Endoscopy | Bladder Biopsy & Tumor Resection (TURBT)

Indications are described above. TURBT aims to:

1. Establish a diagnosis by providing a sample for microscopic analysis.

2. Remove as much tumor as possible - with the goal of removing all the tumor and curing the cancer.

The benefits include establishing a diagnosis and potentially curing the bladder cancer. This is all in the service of avoiding the consequences of untreated bladder cancer.

Untreated bladder cancer may be a life-threatening cancer. Untreated high-grade bladder cancer invariably progresses and may cause a number of complications including but not limited to: pain and suffering, bleeding including urinary retention from clot, obstruction of the kidneys (which may result in permanent loss of function and kidney failure), obstruction of outlet, perforation of the bladder and erosion through the bladder and invasion to adjacent organs (bowel, pelvic floor) and spread through out the body.

Low grade bladder cancers have a limited ability to metastasize and spread by may cause bleeding, obstruction and pain.

Please review the detailed description of risks in the section below. Long-term complications are very uncommon but short term disability is expected. Risks may be categorized as:

1. Immediate surgical complications: bleeding, infection, perforation.

2. Long-term surgical complications (see below).

3. Temporary post-operative symptoms. Urinary urgency, frequency (often severe every 15-30 minutes), burning during and after urination, blood and debris in the urine are common during the healing phase. These are expected to completely resolve over 3-6 weeks, and often sooner.

4. Risks associated with anesthesia and surgery in general.

TURBT is a minimally invasive surgery typically taking 15-60 minutes . TURBT is usually performed in the operating room and is done on an outpatient basis (i.e. no overnight stay is required). You should not have any pain during the surgery.

TURBT is done transurethrally - this means that there is no external cutting. A resectoscope is utilized to access the bladder through the urethra (the urinary pipe through which people urinate). A resectoscope is essentially a slim metal pipe through which surgery can be done in a minimally invasive way.

Anesthesia is required and this may range from some sedation and pain medication combined with freezing, a spinal anesthetic (which temporarily ‘freezes’ a patient from the waist down so they have no sensation or pain) through to a general anesthetic. The anesthesiologist will discuss options and the best approach for you.

Prophylactic antibiotics are always prescribed to minimize the risk of infection. Patients should NOT feel any pain during the surgery. Some patients may have a sensation of ‘fullness’ or ‘pressure’ in the pelvis.

The tumor is removed using electrosurgery - an electrically charged loop allows the tumor to be shaved off the inside of the bladder. Either a ‘monopolar’ or ‘bipolar’ approach is used. Once the tumor is shaved off, the shaved area is coagulated to control bleeding. Having said that, there is almost always some minor blood in the urine after surgery and sometimes the bleeding may be more serious. If indicated, small samples (biopsies) may be taken from other areas of the bladder or from the prostatic urethra.

If indicated, additional medication may be placed in the bladder to improve the chances of cure. At the completion of surgery a catheter may be left in the bladder to facilitate drainage or irrigation. Most patients will not require a catheter. Prolonged catheterization (anything longer than a few hours to a few days) is uncommon but may be necessary if a perforation has occurred.

The visual appearance of urothelial carcinoma of the bladder is often very specific. However, there is no substitute or alternative when a diagnosis of bladder tumor is necessary. Because bladder cancer may be life-threatening, an accurate diagnosis is necessary.

Only TURBT can establish risk by identifying the grade of the tumor, depth of invasion and if any adverse pathologic findings are present. Special testing may be necessary on the tissue sample.

In rare cases, a biopsy may be satisfactory but biopsy is simply a TURBT writ small and only useful in select circumstances.

Urine testing (urine cytology) is not accurate enough to establish a diagnosis.

Imaging studies do not provide the information necessary to establish a diagnosis or the risk a tumor poses.

A TURBT is done in the operating room and patients are typically discharged the same day as surgery (day care surgery).

If necessary, an anesthesiologist and potentially an internal medicine doctor will consult you prior to surgery to ensure that the surgery can be conducted as safely as possible. They will inform you of which medications to take or discontinue, any preparations or tests that are necessary prior to surgery.

You will be informed of the date of surgery well in advance of the date. You will be advised of the time that you need to come to hospital one business day prior to surgery.

See above.

The vast majority of patients are able to go home the same day, but some over-night hospital stay, especially elderly men and those who had large bladder tumors that required an extended resection.

If you have a spinal anesthetic you will need to remain in the recovery room until it wears off - this takes about 3 hours.

The majority of patients will go home WITHOUT a urinary catheter.

Irrigation. At completion of the procedure, some patients may require an urethral catheter to allow flushing of blood from the bladder. An irrigation system is used for Continuous Bladder Irrigation (CBI). This flushes out the blood before it has an opportunity to clot and block the catheter. The bleeding will settle and once the outflow is clear, the CBI can be stopped.

