TURBT is both the diagnostic and the first-line therapeutic procedure for bladder cancer. The technical quality of TURBT is the single most important determinant of accurate staging and of recurrence risk in non-muscle invasive disease. A poorly executed first TURBT cannot be rescued by adjuvant therapy.
Indications
- Newly diagnosed or suspected bladder tumour on cystoscopy or imaging.
- Recurrent papillary tumour during surveillance cystoscopy.
- Suspected carcinoma in situ — for biopsy of red patches and selected site biopsies.
- Re-TURBT (4–6 weeks after initial resection) for high-grade T1 disease, incomplete initial resection, or absent detrusor muscle in the initial specimen.
- Diagnostic resection of a presumed urothelial mass to confirm histology and depth.
Contraindications
Absolute
- Untreated, symptomatic urinary tract infection or sepsis.
- Uncorrected coagulopathy.
Relative
- Bladder volume too small to permit safe distension (severe contracted bladder).
- Severe urethral stricture preventing safe instrument passage.
- Pregnancy — defer until postpartum unless oncologically critical.
- Significant cardiopulmonary comorbidity precluding general or regional anaesthesia.
Preoperative Workup
- Cystoscopy and imaging — office flexible cystoscopy to confirm tumour location and number; CT urogram to evaluate the upper tracts.
- Urinalysis and culture — treat any positive culture before elective resection.
- Bloods — CBC, renal function, coagulation, group and screen.
- Anaesthetic assessment — particularly for elderly patients with multiple comorbidities.
- Consent — discuss bleeding, perforation (intra- and extraperitoneal), urethral injury, infection, conversion to open repair, single-dose intravesical chemotherapy, the possibility of re-TURBT, and the need for a urethral catheter post-operatively.
- Antibiotic prophylaxis — single perioperative dose per institutional guidelines; extended courses for indwelling catheters or known infected stones do not apply here.
Positioning
- Lithotomy position with the legs supported in stirrups, buttocks at the edge of the operating table.
- Pad pressure points carefully — peroneal nerve injury and compartment syndrome of the calf are rare but serious risks of prolonged lithotomy.
- Tilt the table slightly head-down (Trendelenburg) for better visualisation of the bladder dome.
- Standard urological surgical preparation and drape exposing the perineum.
Surgical Steps
- Diagnostic cystoscopy. Inspect the entire bladder systematically: trigone and bladder neck, posterior wall, lateral walls, anterior wall, and dome. Identify both ureteric orifices. Map the tumour: number, size, location, configuration (papillary vs sessile), and proximity to the orifices.
- Bimanual examination under anaesthesia before and after resection. Pre-resection assesses for a palpable mass (suggests T3). Post-resection assesses whether a residual mass is palpable, which adds to clinical staging.
- Insert the resectoscope. Bipolar resection is now standard — it allows use of normal saline irrigation, eliminating the risk of TUR syndrome and giving better intraoperative haemostasis.
- Resect the tumour systematically. Start at the periphery and work toward the centre, taking the tumour in fragments. For larger tumours, resect the exophytic portion first, then the base separately to enable accurate depth assessment by the pathologist.
- Take a separate deep-base biopsy that includes detrusor muscle. The detrusor in the specimen is the single most important quality indicator — without it, T-staging is unreliable and re-TURBT is needed.
- En bloc resection (with a Collings knife, monopolar loop, or holmium laser) is increasingly used for smaller tumours where it provides better pathological orientation and avoids the thermal damage of fragment resection.
- Achieve haemostasis with coagulation as you go. Use roller-ball or bipolar coagulation. Avoid coagulating directly over a ureteric orifice — if it is involved, resect through it rather than fulgurating across it, and accept the possibility of vesicoureteric reflux.
- Random / mapping biopsies if there is a suspicion of CIS, positive cytology with normal-looking mucosa, or persistent irritative symptoms — sample the trigone, dome, and bladder walls.
- Inspect for perforation before withdrawing the resectoscope. Look for fat in the field (extraperitoneal perforation), free fluid in the upper bladder (intraperitoneal perforation), or sudden loss of distension.
- Place a urethral catheter — typically a 22 Fr three-way for irrigation. Continuous bladder irrigation is used until the effluent is clear.
- Single immediate intravesical chemotherapy (mitomycin C or gemcitabine) within 24 hours for low-risk NMIBC unless contraindicated (bladder perforation, gross haematuria requiring continuous irrigation, extensive resection, deep muscle resection).
- Document number, size, location, configuration of each lesion; whether muscle was visualised in the specimen; any complications; and whether single-dose chemo was administered.
