coagulate bleeding continually
  • Empty the bladder for resected tissue and clots using an evacuator .
  • Check hemostasis.
  • Insert a 3-way catheter in for continual flushing.

Follow-up

Postoperatively, the bladder is flushed using a 3-way catheter.  

  • The flush fluid/urine should be observed for: 
    • Amount
    • Color
    • Coagulation
  • The rate of flushing should be varied according to the amount of blood in the fluid. 
  • If the fluid stops due to clots, flushing should continue manually with a catheter syringe and sodium chloride 9 mg/ml.
  • Flushing is usually stopped the day after the procedure, but depends on the amount of bleeding. The doctor should determine when to stop flushing. 
  • Use of a catheter should be stopped according to the treating doctor. 
  • After removal of the catheter, observe for: 
    • Spontaneous urination 
    • Urination patterns after the procedure
  • Scanning of remaining urine and flowmetry is performed before discharge.  

Shortly after undergoing a TUR-B, the patient will normally be able to return home, however, he/she must be informed that not until the histology result is available will it be known whether primary treatment is finished. The histology result will often show uncertain resection margins to the sides (margin biopsies) or in depth under the tumor. Not until the patient is considered tumor-free will he/she be able to start the follow-up schedule. The patient should be informed that the cancer may recur after many years and the malignancy (grade) of the tumor can also change when it recurs. When urothelial cancer is diagnosed, there will always be a risk for developing new tumors, especially in cases of malignancy grades.  

Follow-up

A follow-up with cystoscopy will take place after 3 months at the urology clinic.


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