Introduction
In transurethral resection of a bladder tumor, the physician removes the tumor in the bladder through the urethra. The function of the urethra is to carry urine from the bladder to the outside of the body. Transurethral resection of a bladder tumor can be done during a cystoscopy test if the surgeon detects a tumor and after diagnostic tests that detect a bladder tumor. The procedure is performed under general anesthesia. About 75 % of men affected have nonmuscle invasive bladder cancer in which the detrusor muscle does not invade the detrusor muscle and only affects the urothelium or lamina propria. Transurethral resection of bladder tumors has a very high recurrence rate, which may be due to the suboptimal quality of the procedure. Transurethral resection of bladder tumors not only helps in diagnosis and treatment but also helps in tumor grading and staging. Transurethral resection of bladder tumors is technically safe and feasible and provides an outlook for further investigations.
What Are the Preoperative Considerations for Transurethral Resection of Bladder Tumor?
Risk factors for urothelial cancer involve occupational exposure, smoking, chronic infection or inflammation, and a history of pelvic radiation. Detailed examination of hematuria with a history of urinary tract infections. Physical examination to assess the prostate includes digital rectal examination, assessment of the abdomen, genitalia, and body habitus. Investigations include computed tomography intravenous pyelogram, an imaging technology that assesses upper tract pathology along with blood and urine tests. Multiparametric magnetic resonance imaging has specificity and sensitivity of 79 % to 87 % and 87 % to 97 %, respectively, differentiating nonmuscle invasive bladder cancer from muscle-invasive bladder cancer.
Factors That Affect Recurrence and Progression:
Cases of nonmuscle invasive bladder cancer have a very high recurrence rate. A randomized control trial showed recurrence rates ranging from 15 % to 61 % and a progression rate of 1 % to 17 % in a year, and for five years, it was 31 % to 78 %. The recurrence rates depended on clinicopathological factors such as multifocality, size, prior recurrence, carcinoma in situ, and grade.
How to Prepare for Transurethral Resection of Bladder Tumor?
The procedure is performed under general anesthesia, and any procedure involving general anesthesia requires overnight fasting. The healthcare provider should be priorly informed about the medications the individual is taking, especially over-the-counter medications and supplements, to avoid any complications. If the individual is on blood thinners, the health care provider instructs when and how long to stop them. It is advised not to stop any medication without prior permission from the health care provider. If the health care provider advises the individual to take medicines in the morning before the Transurethral resection of the bladder tumor. In that case, the individual is advised to take only one or two cups of water. If the individual takes a shower before the procedure, they are advised not to apply lotion, deodorant, or perfume. The individual is also not advised to drive after the procedure.
How Is Transurethral Resection of Bladder Tumor Performed?
Transurethral resection of the bladder tumor is performed under anesthesia; hence the individual will not experience any pain. During the procedure, a retro scope is inserted into the bladder through the urethra. Hence the word transurethral does not involve surgical incisions. Using the retro scope, the surgeon removes the tumor. The resected tumor is then sent for biopsy for further investigation. The surgeon also cauterizes or fulgurates the remaining cancer cells around the tumor to avoid recurrence and attain a negative surgical margin. Intravesical chemotherapy is a procedure in which the drugs are put into the bladder with a catheter, and in certain cases, the surgeon may perform this procedure.
What Are the Risks of Transurethral Resection of Bladder Tumor?
The risks of this procedure include the following:
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Prolonged or excessive bleeding.
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Risks related to anesthesia.
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Perforation of the bladder.
Individuals with chills, fever or heavy bleeding should seek immediate medical care.
Recovery From Transurethral Resection of Bladder Tumor:
A catheter is inserted into the bladder after Transurethral resection of the bladder tumor for the drainage of urine. The individual may have hematuria (blood in urine) in the beginning while passing urine. Frequent consumption of liquids helps in graining the bladder and avoids future infections. When no more blood passes in the urine, the catheter will be removed.
Challenging Situations During Transurethral Resection of Bladder Tumor:
The following are the challenging situations faced:
Tumors on Anterior and Lateral Walls:
During the resection of lateral wall tumors, there is an increased risk of obturator nerve reflex, which may lead to perforation. The following strategies will reduce the risk of obturator nerve reflex:
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Usage of a short intermittent burst of current.
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Usage of neuromuscular blockade.
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Reducing cutting current.
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Avoid bladder overfilling.
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Usage of bipolar electrocautery.
Anterior wall tumors require suprapubic depression and proper retro scope angles. Anterior wall cases are challenging to the surgeon. Open-angeled loops are an effective method of resection.
Tumors at the Ureteral Orifice:
Ureteric obstruction and scarring are observed in cases with coagulation at the ureteral orifice. Pure cutting settings help in the resection of tumors at the ureteral orifice. In cases of muscle-invasive bladder cancer with cisplatin-based neoadjuvant chemotherapy, pure cutting settings will facilitate satisfactory renal function. Temporary ureteric stent placement for two to six weeks will reduce the risk of vesicoureteric reflux. A follow-up with CT urogram, renal ultrasound, or diethylenetriamine pentacetic acid renal is recommended.
Random Biopsy:
Random biopsies are taken to identify carcinoma in situ in normal-appearing areas. The biopsy specimens are extracted with cold cup forceps, and samples are mostly taken from the mucosa and lamina propria layers. In addition, biopsies are taken from the dome, trigone, anterior, posterior, and left posterior walls. This is called a site-directed biopsy.
Prostatic Urethra Biopsy:
Prostatic urethra biopsy provides tumor staging and is performed in individuals with carcinoma in situ or cases of negative cystoscopy but positive cytology to assess the extent. Carcinoma in situ is superficial and confined to the urethra. However, it extends deeply to the gland's acini, stroma, or ducts. Prostatic urethral involvement depends on the grade, stage, and bladder tumor location at the bladder neck or trigone.
What Are the Limitations of Transurethral Resection?
The limitations involve:
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Suboptimal pathological assessment.
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Bladder perforation.
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Perioperative morbidities in cases of obturator nerve reflex.
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High recurrence and progression rates.
Conclusion
Transurethral resection of bladder tumors is the first line of treatment for bladder cancer. In transurethral resection of a bladder tumor, the surgeon removes the tumor in the bladder through the urethra. This procedure has its limitations and risks. However, advanced techniques help in reducing morbidity and mortality.
