Transurethral Resection of Bladder Tumor (TURBT)

Definition

Transurethral = Through the urethra (tube through which urine exits the bladder)

Resection = cutting away or removal (some people refer to it as a “scraping”)

In short, a special scope termed a “cystoscope” is placed in the urethra and guided up into the bladder. The bladder tumor is cut away completely, or in other circumstances, just biopsied for analysis by the pathologists.

Most TURBTs are performed for transitional cell carcinoma (TCC), the most common type of bladder cancer. There are, however, other far less common types of tumors. In most instances, a TURBT is performed with the intent of removing the entire mass. In cases where the tumor is very extensive, we might only try to sample as much tissue as we need to properly determine the type and extent of the cancer to decide on the next plan of action.

Preparation

As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and /or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc.”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past ten days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

*It is to your advantage not to strain to have a bowel movement in the week after the procedure as it may cause bleeding in the urine. Try to avoid constipating foods in the week before your procedure. You should be eating lots of fruits and vegetables as well as oatmeal and cereals. If you have a known problem of constipation, you might administer an enema one hour before bed the night before your procedure.

Procedure

To review the basics of what we discussed in the office: The actual procedure can take anywhere from 15 to 90 minutes (sometimes longer) depending on the location and size of the tumor.

You will be placed in lithotomy position (lying down on your back with your legs gently elevated in holsters call stirrups). The scope (which has continuous fluid running through it) is carefully inserted into the urethra and advanced into the bladder. We carefully examine the bladder to determine the extent of the tumor. Next, a special electric knife (termed a loop) is used to cut the tumor while simultaneously cauterizing (burning) the blood vessels. In some occasions, we use laser to assist in the procedure. Once the tumor is resected, we may take sample biopsies from uninvolved areas of the bladder or even from the inside of the urethra(prostate channel in men). After the resection is over, all of the tumor pieces (chips) are irrigated out of the bladder. In some cases (large tumors or apparently deep tumors), a catheter might be placed in the bladder to allow proper healing of the bladder wall.

Post Procedure

Depending on the size of the tumor, and the extent of the resection, you might either be discharged home or admitted to the hospital. Depending on the circumstances, we may discharge you home with a catheter for a few days. It is normal for you to feel a strong sense of urgency to urinate. This is from the trauma to the bladder wall and possibly the presence of the catheter. In most patients, this goes away within a couple of hours. Some patients require medications to help relax the bladder while it is healing or while the catheter is in place. Patients may have no blood in the urine, mild blood, or even what appears to be a significant amount of blood or small clots. The blood usually disappears within a day or two. In most patients that are admitted, the catheter is removed the following morning and you are discharged home after you urinate on your own.

Expectations of Outcome

As previously mentioned, there are different reasons that a TURBT is performed. The most common scenario is that we intend to fully remove (scrape out) the tumor while simultaneously staging the tumor (determining how advanced or invasive the cancer is). In instances where the tumor is unable to be completely removed due to its size or location, we will sample as much as we need to properly stage the cancer, with the understanding that we may be recommending another form of treatment. There are instances in which we initially planned to resect the entire tumor, but realize during the procedure that this cannot be safely accomplished.

Possible Complications of the Procedure

All surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. It is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

• Hematuria/Clot Retention/Transfusion: As we cut away the tumor, small blood vessels (arteries and veins) are cut and bleed. Throughout the entire procedure, we cauterize (burn) the vessels shut. At the end of the procedure, we carefully inspect the area to ensure that there is no significant bleeding. There are always some minor, insignificant vessels that slowly ooze. Rarely, a scab of a vessel we cauterized can falloff and cause significant hematuria (blood in the urine). In most cases, we only need to watch the patient, and the bleeding eventually stops. If clots form it can block the urethra or the catheter and we may need to irrigate the clots out. Rarely, we would have to return to the operating room to put the scope back inside the bladder and re-cauterize the blood vessels. If bleeding is prolonged during or after the operation, we may need to check your blood count. It is rare to need a blood transfusion following a TURBT. Urinary Tract Infection or Urosepsis: Although we may give you antibiotics, it is still possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you may feel very ill. This type of infection often presents with the urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may need a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system. If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
• Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): This is uncommon in a short procedure such as TURBT. However, in any operation (especially longer operations or those in which your legs are in stirrups), you can develop a clot in a vein of your leg (DVT). Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
• Urethral Stricture/Bladder Neck Contracture: A stricture is scar tissue that can form anywhere in the urethra following prolonged instrumentation. It typically occurs weeks to months (or even longer) after the procedure. Scar tissue can also form at the exit(neck) of the bladder, and this is termed a contracture. For either condition, it may be necessary to schedule another procedure to open the scar. These procedures can be done with a small blade, electric knife, or with a laser and they are quick and almost always an outpatient procedure. A scar at the tip of the urethra can sometimes be dilated (spread open) in the office. Sometimes, a stricture or contracture can recur in the future.
• Urinary Retention: In a male, pressure from the scope can occasionally cause inflammation in large and/or obstructing prostates. It may block the flow of urine and cause retention (inability to urinate or empty the bladder). In many circumstances, it resolves with a catheter over the next few days. Less commonly are medications or a prostate procedure required.
• Perforation: If the cutting is deep, the wall of the bladder can be perforated. This is far more common in large tumors or those that are at an advanced stage (deeply invading the wall of the bladder). In most cases, we need to leave the catheter in for an extra few days to allow self-healing. If this happens early in the middle of the TURBT, we may stop the procedure, allow it to heal, and finish the procedure another day. Sometimes we may need to perform a bladder repair through an incision in the abdomen.
• Ureteral Injury: On either side of the bladder is a small ureteral orifice. This is the hole through which the ureter (tube from the kidney) enters the bladder. If there is tumor at or near the orifice, it may be necessary to resect there. Within days to weeks, a scar could form over the orifice and block the kidney on that side. Sometimes we can unblock the tube by inserting a stent (small plastic tube) into the ureter through the scope. We may do this during the TURBT procedure if we realize that the orifice has been injured, or in a separate procedure if the problem arises later. In other instances, we may ask the interventional radiologist (radiology doctors that perform minimally invasive procedures) to place a temporary drainage tube into your kidney through a small needle stick in the back. If neither are successful, open abdominal surgery could be necessary to correct the blockage.
• TUR Syndrome: This only occurs in very prolonged resections, and is rarely seen in this procedure. Because many blood vessels may be opened while cutting away the tumor, some of the irrigation fluid may enter the bloodstream and dilute the blood components. With the newer irrigant fluids that we use, TUR syndrome is very unlikely. Severe cases may cause heart or brain complications.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.