Overview of TURBT
Endoscopic treatment with transurethral resection of bladder tumor (TURBT) is the first-line treatment to diagnose, stage, and treat visible tumors. In select patients, office-based fulguration of small tumors allows control of low-risk lesions without incurring the cost and inefficiencies of the operating room. 
TURBT is not effective for carcinoma in situ (CIS) because the disease is often so diffuse and difficult to visualize that surgical removal is not feasible. Therefore, the role of cystoscopy is to establish the diagnosis so that therapy can be instituted. Obvious areas of CIS may also be fulgurated, but the benefits of this have not been proven. When a combination of papillary tumor and CIS is present, the papillary tumor is removed before treatment of the CIS is initiated.
For more information, see Bladder Cancer.
Preoperative Details of TURBT
Patients scheduled for cystoscopy or anesthetic cystoscopy with transurethral resection of bladder tumor (TURBT) must have sterile urine documented prior to instrumentation. Sterility is usually presumed on the basis of a microscopic urinalysis showing no bacteria or white blood cells (WBCs). A urine culture is ideal but not always feasible for surveillance cystoscopy.
The risk of urinary tract infection with instrumentation is approximately 1%. Therefore, the author recommends a single dose of fluoroquinolone for patients undergoing cystoscopy and a dose of intravenous antibiotics (ie, cefazolin, gentamicin) for patients in the operating room. Allergies may prompt the use of alternative antibiotic regimens.
Some patients need additional antibiotics based on a history of valvular heart disease. The American Heart Association guidelines recommend prophylaxis in these patients to prevent endocarditis.
Administer 2 g of ampicillin intravenously or intramuscularly at least 30 minutes before the procedure (or 2 g of amoxicillin orally at least 1 h before the procedure) in moderate-risk patients. In patients allergic to penicillin, vancomycin at a dosage of 1 g intravenously over 1-2 hours, completed at least 30 minutes before the procedure, may be substituted. High-risk patients also receive 120 mg of gentamicin parenterally 30 minutes before the procedure, and they receive a second dose of ampicillin or amoxicillin 6 hours later.
Patients with prosthetics may merit additional antibiotics based on the clinical scenario.
Intraoperative Details of TURBT
General or regional anesthesia can be used.
Complete eradication of tumor is the first step of transurethral resection of bladder tumor (TURBT). Most tumors are papillary and are easily removed by endoscopically transecting their narrow stalk or base. Following this, biopsy of the base is performed to ensure complete removal and the absence of invasion. Muscle tissue (or fat) must be present in the base biopsy specimen to ensure accurate staging.
Medium and large tumors are resected piecemeal prior to transection of the stalk. This ensures that large segments do not remain that might be too large to evacuate through the resectoscope.
Smaller and more friable tumors may be removed at least partially by knocking off fragments with the cutting loop of the resectoscope without the electricity turned on. This sometimes allows partial removal with less risk of bladder perforation.
Pulling the cutting loop away from the tumor is generally much safer than pushing it toward the tumor. Lifting the tumor away from the surrounding normal bladder tissue using the cutting loop is also advisable.
Continuous-irrigation resectoscopes concern some surgeons regarding fluid absorption. However, continuous infusion lessens the bladder wall movement that occurs during filling and emptying and thereby may decrease the risk of bladder perforation. Overfilling also stretches and thins the detrusor, which is another risk factor.
Transurethral resection (TUR) syndrome due to fluid absorption is uncommon unless the tumor being resected is particularly large. If this is a concern, glycine prevents hemolysis, but not hyponatremia.
Overuse of cautery at the base of the tumor increases cautery artifact, which can complicate pathological determination of muscle invasion status.
Postoperative Details of TURBT
Occasionally, a catheter may need to be left in place for 1-3 days after bladder biopsies. It is usually removed in the urology office.
Within the first 24 hours, a single intravesical instillation of mitomycin-C (40 mg in 20 mL of saline) has been shown to reduce the frequency of tumor recurrence and should be considered the standard of care after transurethral resection of bladder tumor (TURBT) or positive bladder biopsy findings. 
A second TURBT should be performed 2-6 weeks after initial TURBT for several patient populations, including after incomplete initial resection, if there is no muscularis propria in the specimen, all T1 tumors, and all high-grade tumors. A second TURBT can be omitted for patients with primary CIS or for solitary low-grade Ta tumors. The rationale for second TURBT is the risk of understaging, as well as the significant risk of residual tumor after initial TURBT.
New TURBT Techniques
Traditionally, TURBT was performed using monopolar electrocautery to provide the necessary energy for resecting the tumor and cauterizing blood vessels. More recently, as bipolar technology has emerged and improved, its application has extended to TURBT, with a potential benefit of decreased risk of bladder perforation from obturator reflex and decreased risk of TUR syndrome. With bipolar technology, the active and return electrodes are very close together on the loop so that the current does not travel through the patient’s body to an external pad, as is the case with monopolar cautery. This also allows for the use of nonconductive isotonic irrigation fluid, mitigating the aforementioned risks of TUR syndrome. 
