Preoperative Evaluation

Maximizing patient health status preoperatively is always beneficial. Attention to cardiopulmonary status, renal function, and identifying any issues with coagulation are of specific concern. Following a detailed history and physical examination, correspondence with a patient’s primary care provider and consultation with an anesthesiologist can help identify areas for optimization before TURBT. Preoperative EKG, chest x-ray, and laboratories (complete blood count [CBC], prothrombin time [PT]/partial thromboplastin time [PTT]/ international normalized ratio [INR], chemistry-14 or comprehensive metabolic panel) allow the patient to be referred for evaluation by a specialist if needed. Blood bank cross matching may need to be considered in select cases.

Medication Counseling

Patients will need to be counseled about which medications (prescription, over-the-counter, and supplements) they should discontinue, how long they must abstain preoperatively, and when it is safe to resume their usual regimen. Special attention must be paid to patients with diabetes or hypertension to ensure euglycemia and normotension in the perioperative period.

The preoperative planning for patients taking anticoagulants (warfarin, dabigatran, apixaban, edoxaban, heparin, etc.) and antiplatelet agents (clopidogrel, prasugrel, ticagrelor, ticlopidine, cilostazol, aspirin, NSAIDs, etc.) requires careful coordination with the prescribing provider. Some patients, such as those with artificial heart valves, cardiac stents, or hypercoaguable states, may need to be admitted and heparinized to mitigate the risk of clot formation (see Chapter 4 ). Postoperatively, determining when patients should resume their usual anticoagulation/antiplatelet regimen will require weighing the risks of bleeding against those of thrombus formation.

Urine Culture and Antibiotic Prophylaxis

A documented negative urine culture is recommended prior to transurethral surgery. Any suspicion of infection should result in immediate culture, appropriate antibiotic therapy, and rescheduling the procedure until the urine has been documented to be sterile on repeat culture. Preoperative antibiotic prophylaxis, usually with a cephalosporin, sulfamethoxazole-trimethoprim, or a fluoroquinolone, is recommended. Of note, prescribers should be aware of the July 2016 black box warning issued by the US FDA regarding fluoroquinolone antibiotics. This warning did not address the use of fluoroquinolones as presurgical prophylaxis, but the potential risk from this class of drugs should be weighed when selecting a preoperative antibiotic. Second-line options include aminoglycosides, ampicillin, or a cephalosporin. The antibiotic choice should be altered in the case of an allergy or certain other aspects of the patient’s medical history, including documented UTI with resistance to that agent, artificial heart valve, joint replacement, etc. Antibiotic prophylaxis is recommended for 24 hours unless the patient has a positive urine culture indicating therapy should be extended.

Anesthesia

Selecting the appropriate anesthetic regimen is a collaborative process involving the patient, anesthesiologist, and surgeon. For TURBT, the choice is between regional (spinal or epidural) and general (laryngeal mask or endotracheal tube) anesthesia. If a regional approach is chosen, the anesthesiologist should be prepared to deepen the patient’s sedation, and even intubate if needed, to prevent the patient from coughing or bucking during the procedure. Sudden movement can result in significant complications, such as imprecise resection, hemorrhage, and bladder perforation. If the tumor is located laterally in the bladder, general anesthesia is appropriate because a paralytic can be given to eliminate leg adduction should current from the resecting loop stimulate the underlying obturator nerve. Similarly, injection of 30 mL of local anesthetic as an obturator block can significantly decrease nerve sensitivity and adductor strength.

Patient Positioning

Proper positioning is a fundamental aspect of any procedure performed in the lithotomy position. The surgeon, anesthesiologist, and nursing team should concur that all bony prominences are adequately padded and that the legs are secured within the stirrups to ensure minimal risk of nerve injury ( Table 25.2 ). The patient should be appropriately covered to prevent hypothermia and its sequelae (impaired drug metabolism, prolonged emergence from anesthesia, coagulopathy, postoperative discomfort) as a significant amount of body heat can be lost ambiently and through the irrigating fluid used intraoperatively. Warming the irrigant or using a warming blanket/forced air device can be beneficial in longer cases. Since patients with malignancy have an increased risk of venous thromboembolism, sequential compression devices (SCDs) are applied to the lower extremities for all cases that may last more than 1 hour, although many surgeons choose to use them for even shorter cases. It is critical to have the SCDs in place and functioning prior to induction, when the risk of DVT increases.