Once the urine is clear, the catheter can be removed. Sometimes this is done before the patient is sent home. Other times, the catheter will be removed a few days after the patient has gone home (either by the patient, a doctor or a nurse - we will specify which).

If you are discharged home with a catheter you will:

• Receive instruction on how to drain the collection bag.

• Be provided information on either how to remove the catheter on your own or have an appointment scheduled with either your urologist or the urology specialty nurse to remove the catheter for you (either in the office or hospital - we will let you know).

• You may be discharged home with a prescription for antibiotics or pain medication.

We recommend avoiding constipation by modifying your diet and taking laxatives (e.g. Restoralax, metamucil, etc.) as preventative measures.

All surgery is associated with some risk and TURBT is no different. These risks can be separated into 2 general categories.

ANESTHETIC RISKS

These are issues that may arise as a result of the specific anesthetic technique or your general health (including your respiratory and cardiac status) and medications (e.g. blood thinners). Anesthesia and, if necessary, internal medicine will assess your risk prior to surgery and inform you of those risks. In some cases, the risk may be prohibitive and surgery may not be possible. Everything possible to optimize your health will be done prior to surgery and you may require additional testing before we can schedule surgery.

PROCEDURE-SPECIFIC RISKS

Post-operative urinary symptoms, some pain and bleeding to varying extents are expected.

• Bleeding. Some bleeding is expected and is usually light and self-limited. Blood transfusion is rarely necessary. The risk of requiring a blood transfusion is very low at much less than 1%. The risk of significant bleeding is increased in patients whose tumors are extensive or those who need to restart blood thinners (anticoagulants or antiplatelets) after surgery.

• Infection. The risk is 5% or less. Patients with indwelling catheters will be at increased risk of infection.

• TUR syndrome. This occurs with excessive fluids absorption and is uncommon in TURBT. This is managed with supportive care.

• Perforation: see below.

• Rare risks (<1%): deep venous thrombosis, septic shock, death, other. The risk of these sorts of complications is very low.

The bladder has a relatively thin wall. A perforation is when a hold is made in the bladder. When perforation occurs, it is a result of an attempt to adequately sample and remove all of the cancer.

Minor, clinically insignificant bladder perforations are fairly common. One study showed that about 50% of patients had bladder perforations during TURBT; however, these bladder perforations were identified with a type of test that does not accurately reflect the sort of circumstances commonly found after surgery - a cystometrogram was performed by filling the bladder >300 mL which is not what would happen clinically unless a patient went into urinary retention after surgery. In practice, about 1 in 100 patients will have clinically meaningful bladder perforations.

When bladder perforations are recognized at the time of surgery, the management is to place a urethral catheter for drainage. This is typically left for 1-3 weeks at which time the catheter is removed. The bladder will almost always heal uneventfully without long term consequences. However, perforation may result in clinically significant spillage of tumor outside of the bladder or formation of urine collections. These rare complications may be life-threatening and require additional surgery to fix them.

Patients with bladder tumors involving the area of the trigone (the area on the floor of the bladder near the bladder neck). The ureteral orifices inhabit this area - where the kidneys drain into the bladder. The ureteral orifices may not be visible and in the process of tumor removal they may be unavoidably resected as well. In most cases, the area will heal without issue but in some circumstances they will scar down and block drainage from the kidneys.

If the ureteral orifices can be identified at the time of surgery, they will usually be temporarily stented for a few weeks. Imaging with ultrasound or CT may be necessary to establish that the ureteral orifices have healed well.

The majority of changes in urination after TURBT are temporary.

Short Term Changes: 3-6 weeks.

It is entirely normal to have temporary changes in urination. Most commonly these changes involve:

• Urinary frequency and urgency: having an inability to postpone urination as well as more frequent urination day and night. In severe cases, patients may struggle to reach the toilet in time and be incontinent. Most patients do NOT require diapers or pads after surgery.

• Transient urinary retention (an inability to urinate). More common in males with underlying BPH. Typically resolves after temporary catheterization and the use of a BPH medication such as Flomax (tamsulosin). May appear in the first few days after surgery.

• Burning with urination.

• Pain at the end of urination. More common in patients with tumors near the bladder neck.

• Blood and debris in the urine. May pass pieces of tissue or clot.

Bladder relaxants and analgesics are effective in minimizing symptoms.

Long Term Changes: longer than 6 weeks.

Long term alteration in urinary function is uncommon. However, based on the extent of the tumor and response to surgery, some patients may experience long term issues with urination. Many of these are amenable to surgical correction. Bladder perforation: usually managed with a catheter to drain the bladder for several weeks but may require open surgery to correct (the latter occurs in less than 1 in 100 cases)

1. Retrograde ejaculation: loss of antegrade ejaculation may occur in males where resection of tumor at the bladder neck is required.

