Trans Urethral Resection of Bladder Tumor (TURBT) in Thailand

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About the Trans Urethral Resection of Bladder Tumor (TURBT)

Cancer in Bladder can be found to vary depending on the type of its origins. It can arise from the lining of the epithelium which is the inner lining of the urinary bladder or the urothelium. Rare forms of cancer are not of epithelial origins like the sarcoma or lymphoma. Tumours in bladder is found to be the 9th leading type of cancer in United States as per a survey conducted in 2012 with 430,000 new cases and mortality of 165000 deaths annually.

About Trans Urethral Resection of Bladder Tumor

The first and foremost question to ask is where is your bladder located? The sac like muscular urinary bladder is located in the pelvis region above the pelvic bone. It is connected to the kidneys through the two ureters that transfer the urine from the kidney to the bladder for storage. An abnormal growth of cells in the inner lining causes a tumour requiring diagnosis and then followed by a turbt surgery.

In most cases the tumour cannot be assessed in the primary stages. There are hardly any notable evidences found when the patient is harbouring a primary tumour.

The next stage is designated as Oa and categorized as a non invasive type papillary cancer.
In the stage next of the stage 0 or the carcinoma in situ the inner lining of the bladder is affected and is still considered non invasive.
In stage I the cancer has spread into the lining of the bladder further but has not affected the muscular wall of the bladder.
While in Stage II the inside part gets affected including the muscles of the bladder making it now invasive.
And when the cancer has spread enough in muscles and the tissues around the bladder like the reproductive organs it is considered to be in stage III.
And in the final or stage IV the cancer will spread to the lymph nodes affecting the organs around it as well.

Causes of developing a tumour in bladder

The causes of tumour in bladder are not always very clear and well defined but it has been linked with smoking, chemical exposure and radiation or a parasitic infection. The abnormal cells undergo some mutation that allows them to multiply in a non orderly fashion and goes beyond control and they do not die thus giving rise to the tumour.

Symptoms of the TURBT

A person suffering from a tumour will experience mild sensation of burning and discomfort in the times of urination for quite a few days. The force of the urinary stream may also undergo significant changes which can be observed for a week to a fortnight. Usually there could be none of the symptoms and in certain cases all symptoms even if experienced may not lead to the conclusion that it is a bladder cancer. There can be blood or clots of blood in the urine along with a tendency of urinating too frequently. Tendency of urinating at night may be felt more but there can be general problems in urine passing. Associated along with this the patient can experience pain on either side of the body.

What is transurethral resection of bladder tumour?

This procedure aims at removing bladder tumours at an early stage by inserting a scope through the urethra leading to the bladder. In the TURBT procedure bladder cancer can be detected by the urologist and potentially allow the urologist to treat various other kinds of bladder related disorders. But 75% of the cancer of bladders that are detected are superficial in nature causing growth only on the surface of the walls of the bladder and does not get very deep. So this facilitates the surgeon to have the tumour removed at the bladder wall level causing no damage to the deeper layers of the organ. The information that is collected while executing the procedure will help the surgeons to decide the type of the abnormality of the tumour and the extent of the tumour. This later allows the urologist surgeons to decide whether further treatments will be required or not.

What are the alternatives for TURBT procedure?

Some of the other treatment alternatives for TURBT are being worked upon while some of them have tremendous side effects

Blue light fluorescent cystoscopy : Enhanced tumour visualization is possible and detection of tumour chances are increased by almost 20 to 25% with this method where an ultraviolet blue light is used. A dye is injected an hour prior to the procedure.

Adjuvant bladder cancer therapy: TURBT is not suitable for many who have high chances of suffering a recurrence within 12 months from the treatment. In this case adjuvant therapy is recommended. It includes intravesicle chemotherapy. Chemotherapy for bladder cancer includes giving medication to curb the abnormal growth of cells. But it also has its sets of side effects like experiencing irritation in bladder and loss of hair, nails and feeling debilitated for a very long period of time.

How is Trans Urethral Resection of Bladder Tumor (TURBT) performed?