Resection

As mentioned earlier, the information gathered during office-based flexible cystoscopy can aid in the planning of TURBT. Adjustments in equipment selection and technique may need to be made based on the size, location, and number of tumors seen ( Figs. 25.1 and 25.2 and Table 25.3 ).

Office-based flexible cystoscopy allows the surgeon to map out the location of tumors and plan an appropriate resection. High-risk or challenging resection areas include the dome (perforation), lateral walls (obturator reflex), and ureteral orifice (obstruction).

Resecting a tumor on the anterior wall of the bladder can be facilitated by using one’s nonoperative hand to apply downward suprapubic pressure (anterior to posterior) to bring the area of interest into view. Care must be taken to control the end of the resectoscope at all times; the dome of the bladder can be perforated resulting in potential bowel injury.

Diffuse Carcinoma in Situ

The initial standard therapy for carcinoma in situ (CIS) is intravesical therapy with attenuated Mycobacterium bovis Bacillus Calmette-Guérin (BCG). If CIS is believed to involve extensive segments of the bladder, representative biopsies with hemostatic fulguration are preferable to cauterizing large swaths of the bladder mucosa. Extensive use of electocautery over a large surface area can result in bladder contracture. Recently, hexaminolevulinate (HAL) has begun to be used in combination with blue-light cystoscopy. This was approved for use in the United States in 2010, and since then experts recommend considering blue-light cystoscopy for assessment of CIS in patients with positive urine cytology, but negative white-light cystoscopy findings.

Tumor Involving the Ureteral Orifice

A tumor near or involving the ureteral orifice poses the challenge of obtaining complete resection and adequate hemostasis while preserving the caliber of the intramural ureter. Resecting with a purely cutting current and the judicious use of pinpoint cautery (with a right-angle cautery electrode) at the lowest effective setting for hemostasis make ureteral stricture unlikely. If postoperative flank pain develops, a renal ultrasound can be performed to evaluate for hydroureteronephrosis. If present, a percutaneous nephrostomy tube can be placed. Tumor location at the ureteral orifice should not deter appropriate endoscopic management.

Reflux of urine into the upper tracts, which may occur with ureteral stenting (either anterograde or retrograde) or via vesicoureteral reflux following resection of the ureteral orifice, has been shown to increase the risk of seeding and tumor occurrence in the ureter and renal pelvis in some retrospective studies. Conversely, Solsona and colleagues found no significant difference in upper tract recurrence patterns when refluxing and nonrefluxing patients were studied post-TURBT. Regardless, close follow-up and monitoring for bladder as well as upper tract recurrence are advisable. Patients who symptomatically reflux after TURBT have been successfully managed with the endoscopic injection of bulking agents. Surgical reimplantation of the refluxing ureter is also possible.

Tumor on the Anterior Surface

Resecting a lesion on the anterior surface of the bladder can be facilitated by using one’s nonoperative hand to apply downward suprapubic pressure (compressing the anterior wall toward the posterior wall) on a bladder only partially filled with irrigant to allow better visualization of the tumor.

Tumor at the Dome

Resection at the bladder dome is challenging because of its anatomic relationships. It is the furthest point from the trigone, making visualization difficult; the more irrigant used to clear away blood the further the point of interest travels from the resectoscope. A continuous flow resectoscope sheath can be especially useful in this situation. Additionally, bowel can overlie the dome and be injured by transmural current from aggressive electrocautery. Lastly, the elderly in general, and postmenopausal women in particular, have significantly thinner bladder walls, making perforation an even greater concern. Taking care not to overdistend the bladder and paying meticulous attention to resection technique and depth are important when working at the dome.

Tumor at the Lateral Wall

In addition to the anesthetic options discussed above, there are several techniques the surgeon can employ to lessen the likelihood of a complication stemming from the inadvertent stimulation of the obturator nerve during resection of a laterally located tumor. Preventing overdistention, decreasing the cutting/coagulation current settings, and the use of intermittent cautery can lessen the incidence of adductor contraction. The endoscopic injection of local anesthetic into the tumor base can also deliver an obturator nerve block if a percutaneous attempt was not made preoperatively. Lastly, use of a bipolar resecting system restricts the flow of current to between the two electrodes of the resecting loop thus decreasing stimulation of the obturator nerve.

