Trans Urethral Resection of Bladder Tumor (TURBT)

• 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. 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

• 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