Key Anatomical Landmarks
- Ureteric orifices — at the lateral corners of the trigone. Identify both early and protect them throughout the resection. Resecting through an orifice is acceptable when the tumour involves it; fulgurating across an orifice causes obstruction.
- Trigone — the smooth triangular area between the ureteric orifices and the bladder neck. Anatomically and embryologically distinct from the rest of the bladder.
- Bladder neck — the muscular ring at the bladder outlet. Resection deep into the bladder neck risks injury to the external sphincter beyond.
- Bladder dome — the most mobile portion of the bladder, lying anteriorly and superiorly. Highest perforation risk because it is the thinnest, and the obturator nerve runs near the lateral wall — direct stimulation can cause sudden adductor contraction.
- Obturator nerve — runs along the lateral pelvic wall close to the bladder. Stimulation by monopolar current causes a brisk adductor jerk that can perforate the bladder. Mitigation: bipolar resection, lower power, or formal obturator nerve block.
- Perivesical fat — visible in the field means perforation. Extraperitoneal perforation usually settles with prolonged catheter drainage; intraperitoneal perforation often requires laparoscopic or open repair.
Complications
Intraoperative
- Bladder perforation (extraperitoneal more common than intraperitoneal).
- Obturator jerk with associated injury to the lateral wall or pelvic vessels.
- Ureteric orifice injury or obstruction.
- Bleeding — usually controllable endoscopically.
Early postoperative
- Haematuria requiring continuous irrigation.
- Clot retention.
- Urinary tract infection, including post-procedural sepsis.
- TUR syndrome (hyponatraemic encephalopathy from hypotonic irrigant absorption) — historical with monopolar resection; not seen with bipolar in saline.
Late
- Urethral stricture, particularly in men.
- Bladder neck contracture.
- Vesicoureteric reflux after resection through an orifice.
- Persistent or recurrent disease — the main "complication" the patient and surgeon care about.
Postoperative Care
- Continuous bladder irrigation until the effluent is clear, typically a few hours but longer with extensive resections.
- Catheter removal once the urine is clear — often the next morning for routine cases, longer for high-volume resection or for perforation.
- Pain control with simple analgesics; bladder spasm can be managed with antimuscarinics if catheter discomfort is prominent.
- Discharge advice: drink fluids, expect intermittent haematuria for up to 2 weeks, return for fever, severe pain, frank clot retention, or inability to void.
- Histology review at a urology MDT; the pathology drives the next decision (single immediate chemo if not given, induction intravesical therapy, re-TURBT, or radical cystectomy referral).
Tips & Pitfalls
- Detrusor in the specimen is non-negotiable for staging purposes in any tumour that looks more than a small papillary low-grade lesion. If you did not visualise detrusor, plan a re-TURBT.
- Resect to depth, not just visually clear. A flat-looking base may still contain invasive disease.
- Obturator jerk discipline. For lateral wall tumours near the inferolateral surface, anticipate the jerk — use bipolar, drop the power, deflate the bladder partially, or place an obturator block. Be ready to stop resecting at the first twitch.
- Map and bimanual. A formal bladder map (drawing or schematic) and bimanual examination should be part of every TURBT report.
- En bloc for select cases. Tumours under 3 cm in a favourable location are good candidates and give pathologists better orientation.
- Always identify both ureteric orifices before starting to resect. Use indigo carmine or saline diuresis to confirm if visualisation is difficult.
- Treat positive cultures before TURBT. Sepsis after TURBT is a real and avoidable complication.
- Single immediate intravesical chemo is high yield for board exams and for clinical practice — know when to administer and when to defer.
Key Exam Points
- Detrusor in the specimen is non-negotiable for accurate staging — if not visualised, plan a re-TURBT.
- Resect to depth, not just visually clear: a flat-looking base may still contain invasive disease.
- Always identify both ureteric orifices before starting to resect; use indigo carmine or saline diuresis if visualisation is difficult.
- For lateral wall tumours, anticipate the obturator jerk — use bipolar, drop power, deflate partially, or use obturator block.
- Bladder map (drawing/schematic) and bimanual examination should be part of every TURBT report.
- En bloc resection is a good option for tumours <3 cm in favourable locations — gives pathologists better orientation.
- Treat positive cultures before TURBT to avoid post-procedure sepsis.
- Single immediate intravesical chemotherapy is high-yield — know when to administer and when to defer.
- Catheter removal once urine is clear, typically the next morning for routine cases.
- Histology drives next steps: single immediate chemo if not given, intravesical therapy, re-TURBT, or cystectomy referral.
- Expect intermittent haematuria for up to 2 weeks; return for fever, severe pain, clot retention, or inability to void.