Tumor in Bladder Diverticula

It is critical to remember the anatomic differences of bladder diverticula; by definition, they lack the muscularis propria layer making them thinner and much easier to perforate. This aspect can also make the pathologic staging of lesions within diverticula more difficult. Golijanin and colleagues from Memorial-Sloan Kettering Cancer Center have put forth post-TURBT staging and treatment recommendations based on their experience. They suggest that conservative treatment is appropriate when the tumor is confined to the diverticula, it can be resected in its endoscopic entirety, and the patient is agreeable to close follow-up. For large or high-grade tumors, transurethral biopsy followed by partial cystectomy may be more prudent than attempting complete transurethral resection.

Restaging Transurethral Resection of Bladder Tumors

American Urological Association (AUA) guidelines and European Association of Urology (EAU) guidelines recommend repeat resection for all patients with lamina propria invasion without muscularis propria present in the specimen. In addition, EAU guidelines recommend restaging in all T1 tumors as well as all high-grade Ta tumors. According to AUA guidelines, repeat resection is considered for patients with high-grade Ta bladder cancer and T1 tumors with muscularis propria in the specimen.

Restaging TURBT is typically performed 6–8 weeks following initial resection. Richstetter and colleagues found that residual tumor was found in 38% of restaging TURBT specimens. The risks of restaging TURBT are similar to the risks of initial TURBT and include anesthetic risk, bleeding, perforation, potential delay of definitive therapy, and increased difficulty with future therapies such as cystectomy.

“Radical” Transurethral Resection of Bladder Tumors for Muscle Invasive Bladder Cancer

Bladder preservation surgery for select patients with bladder cancer is an option. This can be achieved with combined chemoradiation. The patients undergoing this approach must be willing to undergo lifelong surveillance cystoscopy, multiple TURBTs, and possible intravesical therapy. Recurrent T1 or T2 disease with restaging indicates that patients should not undergo bladder preservation. Candidates for bladder preservation are limited to those who are not surgical candidates due to comorbidities or those who refuse cystectomy.

Monopolar Versus Bipolar Electrocautery

Both bipolar and monopolar electrocautery can be used for transurethral resection of bladder tumors. A recent study retroactively compared monopolar versus bipolar TURBT. The study examined perioperative complications in monopolar versus bipolar TURBT. They found that bipolar TURBT was associated with a lower incidence of bladder injury, with slightly shorter postoperative length of hospitalization and lower costs. In contrast, Venkatramani and colleagues found that bipolar transurethral resection was not superior to monopolar with regard to obturator reflex, bladder perforation, or hemostasis. However, other authors have reached the opposite conclusion.

Reducing Cautery Artifact

While typically not considered a complication, excessive cautery artifact is both counterproductive and preventable. Cold-cup biopsies can be obtained prior to resection or fulguration. Adjustment of the resectoscope’s power to the lowest effective setting combined with the preferential use of pure cutting current also aids the pathologist in his or her grading/staging evaluation. Alternatively, obtaining hemostasis via fulguration after adequate specimens have been obtained helps to preserve the microscopic appearance of the samples. There are differing opinions on whether use of bipolar energy decreases the degree of cautery artifact when compared to monopolar resection.

Use of Lasers

Several different types of lasers have been used to treat bladder cancer, including neodymium-YAG, argon, potassium titanyl phosphate (KTP), and holmium-YAG. The neodymium-YAG was found to be equally as effective as conventional TURBT in a prospective randomized trial, making it the laser of choice for some surgeons. Since laser energy vaporizes or coagulates the tissue it contacts, cold-cup biopsies should be performed prior to using the laser to resect a suspicious lesion. Likewise, determining tumor depth or muscular invasion is not readily possible with this type of resection, making patients with papillary, low-grade tumors the most appropriate population for this technology.

A recent meta-analysis reviewed seven randomized control trials to evaluate transurethral laser therapy for nonmuscle invasive bladder cancer. The study demonstrated decreased obturator reflex, decreased bladder perforation, and decreased length of stay for laser therapy compared to TURBT. Yang et al. also performed a retrospective analysis of laser vaporization versus TURBT and demonstrated that phosphate laser vaporization for nonmuscle invasive bladder cancer resulted in fewer perioperative complications and lower recurrence. The most significant complication of laser use is the transmural passage of energy resulting in the perforation of an adjacent structure, such as an overlying loop of bowel, but this risk is low.

