Minimally Invasive Urologic Surgery Fellow, University of California, Irvine
The transurethral resection of bladder tumors (TURBT) is truly one of the earliest minimally invasive surgical techniques. Although most urologist and urology residents are very adept at the technique, it has been little over 70 years since the instrumentation was developed to excise bladder tumors transurethrally. Prior to this era, large bladder tumor were excised via open incisions and often associated with multiple complications. Today, open tumor resections are rarely, if ever, performed.
The primary indication for TURBT is evidence for a bladder mass, which may be diagnosed on local cystoscopy or radiographic imaging. TURBT provides accurate staging information with regard to bladder tumor histology, grade and local stage. TURBT is also indicated for the treatment of superficial bladder cancers, and makes up the primary treatment (supplemented by intravesical therapies) for these types of tumors. TURBT can also be indicated as a palliative procedure to reduce symptoms (such as bleeding) in muscle invasive tumors that are not amenable to cystectomy or radio therapy. It is used to debulk large tumors prior to radiotherapy and is the mainstay of therapy for some bladder sparing protocols. In a small percentage (<10%), TURBT can be curative for muscle invasive bladder cancer; however, most of these patient will usually proceed to radical cystectomy and only in hindsight realize they may have been cured with TURBT alone.
As with all surgical procedures, certain precaution must be taken prior to performing a TURBT. While there are few placebo controlled trials examining the effects of antibiotic prophylaxis, all patients should undergo preoperative urine analysis and culture. Treatment with the appropriate antibiotic if a positive urine culture is present is prudent. Only patient with sterile urine should undergo a TURBT. Refer to the AUA Guidelines for the appropriate prophylactic antibiotic recommendations for further information regarding the medication and dose appropriate for your patient.
Limiting the use of anticoagulant medications, such as Coumadin, aspirin or Plavix is also advised. Although heavy bleeding is uncommon with a properly performed TURBT and some surgeons are comfortable performing the procedure while the patient is anticoagulated, most surgeons prefer not to take the risk. Finally, prophylaxis against thromboembolic event should be taken. Above the knee TED stockings or intermittent compression boots is all that is usually required.
Positioning and Anesthesia:
Most anesthesia techniques are appropriate for TURBT. Spinal anesthesia allows for the patient to be awake and alert the surgical team of any signs of TUR syndrome, which is a rare complication of TURBT. Spinal anesthesia, however, does not afford the surgeon the opportunity to paralyze the patient for complex tumor resection along the lateral bladder walls. Tumors present in these locations can be challenging due to the obturator reflex, which will be discussed later. Therefore, if the location of the tumor is unknown, general anesthesia with a LMA or endotracheal tube is preferable. This gives the surgeon the options for short or long term paralysis if necessary.
Prior to any surgical procedure, the surgeon must check to make sure the patient is appropriately positioned. There are many different methods to properly position the patient during TURBT, which varies tremendously among different hospitals and operating rooms. Yellow fins, split leg spreader table attachments and Mitchell slings are all appropriate methods to achieve proper positioning. When the patient is placed in the dorsal lithotomy position, care must be taken to ensure that all pressure points are padded adequately and no joints are flexed more than 90 degrees. Care must also be taken to avoid peroneal nerve injury, which occurs secondary to compression of the nerve on the lateral fibular head.
Once positioned, the perineal area should be adequately cleaned with betadine scrub, chlorhexidene or any other appropriate antiseptic agent. Once prepped, the patient should be covered in sterile drapes. Placing the wires and cords in the appropriate position must then be performed to the surgeon’s preferences. A video monitor should be position directly over the patient abdomen and at the appropriate height to ensure comfort during the resection and limit head or neck strain.
While a full discussion of the instrumentation required to perform a TURBT is beyond the scope of this article, the author prefers an Iglesias type continuous flow resectoscope. An Iglesias resectoscope allows the surgeon to control both the inflow and ouflow, which when adjusted to proper equilibrium will maintain constant bladder volume (keeping the tumor in a fixed position) and clear vision even in bloody fields.
