What are the indications for Transurethral Resection of the Prostate (TURP) with Transurethral Resection of Bladder Tumor (TURBT)?

Indications for TURP with TURBT

The primary indication for combining Transurethral Resection of the Prostate (TURP) with Transurethral Resection of Bladder Tumor (TURBT) is in patients with confirmed urothelial carcinoma of the prostate with ductal/acini or prostatic urethra involvement, requiring postsurgical intraprostatic BCG therapy. 1

Primary Indications

1. Urothelial Carcinoma Involving the Prostate

   • Confirmed prostatic ductal/acini involvement
   • Prostatic urethra involvement
   • Cases requiring post-surgical intraprostatic BCG therapy 1

2. Non-Muscle Invasive Bladder Cancer (NMIBC) with Concurrent BPH

   • Patients with bladder tumors who also have symptomatic benign prostatic hyperplasia 1
   • This combined approach addresses both conditions in a single procedure, reducing the need for multiple surgeries

Clinical Decision Algorithm

Step 1: Evaluate for Prostatic Involvement

• Determine if there is urothelial carcinoma involving the prostatic urethra or ductal/acini
• This is the strongest indication for combined procedure

Step 2: Assess for Symptomatic BPH in NMIBC Patients

• In patients with confirmed bladder tumors, evaluate for:
  • Acute urinary retention
  • Chronic complications (renal impairment, recurrent UTIs, bladder stones)
  • Symptomatic prostatism unresponsive to medical therapy 2

Step 3: Consider Technical Feasibility

• Ensure the patient can be placed in lithotomy position
• Rule out severe urethral stricture that would prevent instrument passage 3
• Evaluate if complete resection of both pathologies can be safely performed

Special Considerations

Fertility Concerns

• The combined procedure causes retrograde ejaculation in approximately 65.4% of patients 1
• For younger men concerned about fertility, consider:
  • Transurethral Incision of the Prostate (TUIP) for prostates ≤30g
  • Modified TURP techniques with selective resection 1

Contraindications

• Severe urethral stricture
• Inability to place patient in lithotomy position due to skeletal/muscle disease
• Patients requiring radical cystectomy 3
• Patients with bladder adenocarcinoma, squamous cell carcinoma, bladder diverticulum cancer, or urachal cancer 3

Procedural Approach

1. Initial TURBT Component

   • Resect visible bladder tumors deep into underlying detrusor muscle
   • For tumors <1 cm, resect along with part of the bladder wall
   • For large tumors, resect in fractions until normal bladder wall muscle is exposed
   • Ensure biopsy specimens include muscular tissue 3

2. TURP Component

   • Perform after completion of the TURBT portion
   • Ensure adequate resection of prostatic tissue, particularly in areas with suspected involvement

Post-Procedure Management

• Follow standard bladder cancer surveillance protocols
• Consider intravesical therapy based on pathological findings
• For patients with urothelial carcinoma of the prostate, administer intraprostatic BCG as recommended 1

Common Pitfalls to Avoid

• Failing to obtain adequate tissue samples including detrusor muscle in TURBT specimens
• Underestimating the need for repeat TURBT in high-risk tumors, T1 tumors, or G3/high-grade tumors 3
• Overlooking the need for prophylactic antibiotics, especially in patients with pyuria 2
• Not considering urodynamic studies to rule out concomitant bladder dysfunction before surgery 2

By following this structured approach, clinicians can appropriately identify patients who would benefit from combined TURP with TURBT procedures while minimizing complications and optimizing outcomes.