TURBT (Transurethral Resection of Bladder Tumour)

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

1. Diagnostic cystoscopy. Perform this at the start of every TURBT — even after a prior office cystoscopy — inspecting the entire bladder and urethra systematically: trigone and bladder neck, posterior wall, lateral walls, anterior wall, and dome. Use a 70° lens for areas that are hard to see (e.g. the anterior wall). Identify both ureteric orifices. Map the tumour: number, size, location, configuration (papillary vs sessile), and proximity to the orifices.
2. 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.
3. Insert the resectoscope. Leave the bladder full when exchanging the cystoscope for the resectoscope, and pass the sheath with a blind or visual obturator — return of fluid after removing the obturator confirms it sits in the bladder. Use a 24-Fr loop. Bipolar resection is now standard: it runs on normal saline (eliminating the risk of TUR syndrome) with better haemostasis, whereas monopolar requires a non-conductive irrigant (sterile water or glycine).
4. Resect the tumour systematically, having confirmed the trigone and both orifices. Small papillary tumours can often be taken in a single swipe at the base, sometimes without current. Large sessile tumours are resected in layers starting at the periphery; once the base is reached, take one swipe at the tumour's edge to set the resection depth — into the muscularis propria but not through its full thickness — then resect the whole base at that preset depth. Use suprapubic pressure and minimal filling for hard-to-reach anterior-wall tumours, and pure cutting current at or near a ureteric orifice. Plan general anaesthesia with a paralytic for lateral-wall tumours to abolish the obturator reflex. If not using continuous flow, empty the bladder every 3–5 swipes so it does not become over-full or too thin. Collect the chips with an Ellik evacuator (or pick them out individually with the loop if only a few) and send them for histology.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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. For a large perforation, stop immediately, empty the bladder, and obtain a cystogram to distinguish extraperitoneal from intraperitoneal — the choice of surgical repair versus catheter drainage depends on the patient's clinical status and the extent/type of perforation. A small perforation can usually be managed by finishing under low pressure with minimal irrigation.
10. Place a urethral catheter — typically a 22 Fr three-way for irrigation. Continuous bladder irrigation is used until the effluent is clear.
11. 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).
12. 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.
• Delayed bleeding — can occur days to weeks after resection; manage with manual then continuous bladder irrigation through a large-bore catheter, and cystoscopic fulguration if it persists.
• 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 sizing — a large resection warrants a 20–22 Fr catheter, removed in 1–7 days; a small resection may need no catheter at all (confirm the patient can void in recovery before discharge).
• Catheter removal once the urine is clear — often the next morning for routine cases, longer for high-volume resection or for perforation.
• Urinary retention usually resolves spontaneously within 1–2 days; if it occurs, discharge with an indwelling catheter and arrange a clinic voiding trial in a few days.
• 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.