BackTable / Urology / Article
Bladder Cancer Resection with TURBT
Devante Delbrune • Nov 22, 2022 • 32 hits
Bladder cancer resection is a commonly performed procedure. The complexity of the resection varies based on the risk or grade of the bladder cancer. While the operative management varies by urologist, the framework and approach provided by Dr. Sam Chang provides a general plan that urologists can utilize.
The approach to bladder cancer resection is broken down into three distinct categories: pre-operative, intraoperative, and post-operative. The pre-operative phase focuses primarily on obtaining information about patient history and symptoms. The intraoperative phase involves specific procedural approaches and techniques, namely the transurethral resection of bladder tumor (TURBT) surgery. Post-operative management consists of documentation, clot retention prevention, stent placement, and revisional resections. Dr. Sam Chang and Dr. Aditya Bragrodia discuss these phases in detail on the BackTable Urology Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Urology Brief
• Prior to undergoing a TURBT, the patient should be evaluated for their smoking history, current voiding symptoms, prior imaging, and procedures. This benefits the patient and provider by providing a clear risk profile for the patient as well as preventing unnecessary imaging or unwarranted cystoscopy.
• A TURBT is typically accompanied with blue light during the surgical resection except for cases where deemed ineffective, such as extremely invasive disease. Regardless of the use of a blue light, maintenance of adequate bladder distension to minimize bladder injury should be a priority.
• Post-operative documentation is crucial for providing both a clear picture of the patient's disease pathology and guidance on surgical management for future providers.
• Other post-operative considerations are catheter placement determined by patient factors (e.g. hematuria, ease of medical access) and stent placement based on patient presentation of nephrohydrosis.
Table of Contents
(1) Pre-Operative Assessment of Bladder Cancer Patients
(2) TURBT Intraoperative Approach
(3) Post-Operative Management of Bladder Cancer
Pre-Operative Assessment of Bladder Cancer Patients
During pre-operative evaluation, the focus should be on the patient history, symptoms, and prior procedures and evaluations. In patients with a new bladder cancer diagnosis, current smoking status and substance history must be obtained. Next, the physician should cover the patient’s current symptoms. These symptoms are often related to voiding and may include hematuria or frequent urination. The next step varies from patient to patient, but typically involves a review of prior procedures or imaging. This is particularly important as it can save patient time and discomfort by eliminating unnecessary or duplicate procedures such as cystoscopy. It can also be beneficial in determining what future treatments would be most effective for patients with recurrent disease. In Dr. Chang’s practice, if the patient has received prior imaging and the lesions or tumor are obvious, he will abstain from performing a cystoscopy. He primarily reserves cystoscopy for patients who are referrals or have apparent worsening lesions on imaging.
[Sam Chang MD]
Yeah. I mean, to be honest, my history focuses on not necessarily a lot of symptoms, but a little bit in terms of voiding symptoms, that type of thing. But I have gotten better, although I'm still not perfect, getting into their smoking history. Are they active smokers? If they are, are they trying to quit? If they're not trying to quit? So really trying to focus on, hopefully trying to get them off of the cigarette bandwagon here. Second thing then after that is, if we talk a little bit about the symptoms. Then we dive into what kind of evaluation they have had? What's been done? How has it been done? When’s it been done? And, just today, we were at the end of the day on Thursday and we saw a number of patients. Some have treatments spot on that you totally agree with and some have treatments that you are totally unfamiliar with. And so you really want to get an idea and it's something that I really tease out with the residents.
I want to know when the procedure was, when they got their treatment, what kind of treatment they got, et cetera. And so that to me is the key in terms of history, for anybody who has recurrent disease. The first timers, the ones that we diagnose that focus on their smoking history. And then I say, we've got to go to the operating room. So it kind of differentiates until, those that are initial cancer diagnosis, versus those that have recurrence.