Overall Morbidity and Mortality

While TURBT is typically a safe and well-tolerated procedure, urologists must be mindful of the morbidity (5.1% to 43.3% ) and mortality rates (0.8% to 1.3% ) reported in the literature.

Mechanical Difficulties

The list of possible mechanical failures or difficulties that can occur during TURBT is myriad. The surest way to minimize this frustrating event is by carefully examining the selected equipment prior to initiating the procedure. Clear, timely communication between the surgeon and operative team (anesthesia and nursing) regarding unexpected findings, the need for replacement, additional or specialized equipment, or any adjustments in the estimated operative time can help increase efficiency and patient safety.

Problems of Instrument Introduction

Barriers to effective transurethral surgery such as phimosis, meatal stenosis, or urethral stricture should be noted during flexible office cystoscopy. If an operative intervention is needed to correct one of these conditions prior to TURBT, the surgical consent form should be amended and the necessary additional equipment selected. The techniques for circumcision, meatal dilation/meatoplasty, and optical internal urethrotomy (OIU) are described in greater detail in Chapter 26 and other surgical texts. If for some reason office cystoscopy has not been performed prior to TURBT, the surgical consent should reflect the possible need for additional interventions.

Postoperative Bleeding

Postoperative bleeding is the most frequently reported complication of TURBT with rates ranging from 2% to 13%. Intraoperative or postoperative bleeding is typically associated with large tumors and extensive or complex resections. Careful examination of all resected areas under little to moderate distention is important so as not to miss small vessels temporarily tamponaded by a distended bladder. Unfortunately, coughing or bucking by the patient on emergence from general anesthesia can cause a significant increase in blood pressure resulting in a loss of hemostasis. Prompt management (removal of stimulus, sedation, or antihypertensives) can decrease systemic blood pressure and allow clot formation. If symptomatic hypotension or tachycardia ensues that does not respond to a fluid bolus, transfusion of packed red blood cells (PRBC), laboratory work (CBC, PT/PTT/INR, basic metabolic panel), and resuscitative measures are indicated.

Insertion of a transurethral catheter is common post-TURBT. Choosing a three-way catheter (20–24F) enables the use of CBI in the recovery room, if needed. It is critical to include orders for scheduled and PRN manual irrigation with 60–120 mL of normal saline via a 60-mL catheter-tipped syringe to remove any sediment or small blood clots that may have formed. The relatively small lumens of the inflow and outflow tracts in a three-way catheter, even in a large 24F catheter, can become clotted off easily and can lead to iatrogenic bladder perforation if the bladder continues to fill but is unable to drain. Continuous bladder irrigation should only be gravity fed; it must never be attached to an IV pump. Additionally, CBI is contraindicated with a bladder perforation. Titrating the flow for pink urine is usually adequate to limit clot formation. All nursing staff caring for a patient on CBI must be oriented to the apparatus and must strictly monitor and record the amount of irrigant instilled and returned and understand how to calculate urine output (total output − irrigant instilled = urine output).

If the degree of postoperative hemorrhage is significant and results in physiologic changes (hypotension, tachycardia) despite fluid resuscitation or repeated transfusions, returning the patient to the operating room for clot evacuation and fulguration is advisable. If hemorrhage is still uncontrollable, conversion to open cystectomy or embolization of the internal iliac artery by interventional radiology/vascular surgery may be necessary. Selective and superselective embolization techniques have since been developed in the attempt to minimize potential morbidity. In summary, the surgeon should first consider taking the patient back to the operating room for hemostasis. After determining that this is not advisable, other measures may be utilized.

Bleeding Due to Unresectable Disease, Radiation, or Chemotherapy

Significant hematuria in an oncology patient, regardless of cause, will often result in urologic consultation. The urologist should also be familiar with intravesical agents that are commonly used to manage hemorrhagic cystitis due to unresectable tumor, prior external beam radiation, or chemotherapy treatment. Some of these patients may be poor operative candidates, making intravesical treatments valuable temporizing measures.

