Trans Urethral Resection of Bladder Tumor: Causes, Symptoms and Recovery

This procedure, known as Transurethral Resection of Bladder Tumor (TURBT), is designed to detect and remove bladder tumors in their early stages by inserting a scope through the urethra leading to the bladder. During the TURBT procedure, urologists can identify bladder cancer and potentially address various other bladder-related disorders. It's noteworthy that around 75% of detected bladder cancers are superficial, meaning they only grow on the surface of the bladder walls without penetrating deeply. This characteristic allows surgeons to remove the tumor at the bladder wall level without causing damage to the deeper layers of the organ. The information gathered during the procedure assists surgeons in determining the type and extent of the tumor's abnormality. This information is crucial as it helps urologist surgeons decide whether further treatments are necessary.

The bladder, a sac-like muscular organ, resides in the pelvic region above the pelvic bone. It connects to the kidneys via two ureters, which transport urine from the kidneys to the bladder for storage. Abnormal cell growth in the inner lining can lead to the development of a tumor, necessitating diagnosis followed by TURBT surgery.
In the initial stages, tumors are often difficult to detect. Patients may exhibit few notable symptoms when harboring a primary tumor.
Progressing through stages of bladder cancer, Stage 0, also known as carcinoma in situ, represents non-invasive papillary cancer. At Stage I, cancer affects the bladder's lining but has not invaded the muscular wall. Stage II marks invasion into the bladder's muscles, rendering it invasive. Stage III denotes further spread into nearby tissues like reproductive organs. Finally, Stage IV indicates lymph node involvement and spread to surrounding organs.

Causes of tumor in the bladder

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

Symptoms of the TURBT

A person suffering from a tumor will experience mild sensations 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 to urinate too frequently. The 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 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 a high chance 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 the bladder and loss of hair, nails and feeling debilitated for a very long period of time.

If you are about to prepare for the surgery then you shall be asked to quit smoking long before. Depending on the type of tumour in the bladder and ureteroscopy results the plan of surgery shall be discussed with the kind of anaesthesia that may be employed by your surgeon. Right before the procedure there will be a check made on the general fitness of the body and some antibiotics can be prescribed to prevent any kind of infections from the surgery. Compression stocking will be put on and an injection may be administered like heparin to prevent clotting in the veins of the legs.

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.

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. Antibiotics 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. In 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 anymore 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.