  • The techniques of anaesthesia used are all suitable for TURBDT procedure. In case of spinal anaesthesia the patient stays awake and the surgery team can stay alert for any TUR Syndrome. This is a rare complication but cannot be ignored still. But for complex tumours the resection does not prefer spinal anesthesia as obturator reflex where a leg thrust which is very powerful can be felt. So if tumour location is not known general anaesthesia is preferable with endotracheal tube or LMA allowing surgeon the flexibility for long as well as short term paralysis.
  • For achieving proper positioning Mitchell slings and split leg spreader table attachments are employed. In the dorsal lithotomy position when a patient is positioned then care is taken to ensure that all the points of pressure are adequately padded and none of the joints are flexed beyond 90 degrees. Peroneal nerve injury has to be avoided as there are chances of the same during compression of the nerve on the lateral fibular head.
  • With betadine scrub, chlorhexidene or with any other antiseptic agent the area is cleaned, and then covered with sterile drapes. The wires and cords are positioned as per the convenience of the surgeon. On the abdomen of the patient a video monitor is positioned at a suitable height ensuring comfort during the procedure and prevents neck or head strain as much as possible.
  • The Iglesias type continuous flow resectoscope is preferred and it allows the surgeon to control both inflow and outflow which when controlled for proper equilibrium will ensure constant volume in the bladder and having the tumour fixed in position and also have the vision cleared when coming across bloody fields.
  • The bladder has to be prevented from being overfilled and has to be maintained at half the volume all throughout the resection procedure. For small and moderate tumours the attacked area should be directed towards the tumour’s stalk.  The stalk of the tumour is at times hidden by the fronds or papilla of the tumour. Due to this there can be brisk bleeding which is continuous until and unless the large blood vessels. If the stalk does not get identified easily some of the fronds must be trimmed and then the stalk can be addressed.
  • Next the normal bladder mucosa and stalk has to be resected around the stalk circumferentially. During the resection of larger tumours it is suitable to send the chips resected separately for the pathologist so that they can identify the muscle fibers to signify sufficient resection.  Stalk base biopsies which are deep in the muscosa are also good for identifying muscle specimen.
  • Hemostasis has to be achieved after complete resection of the tumour, the resection site bases are painted and the mucosa edge around the tumour can ensure hemostasis adequately.
  • By a highly vascular stalk the papillary tumour is attached to the bladder. In order to get near the stalk surgeon must chip at the tumour’s periphery. The surgery is all about finding the stalk fast and addressing it to control it. That can at least stop the bleeding. But at times due to the size of the tumour it becomes difficult to locate the stalk and the surgeon has to look for the stalk evidence patiently.
  • With the help of an Ellik evacuator the bladder has to be irrigated copiously and the chips must be evacuated. The site has to be monitored to detect any bleeding, and the chips have to be removed before they clog the catheter. The irrigation has to be stopped and any remaining chips should be allowed to settle at the bottom of the bladder. With the help of a loop it must be grasped and manually pulled out from the bladder and Ellik can be used till all the chips are removed.
  • A large bore catheter should be placed. While some surgeons use 3 -way irrigation, this must be avoided to prevent catheter clotting off causing bladder perforation. Manual irrigation can be ideally used to maintain free flow of fluid. Lasix dose is used to create physiologic 3-way irrigation and it can simultaneously treat hyponatremia after the resection.

Recovery from Trans Urethral Resection of Bladder Tumor (TURBT)

A catheter will be given to the patient while going home and nurses will instruct how to maintain it clean and use it as a drainage bag. How to remove the catheter will also be taught which is a very simple and easy step and has very little discomfort associated with it. Antibiotic can be used in the form of ointment around the tip of the catheter to reduce irritation. Usage of an overnight bag is very convenient since it can store the urine for a longer period of time. It happens that there may be some blood clots that may pass while urinating; this must not scare you as it is normal. Addition to the overnight bag while walking a leg bag can also be worn. But if you find persistent clotting and large clots or the catheter is found not draining urine any more you should inform your surgeon.

The total period of recovery is pretty long as 6 weeks and can be divided into two weeks and then the last 4 weeks. During the first 2 weeks the patient is expected to behave as leisurely as possible and do very light activities and sexual activity must be avoided during this period. Of course within the first week one should go and collect the biopsy report and adhere to the medications prescribed by the doctor. In the next 4 weeks the patient can slowly resume back normal activities with periodic checkups with the doctor to understand the health and chances of recurrence.