Use of a 1% alum solution (50 g of aluminum ammonium sulfate or aluminum potassium sulfate dissolved in 5 L sterile water) functions as an astringent by causing protein precipitation and vasoconstriction. This can be delivered in the same manner as saline CBI. The alum will cause a precipitate to form, so manual irrigation via a piston syringe (60-mL catheter-tipped syringe) will be required to ensure adequate outflow. Aluminum absorption is possible, especially if large portions of the bladder have been resected. Signs of aluminum toxicity, which is more likely in patients with renal dysfunction and can be fatal, include lethargy, confusion, seizures, and metabolic acidosis. Alum irrigation should be stopped immediately and bloodwork (serum aluminum level) sent.

Chapter 26 discusses the use of intravenous and oral aminocaproic acid (Amicar; an inhibitor of plasminogen activators, which interferes with fibrinolysis) in the management of post-TURP bleeding. The same regimen can be employed post-TURBT or mixed as a solution for use with CBI. It is important to rule out disseminated intravascular coagulation (DIC) as the source of bleeding by evaluating the patient’s platelet count and fibrinogen level prior to initiating aminocaproic acid therapy.

Instillation of intravesical formalin has been used to manage refractory hematuria due to advanced bladder cancer and hemorrhagic cystitis due to external beam radiation or cyclophosphamide chemotherapy. Formalin causes protein denaturation and precipitation in the bladder mucosa resulting in blood vessel occlusion. This treatment should not be considered first-line therapy, and it is not advisable to use it in the immediate postoperative period because absorption is possible. Pretreatment cystography is recommended to evaluate for reflux and bladder integrity. Complications, both local and systemic, include bladder contracture, urinary incontinence, vesicoureteral reflux, ureteral stricture and obstruction, acute tubular necrosis, vesicovaginal or enterovesical fistula formation, myocardial injury, and bladder rupture. Bladder fibrosis with reduced capacity and resultant urinary frequency is a common side effect.

Bladder Perforation

Bladder perforation is one of the most significant complications associated with TURBT. It can result in numerous sequelae including hemorrhage, TUR syndrome, infection, the need for urgent open surgery, tumor spillage, peritonitis, and death. Mindful assessment of inflow and outflow irrigant volumes during extensive resection may prompt the recognition of serious occult bladder perforations. Bladder perforation typically occurs extraperitoneally, which can usually be managed with drainage via a large caliber urethral catheter (20–24F) for 7–14 days with a cystogram prior to removal. For large intraperitoneal perforations, surgical repair should be performed. This should be performed especially if tumor resection is incomplete and the risk of tumor spillage is high. Drain placement by interventional radiology may be required if there is a large amount of extravasated irrigation fluid.

The incidence of post-TURBT perforation may be underestimated. In a prospective study, Balbay and colleagues performed cystography after TURBT in a series of 36 patients with suspected bladder cancer. They found contrast extravasation in 58.3% of their patients, compared to other series reporting perforation in only 1–5% of cases. The significance of subclinical perforations detected by cystography is unclear. In an editorial accompanying the Balbay report, Soloway raises concerns about the oncologic efficacy of “radical TUR,” meaning that resecting to the point of perforation, even if done deliberately, poses a risk to the patient from tumor spillage. Regardless, one must be cognizant of a possible bladder perforation when performing aggressive resections.

Skolarikos and colleagues attempted to determine the impact of bladder perforation during TURBT on extravesical tumor recurrence by examining the records of over 3400 patients. They found the incidence of perforation to be only 1% and identified several risk factors associated with extravesical tumor recurrence. The most significant risk factor was the need for an open surgical repair of the perforation, followed by the bladder defect being located intraperitoneally, and the tumor size being in excess of 3 cm. They also noted that patients with extravesical disease after perforation repair fared far worse than the rest of the cohort. In contrast, other studies examining outcomes after TURBT-associated perforation did not detect an increase in extravesical disease frequency or poorer outcomes.

Golan and colleagues performed a retrospective review of TURBTs performed at their institution from 1996 to 2008. They identified 15 patients who required open surgical repair of their bladder perforation. They found that bladder perforation requiring open surgical repair is more likely to occur in elderly patients with posterior wall tumors who had prior TURBTs and prior intravesical instillations.