2. Bladder neck contracture: scarring of the bladder neck if extensive resection is required.

3. Urethral stricture: passage of the scope or the catheter may induce a scar within the pipe draining the bladder (urethra). This is usually managed with dilation but in rare cases the stricture may require formal repair with urethroplasty.

4. Incontinence: extensive resection of the bladder neck may result in loss of urinary control. This is very, very rare and if the possibility exists your urologist will discuss this with you.

This is the most single important action following TURBT.

Executive summary: Avoidance of clot urinary retention is the key to a smooth post-operative course. Drink lots of fluids, including at night when you wake to void, until the bleeding subsides. Any fluid will do. Be especially diligent in the first week after surgery. Taper fluid intake after 1-2 weeks but drink more and urinate more anytime you see more blood. Do not exceed 5 liters of fluid per day.

Blood is expected in the urine after surgery and this may continue for up to 6 weeks. In patients who require an anticoagulant, the bleeding may persist for a few months. The amount of blood is usually very small since most of the fluid is urine. The real risk is the formation of clot which can obstruct the catheter or urine. Once one clot obstructs the urethra (or catheter) more clot will form behind the first clot and create more problems.

Bleeding always stops (return trips to the operating room are rarely required) but clot retention always requires intervention and a trip back to the hospital. This may involve irrigating the clot from the bladder, restarting the continuous bladder irrigation or a trip back the operating room.

We may leave a catheter in for several days to facilitate continuous drainage of urine to minimize the risk of clot formation.

Advance to usual diet as tolerated. Avoid foods which constipate you.

Drink enough water to keep your urine reasonably clear! This the the more important thing that patients must do. As the urine clears over the days and weeks following surgery you may decrease the fluid intake. Adjust your fluid intake based on the appearance of the urine and ensure that you drink more, urinate more frequently and rest if you see more blood in the urine. Most patients should drink 8-10 glasses of water (or other fluid) per day and should drink at night (especially for the first week or so).

You can resume your regular diet and fluids as soon as you leave hospital. Feel free to drink coffee, tea, etc. unless you think it is causing you to urinate more frequently or causing pain (it causes no problems in most patients).

Be sure you are able to have easy bowel movements because straining because of constipation may lead to bleeding.

Get up and about as soon as possible after surgery.

Be reasonable and use your judgement.

Walk as tolerated.

Avoid any heavy physical activity or 'exercise' for about 6 weeks after surgery. This will increase the risk of bleeding and risks a return trip to the hospital. Heavy activity and exercise will be different for everyone but in general:

• No lifting anything more than 20-30 lbs.

• No bicycle riding. No going to the gym.

You may start showering the day after surgery, even if you have a catheter. Do not submerge in a tub bath until the catheter is removed.

Review catheter care instructions.

Aside from a single dose prior to surgery antibiotics are NOT routinely prescribed after surgery.

Pain management: most patients do not need anything more than acetaminophen (Tylenol). Use prescription pain medication as needed.

Stool softener should be taken regularly (obtain over the counter at local pharmacy). Stop taking stool softeners once you are having soft bowel movements. Do not take stool softeners if diarrhea occurs. If you have not had a bowel movement by the 3rd day after your surgery, take a laxative.

Regular Medications. You may begin your regular medications when you leave the hospital unless instructed otherwise. If you are on blood thinners, your doctor will tell you when it is safe to resume them. Generally 4 weeks after surgery but your doctor may advise you to start sooner.

Patients who undergo surgery of any kind may need acute medical care during their recovery and are subject to temporary risks directly related to the surgery. Please note that the medical conditions that form the reason for such surgery also pose a number of specific risks.

We advice patients who undergo TURP to have readily accessible medical care for about 6 weeks following the procedure. For patients who develop a complication, this time may be longer.

Travel in country: Patients are generally able to travel by car or plane within days of surgery. They should have easy access to a washroom and follow the instructions as listed above. No heavy lifting, drink fluids and urinate frequently.

Travel out of country: The same advice any travel pertains here but it is very important that you have a good understanding of how you might obtain medical assistance while out of the country. Please review your travel insurance policy and we strongly recommend that you understand what disclosures are necessary under that policy. We are unable to ‘clear you for travel’ or determine if you are eligible for travel insurance but are happy to complete any forms that are necessary for the insurance company to assess your application or claim. Fees will apply.

Please note that most travel insurance policies require full disclosure of all pre-existing medical conditions and any recent changes (including but not limited to surgery and medications). Failure to disclose such information may render your policy void.

We recommend you speak with the insurance company and/or consult a lawyer to answer any questions you have.