Pre-operative Management for TURBT
Mandatory Pre-operative Imaging
CT or MRI of the abdomen and pelvis should be performed before TURBT whenever logistically feasible to allow better anatomic characterization of the lesion and assessment of suspected depth of invasion. 1
- Cross-sectional imaging with intravenous contrast (if not contraindicated) is required for complete staging evaluation 1
- Upper tract evaluation must be completed using CT urography (preferred), MR urography, renal ultrasound with retrograde ureteropyelography, or ureteroscopy 1
- Chest imaging is required to complete staging workup 1
Pre-operative Laboratory Assessment
- Obtain comprehensive metabolic panel including complete blood count, liver function tests, alkaline phosphatase, and renal function 1
- Urine cytology may be obtained around the time of cystoscopy (not as a prerequisite for scheduling) 1
Pre-operative Counseling Requirements
- Discuss curative treatment options before determining therapy plan, using a multidisciplinary approach 1
- Counsel patients regarding complications and quality of life implications including impact on continence, sexual function, fertility, bowel dysfunction, and metabolic problems 1
- Screen for smoking and initiate smoking cessation treatment if appropriate 1
Intra-operative Technical Standards
Resection Technique Based on Tumor Size
Complete resection of all visible tumor with adequate detrusor muscle in the specimen is the primary goal of TURBT. 1
- Small tumors (<1 cm): Resect en bloc with complete tumor plus underlying bladder wall 1
- Larger tumors: Resect separately in fractions including exophytic portion, underlying bladder wall with detrusor muscle, and resection edges 1
- Submit specimens from different fractions in separate containers for accurate pathologic diagnosis 1
- Minimize cauterization to prevent tissue destruction 1
Mandatory Intra-operative Documentation
- Perform bimanual examination under anesthesia 1
- Document completeness of tumor resection (yes/no) and impression of depth of resection 1
- Create a bladder diagram 1
- Ensure adequate muscle sampling, particularly for high-grade disease 1
Biopsy Requirements for Specific Situations
- For solid/sessile lesions or suspected CIS/high-grade disease: Perform selected mapping biopsies 1
- For CIS: Biopsy sites adjacent to tumor and consider multiple random biopsies to assess field change 1
- Random biopsies of normal-appearing urothelium are NOT necessary for most patients, especially low-risk tumors 1
Immediate Post-operative Management (Within 24 Hours)
Single-Dose Intravesical Chemotherapy
Administer single-dose intravesical gemcitabine (preferred) or mitomycin within 24 hours of TURBT if non-muscle-invasive disease is suspected. 1
- Gemcitabine is preferred over mitomycin due to better tolerability and lower cost 1
- Both agents are category 1 recommendations 1
- This approach is supported primarily for low-volume, low-grade disease 1
- Single immediate instillation results in 12% absolute reduction in tumor recurrence (39% decrease in odds) 1
Critical Contraindications
Avoid immediate intravesical chemotherapy in cases of overt or suspected intraperitoneal or extraperitoneal perforation due to documented complications. 1
Timing is Critical
- Efficacy doubles if instillation occurs within 24 hours versus delayed administration 1
- Starting treatment within 6 hours is more effective than 7-14 days later 1
Post-operative Pathology Review
Pathology Consultation Requirements
An experienced genitourinary pathologist should review the pathology when variant histology is suspected or muscle invasion is equivocal. 1
- Variant histologies requiring expert review include micropapillary, nested, plasmacytoid, neuroendocrine, sarcomatoid, or extensive squamous/glandular differentiation 1
- Review pathology slides directly with the pathologist when possible 1
- Referred patients require slide review as substantial differences alter management in 30% of cases 1
Restaging TURBT (Repeat Resection)
Mandatory Indications for Repeat TURBT
Perform restaging TURBT 2-6 weeks after initial resection for the following situations: 1
- High-grade T1 tumors (all cases) 1
- Bulky high-grade Ta disease 1
- Incomplete initial resection 1
- No muscle tissue present in specimen 1
- Lymphovascular invasion present 1
Evidence Supporting Repeat TURBT
- Approximately 30% of T1 bladder cancer patients are understaged without restaging TURBT, resulting in potential undertreatment 1
- 20-40% of Ta high-grade patients without muscularis propria in specimen will have residual tumor and/or unrecognized muscle-invasive disease 1
- Residual tumor (pR1) found in 38% of additionally taken specimens across all stages 2
Current Practice Gap
- Only 4.9% of eligible patients undergo restaging TURBT within 60 days despite guideline recommendations 1
Adjuvant Intravesical Therapy Based on Risk Stratification
Low-Grade Ta Tumors
- TURBT with single immediate postoperative chemotherapy instillation is standard 1
- Observation alone is acceptable 1
- BCG is NOT indicated for low-risk disease 1
High-Grade Ta Tumors
Intravesical BCG is the preferred adjuvant treatment for high-grade lesions. 1
- BCG after TURBT is superior to TURBT alone or TURBT plus chemotherapy in preventing recurrences 1
- Alternative: Mitomycin C if BCG contraindicated 1
- Standard regimen: Once weekly for 6 weeks, followed by 4-6 week rest period 1
T1 and CIS (Tis) Tumors
- Complete endoscopic resection followed by intravesical BCG is standard therapy 1
- Maintenance BCG should be administered for patients with complete response to induction 1
- 90% of patients should complete 1 year of maintenance BCG after complete response 1
Surveillance and Follow-up Protocols
High-Grade Disease Follow-up
- Urinary cytology and cystoscopy at 3-month intervals for first 1-2 years 1
- Increase intervals over next 2 years 1
- Annual surveillance thereafter 1
- Upper tract imaging every 1-2 years for high-grade tumors 1
Low-Grade Disease Follow-up
- Initial cystoscopy at 3 months 1
- If no recurrence during first year, increase intervals between evaluations 1
Management of Positive Cytology with Negative Cystoscopy
When cytology is positive but cystoscopy is normal, evaluate upper tracts and prostatic urethra (in men), and consider ureteroscopy. 1
- Positive cytology may indicate urothelial tumor anywhere in the urinary tract 1
- Perform directed or selected mapping biopsies including TUR biopsies of prostate in males 3
- Random biopsies of normal-appearing mucosa to detect CIS 3
Complications and Risk Management
Common Complications (8.1% overall rate)
- Pain or spasm (3.0%) 4
- Urinary retention (2.8%) 4
- Infection (2.1%) 4
- Bladder perforation (0.5%) 4
- Over 85% are Clavien-Dindo grade I or II 4
Risk Factor for Complications
- Prior complication is the only significant predictor of subsequent complication on multivariable analysis 4