In case of large papillary tumors with a small pedicle, retrograde resection can be considered. It has a higher risk of bladder wall perforation, but it may allow an “en bloc” resection of bigger pedunculed tumors. A better control of the resection depth is achieved with small and fast resection impulses. Then an anterograde resection of the base is performed. When choosing this approach always remember to take care that the resected fragments allow extraction through the resector sheath. If the tumor is too big it will be impossible to remove without previous fragmentation. It is very difficult to resect in smaller parts a free floating tumor (Fig. 52.2).

Extraction of the specimen after the resection of the tumor. According to the sample size, removal of the specimen can be done manually with resectoscope or with Ellik evacuator. In case of Ellik use, after removal of specimen it is necessary to re-inspect the bladder to check for bleeding and to confirm the complete removal of all fragments.

Then it is important to sample the underlying bladder wall with muscular tissue and the edges of the resection area and label them separately to allow a complete pathological evaluation of existence and depth of tumor invasion into the lamina propria and detrusor muscle. The ideal depth should permit good detrusorial sampling without causing a perforation (Fig. 52.3).

Hemostatic control is performed by selective coagulation of bleeding vessels, resection bed and edges of resection area. Residual bleeding is checked under minimal bladder filling.

At the end of the procedure an indwelling three-way bladder catheter is placed with continuous bladder irrigation. The flow is determined by the degree of residual hematuria.