Successfully resecting a bladder tumor should be performed with a simple and methodical plan. The bladder should not be overfilled and generally maintained at about half full for the duration of the resection. For smaller to moderate sized tumors, the area of attack should be directed toward the stalk of the tumor. While the fronds or papilla of the tumor often hide the base or stalk of the tumor, brisk bleeding is often encountered and continuous until the large blood vessels in the stalk are controlled. If the stalk is not easily identified, some trimming of the fronds must be completed before attacking the stalk.
Once the stalk is identified, normal bladder mucosa and stalk should be resected circumferentially around the stalk until the resection is completed. When resecting larger tumors it is best to send these resection chips separately in order for the pathologist to identify muscle fibers signifying an adequate resection. Biopsies at the base of the stalk, deep to the mucosa, are also prudent and help the pathologist identify muscle in the specimen. After complete resection of the tumor, hemostasis must be achieved. Painting the bases of the resection site and the edge of the mucosa around the tumor will ensure adequate hemostasis.
As described above, most bladder tumors are composed of a large papillary tumor attached to the bladder by a highly vascular stalk. Care must be taken to chip away at the periphery of the tumor in order to get near the stalk. The key to any TURBT is finding the stalk quickly and controlling it. Once the stalk is identified and controlled, most, if not all, bleeding will cease. Finding the stalk, however, can sometimes be difficult because of the size of the tumor. The surgeon must be patient and carefully look for evidence that the stalk is in sight.
The bladder should then be copiously irrigated and all chips evacuated with an Ellik evacuator. Inspection of the resection site should be performed to ensure no bleeding is seen. All chips must be removed for fear that they could clog the catheter. Ensure no chips are within the bladder by inspecting the base of the bladder with the irrigation turned off. This will allow any chips to sink to the bottom of the bladder and be identified. Grasp them with the loop and manually pull them out of the bladder if there are only a few pieces remaining or continue to use the Ellik until all chips are removed. A large bore (20-24 french) catheter should then be placed. Although some surgeons routinely use 3 way irrigation, this should be avoided for fear of the catheter clotting off and causing a bladder perforation. Manual irrigation should be used to maintain the free flow of fluid. A dose of Lasix can also be used to create a “physiologic” 3 way irrigation, as well as treat mild hyponatremia after the resection
Tips for Success:
Although TURBT is a relative common procedure, it can be associated with a number of complications, some of which are devastating. In order to avoid these issues there are a number of tricks and tips that can help novice or experienced resectionists complete the procedure uneventfully.
Keep a Clear Visual Field
One of the most important aspects of the resection is maintaining a clear visual field. This can become challenging with large and extremely bloody tumors. Continuous flow irrigation and an Iglesias type resection scope can allow for clear vision, even in a bloody resection. The novice surgeon must learn the proper amount of inflow and outflow to maintain clear sight without overfilling the bladder. Overfilling can lead to bladder perforations or difficulty in accessing the bladder tumor. If the resection is particularly large and the bladder is filled with multiple TUR chips, a clear visual field can also be achieved by copiously irrigating the TUR chips out of the bladder with an Ellik evacuator.
Avoid Delayed Bleeding
A simple method to avoid delayed bleeding can be performed at the end of the procedure. Once all the chips are removed, the bladder should be filled approximately halfway. With the scope at the bladder neck, the inflow should be turned off and the outflow left open. Let the bladder passively drain. Care should then be taken to look for any areas of blood raining down. This suggests active bleeding that should be treated with electrocautery prior to completing the procedure. Final, after completely emptying the bladder, fill the bladder up again half full and remove the scope. A foley should then be placed with the bladder partially full in order to ensure the catheter is in the correct place and freely draining.
Use of the Ellik
The Ellik evacuator is a handy instrument designed to collect TUR chips or stones in the bladder. It will collect the chips (trap them in a container), while allowing the surgeon to continuously irrigate the bladder. The Ellik can also cause injury to the bladder. In order to avoid injuries, the Ellik should not be placed directly on the resection site. It should also be moved to different areas of the bladder with each squeeze of the irrigation pump. This will minimize mucosal trauma or perforation. The Ellik should be filled completely with the irrigation fluid and have no air bubbles within the container. Excess air can become trapped in the bladder and lead to a perforation or explosions. The inflow should also be on for the first couple of irrigation pumps, and then turned off to reduce overfilling the bladder.
