Bladder Cancer
requires relaxation of the abdominal wall and often is aided by one hand pressing down on the lower abdomen. The location, configuration and number of tumours should be documented. A photograph is most useful and there are many systems that can be used to document this information for the patient record. ‘A picture is worth many words’ and I tend to refer to prior pictures as much as the dictated word when I discuss the results with a patient after the procedure or review my prior endoscopic procedures. The surgeon then performs any upper tract study that may be required, e.g. retrograde contrast study, ureteroscopy.
Tumour Resection
It is now time to remove any tumours and biopsy any areas that are suspicious for CIS or other neoplasms. A cold cup biopsy is very useful as it provides the best sample for the pathologist to determine grade and aid in the determination of depth of invasion, if present. It obviously avoids cautery artefact. If tumours appear low grade and confined to the urothelium, removal with the biopsy forceps and fulguration is safe and effective. I see no reason to obtain muscle for such tumours. On the other hand, if a tumour appears to be high grade, muscle should be part of the specimen to determine whether the stage is Ta, T1 (lamina propria invasion) or at least T2 (invasion of the muscularis propria).2
Obtaining muscle in the specimen is not
always simple, as indicated by the publications indicating the understaging of Ta/T1 tumours, as revealed by the discordance of the depth of invasion when comparing the result of the initial and second resection.13
walls of the bladder and I find it superior for tumour resection in these locations, while minimising the risk of perforation. I am not a believer that it is acceptable to perforate the bladder in an attempt to resect all of a tumour. If a tumour extends through the entire thickness of the bladder it is most unlikely a TUR will remove it all.
I use a strainer to retrieve the specimen during the procedure. It only takes one occasion to finish a case and search for the crucial specimen to emphasise the need for care in retrieving the tissue. I do not like to search the drapes for the small bits of tissue. A disposable strainer serves the purpose quite well.
The surgeon should ensure that the cautery peddle is positioned so as to be comfortably within reach. We recommend that the urologist practise stepping on the peddle prior to engaging the tissue with the activated loop. We liken this to a golf or baseball player taking a practice swing. The actual tumour resection should be performed in an orderly fashion beginning at one end of the tumour and resecting with a slow steady motion at a depth designed to safely remove all tumour and obtain muscle when necessary. It is useful to initiate the resection in normal urothelium and then continue into the tumour. This is particularly important for a repeat TUR. Some clinicians advocate that one should take a separate specimen from the depth of the resection and send it to the pathologist separately.15
This has led to the guidelines stipulating that following resection of a T1 tumour (and some advocate for high-grade Ta also) one should take the patient back to the operating room for a second resection to remove any residual tumour, which includes a re-resection of the site of prior resection to allow enhanced accuracy of staging.14–16
Proper staging is the basis for treatment of bladder cancer.
A recent paper highlighted some of these points. Mariappan et al.17 reviewed 398 TURBTs for Ta/T1 bladder cancers and determined whether or not muscle was in the specimen. When muscle was present, the three-month recurrence rate was 22 % and when not present, this rate was 44 %. TURBT by a more senior surgeon was also a predictor for muscle in the initial specimen and a lower three-month recurrence rate. The fact that only 67 % of all patients had muscle in the specimen highlights the fact that it is not easy to ensure this occurs even when the policy is to obtain muscle in TURBTs.
The urologist should strive to remove all tumour even if the tumour appears large and is obviously invading the muscularis propria. Once faced with the alternatives of cystectomy or bladder preservation, a patient may elect the latter and this requires a ‘complete resection’ for a chance of success.18
A patient’s age or co-morbidity may dictate
a bladder preservation approach and once again a ‘complete TURBT’ is an important prognostic factor for success.
Just as in sports, there may not be one perfect way to swing and hit a ball, so too there may be different manoeuvres that facilitate TURBT. I prefer to sit during endoscopy and tumour resection. The camera can swivel and thus there is no need to rest one hand on the camera. I position my right hand on the resectoscope with my thumb in position to move the loop. My left hand either rests on the left side of the sheath or provides suprapubic pressure and moves the bladder towards the resectoscope. I will select a right-angle or 90 degree loop for the removal of tumours at the bladder neck or trigone and a bladder wall or angled loop for all other locations. The angled loop conforms to the
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One can consider obtaining cold cup biopsies from normal-appearing urothelium. The likelihood that normal-appearing urothelium contains CIS is low and thus in the absence of a specific indication for sampling of ‘normal’ bladder, i.e. partial cystectomy candidate or positive cytology without evident tumour, I do not perform selected site or random biopsies.19,20
The Prostatic Urethra
There is no perfect rule about when to perform TUR of the prostatic urethra to sample the urothelium at this location. There are some patients at risk of tumour in the prostatic urethra and when in doubt, this region should be biopsied. If tissue from the prostatic urethra is important it should be obtained with the resectoscope and not with cold cup biopsies.21–24
The goal is to obtain a sample of the prostatic
ducts as well as the urothelium. If the ducts are invaded by a high-grade urothelial carcinoma (UC) then stroma must also be present to evaluate whether there is stromal invasion. Patients more likely to have UC in the prostate are those with high-grade UC at the bladder neck, CIS, multifocal high-grade UC, post-bacillus Calmette-Guérin (BCG) for CIS or high-grade Ta/T1.23,24
There may
be some additional morbidity as a trade-off for a resection of even some of the prostate. The requirement for a urethral catheter and the possibility of retrograde ejaculation are two of these consequences.
Fluorescence Endoscopy
Now that we have covered the basics, are there methods we can utilise to enhance the current endoscopic methods to ensure a safe and complete removal of all tumours in the bladder? There is substantial evidence that many TURBTs do not remove all tumour. Fluorescence endoscopy (FE) was developed to improve the ability to identify neoplastic urothelium.25–27
FE requires instillation of an exogenous
photosensitiser into the bladder approximately one hour prior to the endoscopy. The agent used in almost all current studies is hexaminolevulinic acid or Cysview™. A specially designed light source is required. The urologist examines the bladder first with conventional
EUROPEAN UROLOGICAL REVIEW
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