Transurethral resection of a bladder tumor (TURBT) is indicated after diagnosis of a new or recurrent lesion in the bladder that is suspicious for malignancy and requires tissue confirmation of histopathology and therapeutic resection. This technique can be performed under general or regional anesthetic. Resection of lateral wall bladder tumors should be performed under general anesthetic with a paralytic agent to avoid inadvertent bladder wall perforation from an obturator nerve reflex. Complete resection of the tumor or tumors is the primary goal and may require staged resection in the case of some large tumors.
Choice of irrigant for TURBT depends on the type of resectoscope being used. Whereas monopolar resectoscopes require sterile water or glycine for conduction of electricity, newer bipolar resectoscopes can be operated with saline.
Place the patient in the modified dorsal lithotomy position. Perform a bimanual examination with the patient under anesthesia and assess for palpable or fixed pelvic masses. Prepare and drape the genitals in a sterile fashion.
Perform a thorough cystoscopy at the beginning of every TURBT, including visual inspection of the bladder and urethra. This should be performed even when the patient has undergone a prior office cystoscopy. Use the 70-degree cystoscope lens if visualization of some areas of the bladder is difficult (i.e., anterior bladder wall).
Exchange the cystoscope for a resectoscope. Leave the bladder full when removing the cystoscope and place the resectoscope sheath with either a blind obturator or a visual obturator if needed. Removal of the obturator and return of fluid confirm appropriate positioning of the sheath in the bladder.
Place the resectoscope with a 24-Fr loop into the bladder. Confirm the location of the bladder trigone and ureteral orifices in relation to the bladder tumor. Resect tumors in a systematic fashion. Smaller papillary tumors can often be resected in one swipe at their base, sometimes without the use of electrical current. Use suprapubic pressure and minimal bladder filling to resect anterior wall tumors that are hard to reach. Resect larger sessile tumors in several layers, starting at the periphery. When the base of a large tumor has been reached, perform one swipe at the tumor’s edge to set an appropriate depth of the resection. This should include muscularis propria without extending through its entire thickness ( Fig. 46.1 ). Continue to resect the entire base at the same preset depth. Resect tumors at or near the ureteral orifice with pure cutting current. If resection is being performed without continuous flow, stop to empty the bladder every three to five swipes to ensure that it does not become too full or too thin.