Pros and Cons

Pros

  • It is the first line treatment which can detect stage and do treatment of visible tumours.
  • It can control low risk lesions without cost incurrence and inefficiencies of the operating room

Cons

  • It is not effective for carcinoma in situ
  • Runs the chances of recurrence
  • Recovery period is long

Patient Stories

Frequently Asked Questions

What is the health care infrastructure of Thailand / Why should opt for Thailand as a destination for your medical treatment
Hospitals in Thailand have seen an increase in number in the past few years. One of the many reasons for such surprise growth in the healthcare division can be the development of the public health sector which comprises 9,765 health locations along with 1,002 hospitals. As the Public Hospitals in Thailand are operated by the MOPH (Ministry of Public Health), the Private Hospitals in Thailand are regulated under the Medical Registration Division. The treatments in Thailand are also keeping up with that of other major countries all across the globe. As of 2002, the Thai Government has provided a countrywide general healthcare system that covers 99.5% of the Thai population and ensures high-quality treatments in Thailand and affordable primary medical amenities to each and every citizen of Thailand. In the year 2009, the total national expenditure on healthcare was 4.3% of the GDP of Thailand. Due to such medical advancements in Thailand, the country has become the most preferred medical destination in the world providing wide-ranging medical treatments at highly-reasonable rates at good hospitals in Thailand.
What are the conditions of the hospitals in Thailand? Are they JCI certified? What is the quality of the support staff in the hospitals?
The Joint Commission International (JCI) is a global leader in health care accreditation. JCI accreditation is considered a gold standard in worldwide health care. It provides the most skilled and experienced healthcare professionals in the medical industry, as evaluators of the rigorous international standards in healthcare quality and patient safety. Here are a few JCI certified hospitals in Thailand :
  • Yanhee Hospital
  • Bumrungrad Hospital
  • Bangkok Hospital
  • Chaophya Hospital
  • BNH Hospital
  • Ramkhamhaeng Hospital
  • Vejthani Hospital
  • Bangkok Hospital Phuket
  • Samitivej Sukhumvit Hospital
  • Praram 9 Hospital
  • Chiangmai Ram Hospital
  • Sikarin Hospital
  • Synphaet Hospital
  • Bangkok Hospital Samui
  • Nonthavej Hospital
  • Bangkok Hospital Pattaya
  • Samitivej Srinakarin Hospital
  • Samitivej Sriracha Hospital
Are the doctors/surgeons in Thailand of the best quality?
Thailand is gaining recognition for the quality of its healthcare services after the US magazine CEOWORLD placed Thailand 6th in its 2019 list of countries with the best healthcare systems. Thai doctors gain a lot of skills during their course and this helps them practice effectively. Many doctors and surgeons also visit other countries for training and certification courses to enhance their skills and knowledge. Most doctors are exposed to a public and private healthcare system in order to be able to work in any condition. It is a collective effort from all the professionals to maintain the standard of health and Thailand is doing just that.
What is the process for obtaining a medical visa in Thailand?
Currently, medical tourists To Thailand are allowed in from 34 countries. All visitors must have proof of travel health insurance that covers a minimum of US$100,000 of medical costs incurred in Thailand, including medical costs in the event that they contract COVID-19. Under the CCSA regulations, medical tourists have to arrive by air to ensure effective disease control, not via land border checkpoints. All must have an appointment letter from a doctor in Thailand and entry certificates issued by Thai embassies across the globe. People wanting to visit Thailand for medical procedures need to contact the Thai Embassy in their country to organize the visa and paperwork. Thailand’s major hospitals will provide potential candidates with an appointment letter. Permission for medical tourists to be accompanied by up to three attending persons is intended to allow such patients to have spouses, parents, or assistants in attendance during their treatment in Thailand. However, such persons will have to conform to all the same entry requirements as the medical tourists themselves, including visas and health status.
What support services does MediGence provide in Thailand?
MediGence enables you to plan and manage your medical decisions better. These are some of our services offered:
  • Expert Opinion
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  • Visa Assistance
    We provide and help prepare documentation for visa approval and coordinate with the embassy to expedite the visa process.
  • Accommodation Arrangements
    We propose to you a choice of accommodation based on your preference such as long stay, short stay, or luxury properties.
Which are the best cities in Thailand for medical treatment?
Bangkok is the capital of Thailand and the most sought - after destination for healthcare. It has more than 10 of the major hospitals in Thailand. The cost of treatment in Thailand is reasonable here. People tend to spend their recovery time in Bangkok as well as it is a beautiful city to visit as a tourist.

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