Tumors at the Dome
Tumors at the dome of the bladder can be very challenging cases. This is due to the difficulty in reaching the tumor and high risk of intraperitoneal perforation if the resection is too deep. In order to address the first issue, (accessing the tumor at the dome), carefully manipulating the inflow and outflow to the desired bladder filling will help keep the tumor in an area that is easily accessible. Applying pressure just above the pubic symphisis by the surgeon or an assistant can help push down the dome of the bladder allowing access to the tumor. Sometimes the Trendelenberg position can also help. This trick tends to be most effective when the patient has a large pannus by shifting the abdominal wall superiorly. The assistant must remain with stable pressure during the actual resection in order to avoid perforating the bladder. The risk of intraperitoneal bladder perforation is much higher at the dome, especially in older women who have much thinner bladder walls. During a resection of a tumor at the dome, the surgeon must be aware of this and avoid deep swipes. If the tumor is still inaccessible, a long resected scope is needed. In most cases, this will solve the problem.
Tumors at the Ureteric Orifice
Tumors are the ureteric orifices also pose a potential problem. The fear is that ureteric strictures can occur after resection. Although this complication is rare, most surgeons do not want to take the risk. In order to avoid the risk of stricture, many surgeons will only use pure cut at the ureteral orifice, although fulguration is often needed to control bleeding. Placing an insulated guidewire into the ureteral orifice during the resection, then placing a double j stent can also be used to avoid stricture. The stent can be left in for ~ 6 weeks and after removal a follow up ultrasound or IVP should be performed to rule out any evidence of obstruction. If the tumor completely obscures the ureteral orifice, then there is no choice but to resect the tumor. Often the lumen of the ureter will become apparent at the end of the resection, and in which case a double J stent can be placed. However, there has been little evidence that resecting the ureteral orifice will result in complete stricture of the orifice after resection. Vesicoureteral reflux is more often associated with a resection at or near the ureteral orifice; therefore, the surgeon must be aware of this potential issue and perform surveillance of the upper tract more diligently.
Every surgical procedure has risks and complications. Thankfully, the risks of a TRUBT are generally low; however, urologists performing TURBTs must be aware of the following complications and ways to treat them.
Bleeding is common during TURBT, however, once the stalk of the tumor is identified and controlled most of the bleeding generally stops. Judiciously fulguration of the resection site, edges of the mucosa at the resection site, will control most of the bleeding. If there is persistent bleeding despite a dry resection site, bleeding from the bladder neck or large friable medial lobe of the prostate may be the culprit. Judicious fulguration at these sites often only exacerbates the problem and the best course of action is to place a foley catheter and complete the procedure. Halting the procedure and returning at another day may also be another option is bleeding is too heavy and visualizations is extremely poor.
Perforation of the bladder during a resection is extremely common and usually of no major consequence. The appearance of the fat in the resection will signify a complete bladder perforation. This usually occurs at the end of resection in an attempt to obtain muscle in the specimen, with poor visualization, aggressive resection of the stalk in patient with thin bladder walls, at sites of previous resections or as a complication of stimulating the obturator nerve causing the patient leg to jump. To avoid perforations, smaller bites or the use of a cold cup biopsy forceps at the base will avoid this complication.
Small bladder perforations are usually of no major consequence. If adequate hemostasis is achieved and there appears to be no major loss of fluid through the perforation site, these can be managed by leaving in the catheter for a few extra days after the resection (3-5 days postoperatively). If the perforation appears larger, but is not associated with marked distention or evidence of violation of the peritoneum, it could also be managed with a foley catheter for a longer period of time (10 days). The patient should be covered with broad spectrum antibiotics and examined frequently by the surgeon or house staff to make sure that they are not deteriorating or requiring exploratory laparotomy in the immediate post-operative period.