[Sam Chang MD]
Why do a procedure over again, other than you just want to charge that patient for a procedure and have them go through the discomfort of an in office cystoscopy. That's for lesions that are obvious. I mean, you've gotten scans, you've gotten some ultrasounds where there's a papillary lesion or multiple papillary lesions or multiple solid worsened lesions or there's calcifications and something. You know, you're going to take that individual to the operating room. So in all honesty, I don’t do an office cystoscopy. If there's any doubt. You'll get referrals for bladder lesions, bladder, mass, that type of thing. Yeah I’ll definitely cysto those people and do office cystoscopy in order to try to avoid that in anesthetic procedures down the line. But, there are times where you don't know and yeah, you need an office cystoscopy but I think if it's pretty clear on imaging, then I really don't like doing an office cystoscopy.
Listen to the Full Podcast
Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs.
Follow the button below to get started with CMEfy.
Stay Up To Date
TURBT Intraoperative Approach
After conducting a patient evaluation, the next step involves determining a plan of care. When surgical treatment or chemotherapy is indicated, a urologist will often begin by performing a TURBT. The procedure is often performed with the assistance of blue light, however, the use of blue light is contraindicated if a patient has an extremely invasive disease minimizing that minimizes the tool’s benefit.
Dr. Chang recommends starting at an area of normal tissue and resecting through to abnormal tissue, taking into account resection tissue size. Obtaining a properly sized resection tissue allows a pathologist to accurately perform their diagnostic analysis. In practice, Dr. Chang utilizes a cold cup biopsy approach to best maintain biopsy layer organization.
During the procedure, adequate bladder distension can be maintained by utilizing continuous bladder irrigation. An underdistended bladder can lead to increased tissue damage during resection loops and unanticipated “bite” sizes of resection tissue. To best counter this issue, urologists can utilize the staccato method. This method also allows the surgeon to avoid an obturator jerk reflex and have more control of their electrical cautery.
[Sam Chang MD]
Yeah, so would say probably blue light. I would say, 80% are done with blue light, just all comers, initial diagnoses, followup diagnosis, that type of thing. There are certain scenarios where we always use blue light. For instance, recurrent disease, multifocal disease. Those with positive cytology. We haven't been able to find something. Those always get blue light. We know patients with invasive disease that we're doing bladder sparing that we're doing basically a maximal TUR prior to initiation of, chemotherapy and radiation therapy, trauma modality. I don't do blue light. I'm resecting invasive disease. I don't see a huge benefit of finding a small papillary area somewhere else. But, some of the tricks, again, it's like anything that we do in medicine. This is one where you really need to see a couple. And then you need to kind of see what happens? Well, then the transition is to someone with a papillary tumor. That's not too deep, it's not too large. The residents start resecting kind of basically superficial. So they get an idea and then I gradually then employ them into okay. We start, and I always like to start a resection in normal appearing bladder. And it's a combination of both speed and sense of judiciousness so you can go both ways.
You can be so careful you get so much cautery artifact. You really don't have a good specimen and it gets massery or whatever. Or you go too quickly and you get a hole that's much larger than you'd like. So I really focus on a combination of speed and judiciousness. I want to start in normal tissue. I want to resect and I want to resect in a way that I'm removing as much tissue as possible with each resection bite. So early on, everyone tends to get small bites and feel comfortable. And that's a good start, but I really want to emphasize to them. Look, we need to get tissue specimens that are helpful for a pathologist. Let's actually get a real specimen bite and go through there. I'm very much into separating specimens when I can. Sometimes you can't do that, but I really like to resect normal deep, send that off. If it's a large tumor, then resect as much as I can of the superficial stuff, send that off. But then I send separate specimens, hopefully of good quality, less cautery artifact of the kind of mucosa, T1, hopefully T2 kind of combination, just to help our pathologists out as much as possible. So I think those are just some initial tricks.
[Sam Chang MD]
Yeah, I think I use cold cups as much as anyone. Cause I tend to, when I'm concerned about a tumor, I tend to use both a loop and a cold cup. So what I like to do is actually resect the tumor and then an area where I think there might still be some tumor might resect maybe before the last resection. I like a combination of mucosa, hopefully laminate propria muscle, right at the edge of your previous resection site. It takes several of those biopsies to give pathology a noncauterized specimen. And hopefully one that has orientation of mucosa, lamina propria and muscle.
