Cystoscopy and Transurethral Resection of Bladder Tumors with Stent and Foley Catheter Placement

Bladder cancer is the sixth most common cancer in the United States. Transurethral resection of bladder tumor (TURBT) is a common urologic surgical procedure used to diagnose, stage, and treat bladder cancer. We present a patient who had multiple episodes of gross hematuria and was found to have multifocal bladder tumors. In this case, TURBT was performed to confirm the diagnosis of bladder cancer, remove all visible bladder tumors, and prevent further episodes of gross hematuria.

Bladder cancer; transurethral resection of bladder tumor; urology; urologic oncology.

Bladder cancer is the tenth most common cancer in the world, the sixth most common cancer in the United States, and the fourth most common cancer in men.¹ Bladder cancer has the highest median age at diagnosis of all cancer sites (73 years).² According to guidelines from the American Urological Association, transurethral resection of bladder tumor (TURBT) is the standard of care surgical procedure for initial diagnosis and staging of bladder cancer and treatment of the primary bladder tumor.³ In patients who have recurrent episodes of gross hematuria and/or clot retention, TURBT is used to stop ongoing gross hematuria or prevent further episodes that otherwise would result in anemia, catheterizations, and hospitalizations.

The patient is a 63-year-old male who presented to the urology clinic with a two to three month history of gross hematuria associated with lifting heavy objects. He underwent a hematuria evaluation with a CT urogram for upper tract imaging. The CT urogram demonstrated two enhancing bladder masses, and the patient was then referred for a TURBT. His past medical history was significant for psoriasis managed with topical medication. He occasionally smoked cigars and denied any chemical exposures. His American Society of Anesthesiologists (ASA) score was I (a normal healthy patient). His prior surgeries included brain surgery at age 12 for a blood clot, knee surgery, finger surgery, and vasectomy. He was not on any anticoagulation. Prostate Specific Antigen (PSA) blood test was performed and was slightly elevated at 4.89 ng/mL. A urine culture was obtained for preoperative testing and showed no growth.

Physical exam was unremarkable. On genitourinary exam, he had a circumcised phallus with meatus in center of the glans. The right hemiscrotum had prominent varices, which the patient noted had been present for many years. On rectal exam, prostate was enlarged and without nodules.

The patient underwent a CT urogram, which demonstrated at least two enhancing masses measuring 2.3 cm and 0.7 cm in the left posterior bladder. There were no lesions present in the upper tracts and no evidence of metastatic disease.

The most common histologic type of bladder cancer is urothelial carcinoma (>90% of cases), which is graded as low grade or high grade. High grade urothelial carcinomas have a greater risk of bladder wall invasion and metastasis than low grade. Approximately three-quarters of bladder cancers are non-muscle-invasive (NMIBC) at diagnosis (AJCC Stage <II).¹ NMIBC has a high recurrence rate (30–70%), but a low risk of death. The American Urological Association provide risk stratification categories for NMIBC based on stage, grade, tumor size, and multifocality.⁴ The risk category (low, intermediate, and high risk) is based on the risk of recurrence and the risk of progression to muscle-invasive disease and guides treatment and surveillance protocols. Muscle-invasive bladder cancer is life-threatening and requires more intensive treatment consisting of neoadjuvant chemotherapy followed by radical cystectomy, a major extirpative surgical procedure to remove the bladder and reconstruct the urinary tract.

The standard of care for initial diagnosis and treatment of a bladder tumor is a transurethral resection of bladder tumor, a surgical procedure performed under general anesthesia in the operating room. While TURBT is overall a low-risk surgical procedure, it does require general anesthesia with paralytic agents and is performed in high risk patients (i.e. older adults with multimorbidity).⁵ TURBT has a higher risk of complications in frail older adults.^6,7 In certain patients with recurrent, small subcentimeter bladder tumors, a clinic procedure to biopsy and fulgurate the tumor using a flexible cystoscope may be considered under local anesthesia. Other options specifically for small tumors or AUA low risk or intermediate risk tumors include active surveillance or chemoablation via bladder instillation of a chemotherapy agent.^8–10

Performing a high-quality TURBT is critical to accurately diagnose and stage bladder cancer, as well as to improve oncologic outcomes like recurrence. The key goals of TURBT are as follows:

• To conduct a thorough evaluation of the bladder characterizing the number of bladder tumors, the location of bladder tumors, tumor size, and appearance;¹¹
• To obtain adequate tissue to enable a pathologist to delineate the bladder cancer histologic type (urothelial carcinoma an/or others including variant histologies), the grade (low grade/high grade), and the tumor stage;
• To obtain adequate sampling of the muscle layer of the bladder wall to assess for muscle-invasive disease; and
• To fully resect all visible tumors.
  

