Dr. med. Dirk Manski

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Transurethral Resection of the Bladder (TURB): Technique and Complications

Indications for transurethral resection of the bladder (TURB)

fig1: TURB transurethral resection of bladder tumor
TURB: resection loop at the base of papillary bladder tumor histology: Ta low-grade bladder cancer.
fig2: TURB resection loop
TURB of a solid bladder tumor: histology: T1 high-grade bladder cancer.

Surgical Technique of Transurethral Bladder Resection

Preoperative patient preparation:

Urinary tract infection excluded or treated, Perioperative antibiotic prophylaxis, lithotomy position.

Anesthesia:

Spinal anesthesia or general anesthesia is needed for TURB. Spinal anesthesia offers theoretical advantages for the initial postoperative period: the patient is calm without pressing or coughing, and the manipulation of the catheter is possible without pain. General anesthesia with muscle relaxation eliminates the risk of an obturator reflex (see complications) and is preferable for lateral tumors.

Cystoscopy:

Check for the width of the urethra, and search for urethral tumors. The mucosa of the bladder (and prostate) is examined to identify all flat and papillary tumors. Document the size, number, localization, and appearance of all visible lesions before TURB.

Fluorescence cystoscopy:

Fluorescence cystoscopy with blue light after prior instillation of hexaminolevulinate (Hexvix) results in better detection of urinary bladder carcinoma with a 20% higher tumor detection rate and 40% improved detection of CIS (Jocham et al., 2005).


Fluorescence cystoscopy of bladder carcinoma with hexaminolevulinate (Hexvix): standard cystoscopy is shown on the left, the same location with fluorescence cystoscopy on the right side. All lesions were Ta low-grade.
figure Fluorescence cystoscopy of bladder carcinoma

Indications:

High-grade cells in urine cytology, all patients with a history of multifocal or high-grade carcinoma.

Technique:

Instillate hexaminolevulinate (Hexvix) into the bladder one hour before TURB. Perform cystoscopy with white and blue light, resect (TURB) all abnormal lesions under both examination conditions.

Contraindications:

Intravesical therapy or TURB in the last 6–10 weeks, urinary tract infection, women of childbearing age.

Standard TURB

figure Standard bladder tumor resection 1: The bladder tumor is resected with the resection loop from top to bottom
Standard bladder tumor resection: The bladder tumor is resected with the resection loop from top to bottom.


figure Standard bladder tumor resection 2: The tumor base is resected reaching into the tunica muscularis
Standard bladder tumor resection: The tumor base is resected reaching into the tunica muscularis.

En-block resection:

En-block resection is a good option for smaller tumors under 3 cm in size. Advantages are better detection of infiltration depth by the pathologist and less tumor cell seeding in the urinary bladder. The retrieval of larger tumors through the urethra is problematic. The first step is circular coagulation of the tumor base, followed by a circular incision into the tunica muscularis with the resection loop. With careful application of electrocautery, the tumor base is dissected out of the muscularis while pushing or pulling with the resection loop. Laser techniques and using a waterjet scalpel for dissection in the bladder wall are also reported (Kramer et al., 2012).

figure En-bloc bladder tumor resection: Circular incision into the tunica muscularis.
En-bloc bladder tumor resection: Circular incision into the tunica muscularis.


figure En-bloc bladder tumor resection: The tumor base is dissected out of the muscularis.
En-bloc bladder tumor resection: The tumor base is dissected out of the muscularis.

Postoperative Care after TURB

Early instillation of Mitomycin C:

General measures:

Early mobilization, thrombosis prophylaxis only for patients with risk factors, pain medication, and antimuscarinic agents against catheter-related discomfort.

Irrigation catheter:

Irrigation prevents clot formation and may reduce the risk of tumor recurrence. Remove the catheter after 1–3 days, depending on the resection depth and postoperative bleeding.

Complications of transurethral resection of the bladder (TURB)






Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z



References

Collado, A.; Chechile, G. E.; Salvador, J. & Vicente, J. Early complications of endoscopic treatment for superficial bladder tumors
J Urol, 2000, 164, 1529-32



  Deutsche Version: Transurethrale Resektion der Harnblase (TURB)