[Aditya Bagrodia MD]
I think that sounds great. I totally agree with you. The art of it, and I think the perfect amount of distension to keep your loop cutting through it. Like, a knife through butter. If it's under extended, you're gonna cauterize the crap out of your specimen. If it's over distended, particularly in a thin-walled bladder, et cetera. That you know, comes around with its risks. But I think that perfect amount of distension. And then, I've actually kind of gone back to a staccato type of resection, to minimize some of that cardio artifact. And I always tell the residents, if anything feels off, just take your foot off the gas first things first, you've just gotta let go. And you know, you're not going to have a big hole or a perforation or something terrible like that.
[Sam Chang MD]
I think your point of the perfect amount of distension is one of the most difficult things as residents go through this procedure to, understand and to pay attention to. But it's that, they either will get a false sense of security because we'll have a continuous flow in terms of just an open bottom stopcock and they think, oh, everything's fine. And then what, what ends up happening is they're overdistended and they don't appreciate that. Or because they have continuous flow the bladder hasn't filled up enough and they think everything is okay. And just, as you say, you have a combination of char or when your bladder is under distended and you take a big bite. Your bite is much bigger than, you've anticipated, the bladder folds on itself. And then when you distend the bladder, there's some fibers or fat layers. And so that combination of constant recognition. And so I think appreciation is really important.
This staccato method, we just, I actually just talked to a chief about that yesterday. Honestly we were resecting laterally and just went over. What are ways we can avoid an obturator reflex and you know, there were some struggles. And it's one of those things where we're probably not as good as programs should be in terms of really working on resection. And so we talked about staccato and just, as you said, look, by doing that staccato, if there's a kick, if there's an issue you're not constantly jammed on that electric cautery burning a hole where you don't want it to burn. So I love both those points.
Post-Operative Management of Bladder Cancer
Post-operative management of bladder cancer resection consists of surgical documentation, potential stent and catheter placement, and evaluation for chemotherapy. Following a TURBT or any surgical procedure, it is crucial to have clear and thorough documentation for the best continuity of care. Important information to include is the location of the tumor, initial descriptive morphology, post-resection morphology, and disease status (e.g. areas of residual disease).
In addition to documentation, it is important to ensure the patient has patent ureteral orifices. This is done through the use of ureteral stents. Evaluation for urethral stent placement can be done by either visualizing the urethral orifice via imaging (e.g. CT-Scan or ultrasound) or close follow-up within one week for signs of hydronephrosis (e.g. flank pain). It is also imperative to prevent clot retention through urinary catheterization. The average catheter duration is 3-4 days as determined by evidence-based guidelines and patient-specific factors such as ease of access to medical facilities, catheter education, and convenience. Additionally, in practice, Dr. Chang will administer gemcitabine therapy monthly for 6-12 months for patients who are older, have recurrent low-grade tumors, or have increased morbidity. Regardless of immediate post-operative management, all patients should receive a 6-month follow-up appointment unless pathology indicates earlier intervention.
[Sam Chang MD]
Did you say to make sure that's included in the operative note? So I don't harp on that as specifically as I should. What I do harp on is when you dictate your operative note for a bladder tumor, I want, whatever way you describe it, it can be systematic, but in a way that it's, as if you were looking in the bladder and you know, what's going on.
Okay. I need to know what's going on at the dome. Is it near the urethral orifice? What does it look like? You don't have to use the exact terms. Just give me terms that tell me, you know, and so I tell them I'll use terms like carpeted and covered. You know, just so you would have an idea of exactly the points that you raised regarding location size, the nature of the tumor, all those things are essential. And then at the end of the procedure, what do things look like? You know, completely resected or, you know, concerned about residual disease. All those things I think are important because you're going to be the next individual back in that bladder or evaluating the bladder you want to know. And undoubtedly, one of the things that I've done more now than I've done in the past is I've done stage resections. When I know that I'm going to come back, I want to clear out as much of the bladder in an area safely as possible. Because then I will have an idea of the stage of the tumor. So if at that point I understand I've gotten an invasive disease, I want to move forward. If not, then do tend to come back within a couple weeks or so and do a repeat resection.