Current AUA guidelines also recommend instilling a perioperative dose of intravesical chemotherapy (e.g. gemcitabine or mitomycin C) following the TURBT for AUA low or intermediate risk tumors.⁴ However, in this patient’s situation, we did not instill chemotherapy because of the extensive resection and the risk that the chemotherapy could reflux to the kidney and cause damage in the setting of a ureteral stent.

Transurethral resection of bladder tumor is the standard of care for initial diagnosis and treatment of bladder cancer. Conducting a high-quality TURBT with complete resection of all visual tumors is critical to ensure diagnostic accuracy and to improve oncologic outcomes, particularly recurrence. TURBT begins with a thorough and systematic examination of the bladder using either the rigid cystoscope or the resectoscope with 30- and 70-degree lenses. The surgeon should systematically note the number, size, location, and appearance (papillary, sessile, flat, etc.) of each tumor and record these findings in the operative report. The location of the ureteral orifices should also be noted. As in this patient’s case, bladder tumors may overlie one or both of the ureteral orifices, requiring resection of the orifice. When resecting the ureteral orifice, care must be taken to only use the bipolar cutting current and to avoid cautery directly over the ureteral orifice in order to prevent strictures and kidney obstruction.

Following introduction of the resecting loop, each tumor is carefully resected to the muscular layer of the bladder wall to ensure adequate tissue for staging. The tumors are generally sent as separate specimens in order to better stage and grade the bladder cancer. On a large tumor, the superficial tumor and deeper resection should be sent separately to improve yield of muscle in the specimen.

Using bipoloar current for TURBTs enables use of isotonic saline as the irrigating fluid rather than hypotonic water or glycine which reduces the risk of post-TUR syndrome electrolyte derangements such as hyponatremia and hyperkalemia. The obturator nerve runs alongside the bladder, and tumor resection (lateral tumors in particular) may stimulate the nerve, leading to sudden adduction of the thigh muscles and risk of bladder perforation while using the cutting current. We employ several maneuvers to reduce the risk of obturator nerve stimulation including: general anesthesia with paralysis, avoiding overdistending the bladder which brings the bladder wall closer to the nerve, and using lower power on the bipolar cutting current.¹²

Following resection, the coagulation current on the bipolar energy source is used to cauterize resection sites and achieve hemostasis. To confirm that hemostasis has been achieved, we drain most of the fluid from the bladder to reduce distension and observe the resection beds for bleeding. The resecting loop tool can be used for cauterization for small resection beds. For larger areas or bleeding that does not stop with the loop, a rollerball is a useful tool to cover a larger surface area efficiently.

The decision to place a urinary drainage catheter at the end of surgery depends on the extent of resection, plan for perioperative intravesical chemotherapy, and bleeding. In this patient’s case, we placed a urinary catheter due to the extent of resection. While there are no clear guidelines on how long to leave the catheter in place to ensure bladder healing, we remove the catheter 2–4 days following TURBT.

Newer techniques for TURBT include use of additional visualization technologies such as blue light cystoscopy and narrow band imaging to identify tumors or recurrences that are not obvious on traditional white light imaging. The 2024 AUA/SUO NMIBC guideline amendment recommends blue light cystoscopy if available, and narrow band imaging if blue light is not available.⁴ In the future, laser en bloc resection of bladder tumors may help to preserve tumor architecture and may improve staging and assessment of margins.

This patient’s final pathology showed multifocal Ta low grade urothelial carcinoma, which falls into the AUA intermediate risk category. He was started on an induction course of six weekly treatments of intravesical gemcitabine instillations. His first post-treatment cystoscopy was benign and showed no new tumors. On his second surveillance cystoscopy, he was found to have 4–6 papillary tumors in multiple locations, each ranging in size from 2–4 mm.

The standard equipment used in a TURBT procedure include the following:

• Olympus rigid cystoscope (21 or 22 French) with 30-degree and 70-degree lenses
• Olympus resectoscope (27 French) with inner and outer sheaths for continuous irrigation during the TURBT
• Olympus visual obturator to enter the urethra and bladder atraumatically
• Olympus working element
• Olympus EGS 400 bipolar energy source
• Olympus plasma resecting loop (12–30 degree)
• Olympus plasma rollerball for cauterizing large areas of the bladder
• Telfa gauze moistened with saline to collect fresh specimens to send to pathology
• 20 Fr latex coude urinary drainage catheter

In this patient’s procedure, we also performed a ureteral stent placement. Standard equipment for placing a ureteral stent using an Olympus resectoscope include the following:

• Olympus 8 Fr working insert
• Boston Scientific 0.035-in straight Sensor guidewire
• Boston Scientific Contour 6 Fr x 24-cm ureteral stent
  

Tullika Garg currently receives research funding from the Flume Catheter Company, LLC. All other authors report no conflict of interest.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

The authors are grateful to the patient who generously consented to participate in this project to educate others about TURBT.