Transurethral resection of bladder tumour (TURBT) is performed for diagnosis and treatment of bladder cancer. The objective when performing TURBT is to ascertain accurate histological diagnosis of the tumour (type, grade and stage), and to completely resect non-muscle invasive tumours. It may also be used to debulk large tumours prior to radiotherapy and as a palliative measure for symptom control (e.g. bleeding).

Pre- operatively urine analysis should be performed on all patients and any positive urine cultures treated with the appropriate antibiotics. On induction, antibiotic prophylaxis is recommended according to the local guidelines such as aminoglycosides (gentamicin) or cephalosporins (cephazolin, ceftriaxone).

Anticoagulants such as Warfarin, antiplatelet agents and the new orally active anticoagulants (NOACs) should be stopped pre operatively taking into account the half life of the medication according to the indication. Aspirin is generally continued, but can be subject to the surgeon’s preference. Intra-operative TEDS or sequential compression device are recommended for prophylaxis for thromboembolic events.

Informed consent should be obtained from the patient pre operatively, discussing the specific risks of the procedure which include bleeding, infection, TUR syndrome (less likely during TURBT) and bladder perforation. It is generally recommended to have upper tract imaging to exclude the presence of hydronephrosis or tumour. The presence of hydronephrosis may be a clue to the presence of muscle invasive disease near the ureteric orifice for example.

Both spinal and general anaesthesia can be used for TURBT. However, spinal anaesthesia is less of an option for difficult resections such as lateral bladder wall resections where there may be need to paralyse the patient to negate the obturator reflex. In such cases, general anaesthesia with use of an endotracheal tube or LMA (Laryngeal mask airway) is favourable to allow the surgeon the option of temporary paralysis if needed.

The patient is placed in the dorsal lithotomy position which allows the surgeon to adjust the legs as needed during the procedure. Care must be taken to ensure all pressure points are appropriately padded. The ideal height of the irrigation fluid is 60 cm above the level of the pubic symphysis.

It is essential that a bimanual palpation of the bladder is performed and documented before and after TURBT. Tumours that are palpable are likely invasive and if palpable after TURBT this suggests deep muscle invasion or extravesical invasion (pT3). Noting if a mass is mobile or fixed to the pelvis may give further prediction on the degree of difficulty a cystectomy may pose.