While rare, it seems plausible that perforation during TURBT can lead to extravesical disease, which carries with it a dismal prognosis. It is unclear if perforation should prompt consideration of systemic treatment in an attempt to mitigate any increased risk of soft tissue seeding. Additionally, the use of postresection intravesical chemotherapy is contraindicated in the presence of perforation. The loss of the demonstrated risk-reduction benefit of postoperative intravesical chemotherapy combined with a theoretical increase in disease progression due to perforation reinforces the severity of this complication.

Transurethral Resection Syndrome

While TUR syndrome is covered in-depth in Chapter 26 , there are several differences in its etiology and presentation that should be considered when this complication arises after TURBT. Post-TURBT hyponatremia is usually due to bladder perforation and the extravasation/extravesical absorption of irrigant fluid, in contrast to absorption across open prostatic venous sinuses during TURP. Since the irri­gant is not being directly introduced into the patient’s circulatory system and must be absorbed across the peritoneum, the initial presentation may be delayed. Dorotta and colleagues report a case series of four such events and noted that the time to serum sodium nadir was 2–9 hours compared to 1–6 hours following prostatic resection. Hyponatremia, intravascular hypovolemia with an increase in total body water, hypotension, oliguria, acute renal failure, metabolic acidosis, and mental status changes are all described in TURBT syndrome.

Early detection, rapid assessment, and immediate treatment are critical when faced with this complication. Management is nearly identical to that for TURP syndrome described in Chapter 26 . The procedure should be halted, a bladder catheter left in place, “STAT” serum chemistries sent, and resuscitation with normal saline started. The patient’s sodium deficit should be calculated and serial measurements made to ensure the proper rate of correction. Use of hypertonic saline poses the risk of central pontine myelinolysis caused by rapid electrolyte and fluid shifts in the brain, and requires consultation with specialists such as in nephrology or critical care medicine. Diuretics (e.g., furosemide) can facilitate hemoconcentration but should only be used in a euvolemic patient. Drainage of the peritoneum or retroperitoneum can be accomplished via an open surgical procedure with simultaneous repair of the bladder perforation or by placement of a percutaneous drain under ultrasonic guidance by interventional radiology; surgical repair of the bladder can then be performed at a later date once the patient has been stabilized. Transferring the patient to a monitored setting such as an intensive care unit is advisable.

Infection

Dysuria is common after transurethral bladder surgery, so patients may have difficulty differentiating the expected symptoms from infection. Likewise, a dipstick urine analysis will be difficult to interpret. A short course of postoperative prophylaxis with oral antibiotics is reasonable until the bladder mucosa has had an opportunity to heal. A suspected infection should be cultured immediately. Empiric antibiotics can be started and tailored to the sensitivities once they are available.

Urinary Retention

Instrumentation, anesthesia (general, spinal, or epidural), and postoperative narcotics can all lead to acute urinary retention, especially in men. While many patients are discharged from the hospital or surgical center with a catheter in place, most who undergo resection of superficial and/or small to medium lesions may not require an indwelling Foley. Recovery room orders should clearly indicate that patients must void adequately prior to discharge (specify both a volume and the time in which it must be passed), otherwise a urethral catheter should be inserted and an office voiding trial performed. Men who take alpha-1 antagonists or 5α-reductase inhibitors should continue on their medications at the usual prescribed dose. Urinary retention that occurs weeks to months post-TURBT should be investigated with cystoscopy to evaluate for urethral stricture, bladder neck contracture, or tumor recurrence and managed appropriately.

The Effect of Trainee Participation on Transurethral Resection of Bladder Tumor Complications

Transurethral resections of bladder tumor are frequently done in an academic setting and involve residents or fellows who are learning to perform the procedure. Nieder and colleagues prospectively evaluated all TURBTs performed in part by residents or fellows under direct attending supervision. Intraoperative complications were evaluated. Of the 173 TURBTs performed at their institution there were 10 complications including four patients with hematuria requiring transfusion, six extraperitoneal perforations, and two intraperitoneal perforations. This was a complication rate of 5.8%, which is comparable to other studies that did not include residents.

In contrast, Allard and colleagues performed an analysis of all transurethral surgeries (including both TURPs and TURBTs) in the NSQIP user files. They assessed the effect of trainee involvement comparing post graduate year (PGY) 1-2, PGY 3-4, PGY 5, and above versus attending-only resections. In multivariate analysis they found that resident involvement increased the operative time and hospital readmissions within 30 days. Resident involvement was not associated with increased overall complications or need for reoperation.