Endoscopic resection of bldder tumor (TURV)

Endoscopic resection of the Bladder Tumor (TURV) is an essential surgical procedure for diagnostic and therapeutic purposes. It involves removing the tumor from the bladder wall and evaluating it histologically to determine the stage of the disease. TURV is one of the main techniques for treating superficial bladder tumors and staging more advanced tumors.

Objectives of TURV

Tumor removal: Excise visible tumor tissue to achieve oncological cleansing, preventing local growth or progression.
Histopathological diagnosis: Provide biopsy specimens for microscopic analysis to classify the tumor (grading) and determine its stage.
Staging: Determine the depth of tumor invasion in the bladder wall and check for any leakage into muscle tissue.

1. Indications for TURV

TURV is indicated in the presence of:

Bladder neoformations highlighted by imaging examinations (e.g. ultrasound, cystoscopy, CT).
Persistent macroscopic or microscopic hematuria.
Tumor recurrence in patients with a history of bladder cancer.
Monitoring of known tumors to assess therapeutic response or tumor evolution.

2. Patient Preparation

2.1 Pre-operative Assessment

Blood chemistry tests: Blood count, coagulation (PT, aPTT), renal function (creatinine).
Urinalysis: Urine culture to rule out pre-existing urinary infections.
Imaging tests: Uro-CT or MRI to identify the presence of multiple lesions or concomitant pathology.

2.2 Information and Consent

Explain to the patient the risk of tumor recurrence and the possibility of complications.
Inform about the risk of bladder perforation, bleeding, and the need for any adjuvant treatment (such as instillation of post-TURV intravesical chemotherapy).

3. Instrumentation

Resectoscope: An endoscopic instrument that allows tissue to be resected through the diathermic loop.
Diathermic loop: Used to cut and cauterize tissues.
Light source and camera: For optimal visualization of the bladder cavity.
Continuous irrigation: Use of sterile saline solution to maintain clear visibility.
Bipolar or monopolar electrocoagulator: Depending on the technology available and the type of resection required.

4. Operating Technique

4.1 Patient Positioning

The patient is placed in lithotomy, with legs raised and apart, allowing easy access to the urethra.

4.2 Anesthesia

Generally, spinal or general anesthesia is opted for.
Epidural block may be used in patients at risk.

4.3 Inserting the Resectoscope

Lubricating the urethra: Insert the resectoscope carefully to avoid urethral injury.
Bladder cavity exploration: Identify the location, size, and number of lesions.

4.4 Tumor Resection

Resection Margins: Initiate resection around the base of the lesion, maintaining a safety margin to prevent tumor tissue from persisting.
Depth of Resection: Proper staging requires including the detrusor muscle (in cases where muscle invasion is suspected).
Fragment resection: For large tumors (>2 cm), resection can occur in multiple fragments to avoid a bladder wall perforation.
Hemostasis: Use electrocoagulant current to control any bleeding.

4.5 Bladder Biopsies

Random biopsy: In the case of papillary tumors, samples should be taken from suspicious or distant areas to rule out multifocality.
Biopsy of the edges and base: Check for tumor residues for infiltrating tumors.

5. Post-Operative

5.1 Monitoring

Bladder catheter: To prevent clot obstruction, the three-way catheter is kept in place for at least 24 to 48 hours.
Bleeding control: Observe drained urine for bleeding or clots.

5.2 Post-TURV intravesical chemotherapy

Mitomycin C instillation: Applied within 24 hours of surgery without signs of perforation to reduce the risk of recurrence.
Intravesical BCG: In high-risk patients, following scarring, to stimulate the local immune response.

6. Complications

Bleeding: Common but usually controllable with electrocoagulation.
Bladder perforation: Rare but may require prolonged drainage or surgical repair.
Urinary tract infection: Antibiotic prophylaxis may be considered to reduce the risk.
TUR syndrome: Accumulation of hypotonic fluid with a risk of hyponatremia (rarer with the use of saline solutions).

7. Follow-up

Histopathological examination: The report allows the tumor to be classified (grading) and staging to be determined.
Control cystoscopy: Usually after 3 months to check for recurrences.
Intravesical instillations: Depending on the risk of recurrence, BCG instillations or intravesical chemotherapy may be performed at scheduled intervals.
Imaging tests: For muscle-invasive tumors, a periodic CT scan or MRI is recommended to evaluate any metastases.

