Cystoscopy with TURBT: Definition and Clinical Significance
Cystoscopy with TURBT (Transurethral Resection of Bladder Tumor) is a combined diagnostic and therapeutic procedure that involves visual examination of the bladder using a cystoscope followed by surgical removal of bladder tumors through the urethra, serving as the gold standard for diagnosing and treating non-muscle invasive bladder cancer.
Components of the Procedure
Cystoscopy
- A minimally invasive endoscopic procedure that allows direct visualization of the bladder lining using a thin tube with a camera (cystoscope) inserted through the urethra 1
- Enables detection of abnormal areas, tumors, and other bladder pathologies with sensitivity ranging from 87% to 100% 1
- May be performed using white light (conventional) or enhanced techniques such as blue light cystoscopy, which can identify lesions not visible with white light 1, 2
TURBT (Transurethral Resection of Bladder Tumor)
- Surgical procedure performed through the urethra to remove bladder tumors without external incisions 1, 3
- Serves dual purposes:
Clinical Objectives of TURBT
Diagnostic Goals
- Obtain adequate tissue specimen including muscle layer for proper staging 1
- Determine tumor grade, depth of invasion, and presence of carcinoma in situ 2
- Identify histological variants that may affect treatment decisions 1
- Assess for lymphovascular invasion and other prognostic factors 2
Therapeutic Goals
- Complete resection of all visible tumors when technically feasible 1, 3
- Achieve a visually and microscopically complete resection to improve patient outcomes 1
- Serve as definitive treatment for non-muscle invasive bladder cancer 4
- May be part of bladder-preserving approaches for select muscle-invasive cases 1
Technical Aspects of TURBT
Resection Techniques
- Conventional piecemeal resection using electrocautery loop 1, 3
- En bloc resection techniques for improved specimen quality and reduced tumor cell dispersal 4, 2
- Various energy sources may be used including monopolar, bipolar electrocautery, or laser 3, 2
Quality Requirements
- Adequate resection must include muscle in the specimen for proper staging 1
- Muscle may be omitted only in cases of documented low-grade Ta disease 1
- Biopsy of areas adjacent to papillary tumors in cases of suspected carcinoma in situ 1
- Consideration of prostate urethral biopsy in men 1
Clinical Indications for Repeat TURBT
Early Repeat TURBT (within six weeks) is indicated for:
- Incomplete initial resection 1
- No muscle in original specimen for high-grade disease 1
- Large or multi-focal lesions 1
- Any T1 lesion 1
- Select high-grade Ta lesions, especially if no muscle in specimen 1
- First resection that does not allow adequate staging/risk attribution 1
Post-TURBT Management
Immediate Post-Procedure Care
- Consideration of immediate postoperative intravesical chemotherapy within 24 hours for non-muscle invasive disease if no bladder perforation 1
- Mitomycin is the most commonly used agent for intravesical chemotherapy 1
Follow-up Based on Pathology Results
- Further treatment decisions based on tumor stage, grade, and other risk factors 1
- May include surveillance, intravesical therapy, repeat TURBT, or more radical interventions 1
Common Pitfalls and Caveats
Technical Challenges
- Understaging is common with TURBT alone, with up to 42% of patients being upstaged following cystectomy 1
- Incomplete resection can lead to early recurrence and progression 2
- Bladder perforation risk, especially with deep resections 3
Quality Control Measures
- Ensuring muscle is included in the specimen for proper staging 1
- Consideration of enhanced visualization techniques like blue light cystoscopy 1, 2
- Proper orientation and handling of specimens for pathological assessment 2
TURBT remains the cornerstone procedure for both diagnosis and initial management of bladder cancer, with its execution quality directly impacting patient outcomes and treatment decisions 3, 2.