Intraperitoneal bladder perforations can be devastating. Obvious signs of intraperitoneal bladder perforations are loops of bowel seen at the resection site or if the abdomen becomes markedly distended during the resection. Other signs include tachycardia, the Ellik not sucking back when irrigating the bladder, inability to distend the bladder or unusually low return of irrigation fluid. Intraoperative cystogram can also be performed to determine if the perforation is extra or intraperitoneal. If the perforation is intraperitoneal, immediate exploratory laparotomy is required to drain the excess fluid, close the bladder perforation as well as examine the bowel for any evidence of thermal injury. This can be performed through a small Pfannenstiel incision or lower midline incision. There have been some reported cases of peritoneal seeding after an intraperitoneal bladder perforation.
Tumor resections along the lateral walls are at risk of initiating the obturator reflex. This occurs when the high frequency cutting electrode stimulates the obturator nerve as is passing laterally to the bladder. This causes stimulation of the adductors of the ipsilateral leg, resulting in the characteristic jump. The major risk with initiating the obturator reflex is the potential to cause a large bladder perforation as the patient jumps. In order to avoid the stimulation of the reflex, the patient should have end plate motor paralysis on board prior to starting the resection. Spinal anesthesia does not produce an end plate motor paralysis and an additional obturator nerve block must be used to avoid the reflex. Having an assistant brace the leg during the resection may also limit the jump when the nerve is stimulated. Reducing the current on the electrocautery may also limit the amount of nerve stimulation. If the reflex occurs despite these precautions, the surgeon must quickly drop the scope or pull the scope into the prostatic urethra immediately in order to avoid puncturing the bladder. The lower frequency coagulation mode of the electrocautery often does not stimulate the nerve; therefore, short acting end plate paralysis with a LMA or endotracheal tube may be necessary for resecting moderate sized tumors.
Erection can occur during TUR and can become dangerous. They are often secondary to a patient who is too lightly anesthetized. The signs of a developing erection noted by a sudden loss of maneuverability of the scope in the urethra, or the views become suddenly obscured by new bleeding. If the penis feels engorged, stop the procedure immediately. Usually an injection of 200 mcg of phenylephrine directly into the corpus cavernosus as well as heavy sedation will result in a resolution of the problem. Proceeding with the resection while the patient has an erection may limit the ability of the surgeon to adequately resect the tumor, and if severe can lead to damage to the external urethra sphincter if the scope is unable to traverse the prostatic urethra.
The mixing of hydrogen caused by diathermy of tissues and oxygen (both from the resection and outside air) can form an explosive bubble at the dome of the bladder. Most urologists have noted small pops when resecting tumors at the dome, however, large bubbles of mixed hydrogen and oxygen could results in a devastating explosion. During resections at the dome, the tumor should be completely submerged in order to avoid this serious complication.
TUR syndrome is rare during a TURBT, but it can occur. It is the result of dilutional hyponatremia due to massive absorption of water. More common during transurethral resection of the prostate, TUR syndrome is associated with varying degrees of confusion, hypertension, bradycardia, nausea, vomiting and visual disturbances. The surgeon must be aware of these symptoms and have a high degree of suspicion if these symptoms are noted during the procedure or immediately afterwards. If TUR syndrome is suspected, the patient should be given a dose of Lasix immediately and the procedure should be halted.
The immediate post-operative complications that can be encountered after a TURBT include delayed hemorrhage, infection and abdominal pain/distention. Delayed hemorrhage can usually be managed with copious irrigation of the catheter; however, if the bleeding persists, the patient must be brought back to the operating room for identification of the source of bleeding. Standard broad spectrum antibiotics should be administered to cover for infectious complications after the resection, especially if there was a suspected bladder perforation. Finally, patients will often complain of abdominal pain or distention. In this particular situation, the surgeon must decide if the abdominal pain is secondary to bladder spasm or something more sinister. If there was a noted perforation during the procedure, the abdomen should be carefully inspected to ensure that an intraperitoneal bladder perforation did not occur. If the pain persists and is not relieved with antispasmodics, exploratory laparotomy should be considered to rule out the possibility of an intraperitoneal bladder perforation.
TURBT is a very common and relative safe procedure. Good clinical judgments and adherence to sound surgical principles will ensure adequate resections with low rates of complications.
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Phillip Mucksavage, MD
Minimally Invasive Urologic Surgery Fellow, University of California, Irvine