[Sam Chang MD]
How bloody are they? What does it look like? You know, all those things. And you know, I'll be honest early on. I tried to not leave a catheter in anybody. I really tried to limit that. Now I'd probably leave catheters in more than I have ever, because like anything in medicine you want to be evidence-based. But if you just had a couple recently, they've come back with a clot retention or went into retention for whatever reason. And they're in an outside ER or our ER. I tend to almost leave a catheter in everyone for the recovery room. And just to add a lot of them are getting perioperative chemotherapy different that they have a catheter. For women it has to be pretty deep and pretty extensive for me to send them home with a catheter or pretty bloody. For older men my kind of threshold for keeping a catheter in is pretty low. Now I think the more difficult question is how long? I don't want to leave it in three weeks, two weeks. I usually leave it in. I usually resect Mondays and Tuesdays, those are my main OR days. So usually I get the catheter out early in the morning Thursday, or early in the morning Friday. So they don't have to worry about a catheter over the weekend. And if they get into trouble, we can deal with it before the weekend.
[Aditya Bagrodia MD]
Yeah. So, I mean, to me, that's an inconvenient, not dangerous situation. And I certainly take into account the patient's comorbidities. If they're older, second, I'm trying to keep them out of the OR, I'm trying to really do that. So if it's a solitary, less than three centimeter tumor, and it looks like. I'll give them a dose. I mean, just like yourself, most of these patients are coming in and referred and they've already had a resection. So recurrent low grade tumors, status, post, and induction course of BCG.
I always think it's good to reimage the upper tracks. Make sure they're not having drop mets from the upper tracks. I think that's something I've seen at least a handful of time. One of the things with flexible blue light that I liked is, we would actually just instill lidocaine. It came at the same time as the Cysview. And my like rate of office biopsy, full operations went up you know, so I'm saving trips to the OR, I'm able, I feel a little bit, it's like a bit of a, less of a, to do to. Just be like, all right, you know what a we've already got a catheter going in let's biopsy, full grade it. And then the final bit is I'll actually scope them a little bit more frequently early on. So if I'm picking up these low grade tumors and I've established that they're low grade, I can kind of handle them without an anesthetic and everything that kind of comes along with that.
But yeah, I mean, with you, then it's going to be, you know, a bit of a judgment on the natural history. If there were current low grade by definition, they're intermediate risk. And to me, intermediate risk is super heterogeneous. You know, low grade recurrent or multifocal low grade, like I'm not worried about that.You know, it's like mowing the lawn or spring cleaning. It's a high grade that kind of changes the game. So to kind of summarize. Image the upper tracks, solitary low grade tumors, older patients are really want to keep them out of the OR. That's kind of, I think, an ideal candidate for a single post-up installation. If they keep on rapidly recurring, then I try to do everything I can to save them trips to the OR. And, you know, I'm really reluctant to use BCG for low grade disease, unless I've kind of burned through everything
[Sam Chang MD]
Do it once monthly for 6 to 12 months. And what I've found in certain patients just and who do I put those on. On people who have shown me a real tendency to recur quickly with high volume, even if it's low grade, just nuisance wise to control. And so I will put them on monthly and I'll be scoping them in between. And if they respond well and are doing well, then I'll put them on once a quarter for a year. And then if they're still doing it and people tolerate gemcitabine, I think really well. I do the same with patients that I've given gemcitabine, for BCG unresponsive disease. Now I do a little bit more gemcitabine and docetaxel. But there are definitely patients that I've salvaged that I've given gemcitabine induction done well, and I put them on maintenance gemcitabine. And they don't want to stop because they'd been through the whole BCG and they're worried about their bladders removed and I've definitely had some long-term players on maintenance therapy. So I think that's really important.
Dr. Sam Chang
Dr. Sam Chang is the chief of urologic oncology at Vanderbilt University in Nashville, Tennessee.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Cite This Podcast
BackTable, LLC (Producer). (2022, July 20). Ep. 46 – Techniques & Maneuvers for Optimal TURBT [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.