Wang and colleagues were the first to report on bipolar TURBT and compared the pathologic specimens from 11 patients who underwent bipolar TURBT with a matched historic cohort of 11 patients who underwent standard monopolar TURBT.  No differences in the degree of cautery artifact were noted between the 2 groups, and a full and proper diagnosis was achieved in all cases when assessed by a single pathologist who was blinded to the form of electrocautery used.
Yang and associates retrospectively compared clinical and pathologic results in 115 patients who underwent bipolar (n=64) versus monopolar (n=51) TURBT.  Postoperative change in hemoglobin (-0.58±0.91 g/dL vs -0.95±1.28 g/dL, P =.038) and mean duration of catheterization (2.20±0.96 d vs 2.65±1.45 d, P =.026) favored the bipolar TURBT group. No difference in the grade of thermal damage was noted between the 2 groups as well. Furthermore, reducing the power settings to 50-W cutting and 40-W coagulation may reduce the incidence of obturator nerve reflex and bladder perforation to close to zero while still maintaining diagnostic and therapeutic efficacy. 
Photodynamic diagnosis (fluorescence cystoscopy)
Photodynamic diagnosis (PDD) has emerged as a viable adjunct to white-light (WL) cystoscopy to assist in the performance of a complete TURBT.  Lesions can be missed using WL cystoscopy, and PDD has been developed to assist in the detection of these lesions, reduce the rate of recurrence, and improve the completeness of resection. PDD exploits the photodynamic properties of several compounds, including hexaminolevulinate (HAL) (Hexvix, Cysview, Photocure; Oslo, Norway) and 5-aminolevulinic acid (5-ALA).
Approximately 1 hour prior to planned TURBT, 50 mL of reconstituted solution of HAL is instilled into the emptied bladder via an intravesical catheter. Following instillation, protoporphyrin IX accumulates preferentially in neoplastic tissue, producing a clearly demarcated red fluorescence with illumination with blue-violet light (380-440 nm). Cysview (HAL hydrochloride) was approved by the United States Food and Drug Administration in 2010 for use with the Karl Storz D-Light C PDD system with the blue-light (BL) setting as an adjunct to the WL setting in the detection of nonmuscle invasive papillary cancer of the bladder in patients suspected or known to have lesions on the basis of a prior cystoscopy.
A recent meta-analysis reviewed the raw data from prospective studies on 1,345 patients with known or suspected nonmuscle invasive bladder cancer on whom HAL and BL as an adjunct to WL cystoscopy.  HAL BL cystoscopy detected significantly more Ta tumors (14.7%; P < .001) and CIS lesions (40.8%; P < .001) than WL cystoscopy. Furthermore, recurrence rates up to 12 months were significantly lower overall with BL HAL versus WL cystoscopy (34.5% vs 45.4%; P =.006).
The European Association of Urology 2013 guidelines on nonmuscle invasive bladder cancer recommend PDD in patients who are suspected of harboring a high-grade tumor for guidance of TURBT. It is possible that BL HAL–assisted TURBT improves completeness and quality of resection and might obviate the need for perioperative intravesical instillation of chemotherapy or a second TURBT, but further study is needed in this area to test this hypothesis.
While 5-ALA is not currently approved for routine clinical use for the detection of bladder cancer in Europe or the United States, it has been extensively studied in numerous clinical trials. Furthermore, orally applied 5-ALA has been approved in Europe to enhance intraoperative detection of malignant glioma. Inoue et al evaluated the clinical value of PDD with intravesical (n=75) and oral (n=135) instillation of 5-ALA and PDD-guided TURBT for nonmuscle invasive bladder cancer in a multi-institutional retrospective study in 210 patients.  Rates of recurrence were compared with historical controls subjects who underwent TURBT with WL cystoscopy. 5-ALA–guided TURBT improved detection of CIS, as 72.1% of flat lesions (including dysplasia and CIS) could only be detected with BL 5-ALA–assisted TURBT. The route of administration of 5-ALA (oral vs intravesical) did not affect diagnostic accuracy or recurrence-free survival.
The management of nonmuscle invasive bladder cancer is expensive, stemming from high recurrence rates necessitating repeat TURBT and frequent surveillance cystoscopies. As HAL and 5-ALA have been shown to help increase the detection and reduce the recurrence of nonmuscle invasive bladder cancer, this technology may reduce the cost of bladder cancer management. Garfield et al assessed the cost effectiveness of BL HAL–assisted cystoscopy as an adjunct to WL cystoscopy versus WL cystoscopy alone at the time of initial TURBT and noted a cost savings of nearly $5,000 in the PDD group in their model over a 5-year projected period. [10, 11]
Narrowband imaging (NBI) technology takes advantage of the hypervascular nature of bladder cancer to aid in differentiation of normal urothelium. WL is filtered into 2 bandwidths of 415 and 540 nm, which is preferentially absorbed by hemoglobin in hypervascular neoplastic tissues. A recent meta-analysis evaluated the diagnostic accuracy of NBI-assisted cystoscopy compared with WL cystoscopy for nonmuscle invasive bladder cancer.  NBI detected tumors in an additional 17% of patients and found an additional 24% of tumors compared with WL cystoscopy. No difference in the rate of false-positive tumor detection was noted between NBI and WL cystoscopy. NBI may be a useful adjunct for the detection and management of nonmuscle invasive bladder cancer.