8. Conclusion

TURV is an essential procedure for treating and staging bladder cancer. Its effectiveness depends on the accuracy of the resection, the correct biopsy sampling, and appropriate patient management in the postoperative period. Rigorous follow-up is essential to monitor for recurrences and ensure an improvement in prognosis.

Note: The effectiveness of TURV may vary based on operator experience and available technology. Advanced techniques, such as bipolar resection and real-time imaging techniques (such as fluorescence cystoscopy), can improve surgical outcomes and diagnostic accuracy.

Informed Consent for Transurethral Resection of Bladder Tumor (TURBT)

Procedure Information

Patient's Name: ...........................................................
Date of Birth: .....................................................
Procedure Date: .....................................................

Dear Patient,

You have been advised to undergo a procedure called Transurethral Resection of Bladder Tumor (TURBT). This procedure allows for the removal of one or more tumors from the bladder wall through the urethra, without requiring any skin incisions. TURBT serves both a therapeutic role, by removing tumor tissue, and a diagnostic one, as it allows for a histological analysis of the removed tissue to determine the tumor type and any depth of invasion into the bladder wall.

Objectives of the Procedure

Tumor Removal: To excise the visible tumor tissue to reduce the risk of local growth or spread.
Diagnosis: To provide samples for histopathological analysis and determine the stage of the disease.
Staging: To assess the depth of tumor infiltration, which will help guide further treatment.

Risks and Potential Complications

As with any surgical procedure, there are potential risks and complications. The main risks associated with TURBT include:

Bleeding: Bleeding may occur during or after the procedure. In some cases, additional treatment may be required to control bleeding.
Bladder Perforation: During resection, the bladder wall may be perforated. In most cases, minor perforations can be managed with extended catheterization, but in rare cases, surgical repair may be needed.
Urinary Tract Infection: A urinary tract infection may develop after the procedure and can be treated with antibiotics.
TUR Syndrome: A rare complication caused by fluid absorption during the procedure, which can lead to electrolyte imbalance (hyponatremia).
Tumor Recurrence: Even after removal, it is possible for the tumor to recur. Periodic follow-up will be scheduled to monitor this.
Pain or Urinary Symptoms: Painful urination or small blood clots in the urine may occur in the days following the procedure.

Consequences of Not Undergoing TURBT

If TURBT is not performed, the bladder tumor may continue to grow and spread through the bladder wall and surrounding tissues. Failure to remove the tumor increases the risk of progression to a more advanced stage, with possible invasion into the bladder muscle and, in some cases, potential spread to other organs. This may require more invasive procedures, such as a cystectomy (removal of the bladder), and additional treatments such as chemotherapy or radiation therapy. Additionally, untreated bladder tumors can lead to increasingly severe urinary symptoms (such as blood in the urine, difficulty urinating, and pain), resulting in a reduced quality of life and fewer chances for complete recovery.

Alternatives to TURBT

In certain cases, an observational approach or other therapeutic options may be considered. However, TURBT remains the preferred treatment for most bladder tumors. In cases of invasive or advanced tumors, adjuvant therapy, such as intravesical chemotherapy, may be considered.

Post-Operative Care

After TURBT, it may be necessary to temporarily place a bladder catheter to help drain urine and prevent blockage. The duration of catheter use depends on the extent of the procedure and any complications. Follow-up appointments and any additional treatments will be scheduled as needed based on the histopathological report.

Consent to the Procedure

I declare that I have received and understood the information regarding the procedure, the potential risks and benefits, the possible complications of TURBT, and the risks associated with not undergoing the procedure. I have had the opportunity to ask my doctor questions, and they have been answered fully and clearly. I understand that TURBT may not completely remove the tumor and that further treatments or follow-up appointments may be required.

I confirm that I have received clear explanations regarding alternative options and understand that TURBT is the treatment of choice for my current condition.

I freely consent to undergo the transurethral resection of bladder tumor (TURBT) and any additional procedures or treatments the physician deems necessary for my well-being during the procedure.

Patient's Signature: .................................................
Date: .................................................

Physician's Signature: ...................................................
Physician's Name: ....................................................