TURBT: Resection, Staging and Surgical Judgement

Interactive bladder map & operative flowMap the tumour, then resect with intent — systematic, complete, muscle-sampled.

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Transparent bladder shell with trigone, both ureteric orifices, bladder neck, dome, anterior/posterior/lateral walls, a diverticulum pocket and the obturator nerves running outside each lateral wall.

Tumour presets

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Each preset repositions the lesion and highlights the relevant danger zone and resection considerations.

Operative flow with decision overlays

Visual urethroscopyInspect urethra on the way in — stricture, prostate, false passage.

Full bladder inspectionSystematic survey of all walls, dome, neck — do not tunnel-vision onto the obvious tumour.

Identify both ureteric orificesLocate before resecting; note position relative to tumour and efflux.

Map tumour: number, size, location, morphologySolitary vs multifocal; papillary vs sessile/solid; record for staging tables.

Decide optical enhancementWhite light · NBI · PDD (photodynamic) if available — improves detection of CIS/satellite lesions.

Decide techniqueCold cup · monopolar/bipolar loop · en-bloc resection · roly-ball/fulguration for haemostasis.

Resect tumourShort controlled cuts; orient to the wall; stay aware of the lateral-wall danger zone.

Obtain detrusor muscleSample the deep base unless clearly low-grade Ta — quality marker & staging requirement.

HaemostasisIdentify bleeders; coagulate; confirm clear view before withdrawal.

EUA after resectionRe-assess bimanually for residual mass / fixation.

Catheter · irrigation · intravesical chemo decisionSingle-dose mitomycin where appropriate — withhold if perforation suspected.

Op-note checklistDocument completeness, depth, specimens, complications and onward plan.

Copy op-note checklist +

Pre-filled template — edit inline, then copy.

Danger zonesUreteric orifice & obturator nerve — anticipate before you cut.

Obturator nerve — lateral wall

Resection current at the lateral wall can stimulate the obturator nerve → sudden adductor jerk → loop dives into / through the wall.

Prevention checklist

Recognise the lateral wall danger zone

Discuss obturator block / paralysis with anaesthetist

Use short, controlled cuts

Lower current if appropriate

Avoid overdistension

Keep the loop visible at all times

Be ready to withdraw the scope

Stabilise the patient's pelvis / legs if needed

Convert strategy if unsafe

Ureteric orifice troubleshooting

Tumour close to, or overlying, a ureteric orifice. Identify the UO first and minimise coagulation around it.

Tumour close to UO

Identify the UO first
Careful pure cutting current where possible
Minimise coagulation around the UO
Consider a guidewire before resection if the UO will be obscured
Avoid placing a JJ before resection if it risks cutting the stent
After resection, look for lumen and efflux

UO resected, lumen visible

Document: "UO resected, lumen visible, efflux seen / not seen"
Consider JJ stent if: deep resection, solitary kidney, hydronephrosis, uncertain drainage, or heavy coagulation

UO lumen lost

Attempt guidewire carefully if safe
Consider retrograde study or JJ
If not possible & obstruction risk high: post-op imaging; consider nephrostomy / antegrade stent if obstructed

Warning

Do not give immediate intravesical mitomycin if perforation is suspected.

ComplicationsPerforation recognition, escalation and the second-look decision.

Perforation — extraperitoneal vs intraperitoneal

A · Extraperitoneal

Perivesical fat visible at the defect, limited extravasation.

B · Intraperitoneal

Dome defect, bowel loops visible, abdominal distension.

Decision tree

Conservative

Fat seen, small, stable, haemostasis achieved, no major distension → catheter drainage, observe, no MMC.

Escalate now

Marked abdominal distension, bowel seen, dome perforation, uncontrolled bleeding, sepsis or pain → urgent consultant escalation, repair / exploration, check for bowel thermal injury.

Document

Perforation type, site, estimated severity, that intravesical chemo was withheld, and the catheter duration plan.

Second-look (re-staging) TURBT

Resect the primary site again within 2–6 weeks when indicated. Triggers:

Incomplete initial TURBT No detrusor muscle (except clear Ta low-grade/G1 or primary CIS) T1 tumour High-risk NMIBC Doubt about completeness

Purpose, EUA & the MIBC pathwayWhy are you doing this TURBT? The answer changes the operation.

Decision · what is the purpose of this TURBT?

Diagnostic and staging

Establish histology, grade and stage; map disease extent.

Complete treatment of NMIBC

Fully resect non-muscle-invasive disease with muscle in the specimen.

Palliation of bleeding

Control haematuria / debulk in unfit or advanced disease.

Debulking before radiotherapy / trimodality

Maximal safe debulk to optimise bladder-preservation outcomes.

Confirmed or strongly suspected MIBC

Tap for the teaching point and op-note reminder.

Aim

If imaging/cystoscopy suggests muscle-invasive disease, the aim is not a heroic full-thickness resection. Aim for safe histological confirmation and staging with detrusor muscle, adequate haemostasis, and debulking if radiotherapy/trimodality therapy is being considered. Send the deep portion separately. Avoid perforation and delay to definitive treatment.

Op-note reminder

Ask the anaesthetist whether the patient appears fit for radical cystectomy / major pelvic surgery and document: ASA, frailty concerns, cardiopulmonary concerns, anticoagulation issues, and whether cystectomy fitness requires formal pre-assessment.

Examination under anaesthesia (EUA)

Bimanual palpation — assess mobility and fixation.

Why

EUA before and after TURBT helps estimate clinical stage and detect fixation / residual induration. Document clearly, but interpret cautiously — clinical staging can overstage or understage.

Op-note fields

MIBC pathway

CT / MRI: suspected MIBC→ TURBT: staging / debulking→ MDT→ Systemic therapy suitability→ CystectomyvsTrimodality therapy

Specimen quality & stagingSeparate pots, labelled clearly, with detrusor in the deep base.

Specimen tray

POT 1

Exophytic tumour

The visible papillary / solid lesion.

POT 2

Deep base / detrusor muscle

Sent separately — the staging specimen.

POT 3

Edge / margin

If taken.

POT 4

Abnormal mucosa / CIS biopsy

If indicated.

POT 5

Prostatic urethra biopsy

If indicated.

Technique

Send the tumour base / deep detrusor separately, especially in large, multifocal, sessile or suspected invasive tumours. Avoid excessive cautery artefact. Tell pathology what each pot represents.

Bladder wall depth & T-stage

Ta — mucosa only (non-invasive papillary)

TaT1T2T3T4

Why detrusor matters

Muscularis propria in the specimen lets pathology distinguish T1 from T2 — without it, the tumour cannot be reliably staged and early-recurrence risk rises.

FRCS viva cardsTap a card to reveal the model answer.

Guidelines & evidenceEAU · NICE · landmark studies.

EAU 2026 +

Systematic, complete TURBT
EUA before and after
Detrusor muscle in the specimen
Separate specimens for deep base
Defined second-TURBT indications

NICE NG2 / QS106 +

Detrusor muscle in the resection
Record tumour size & number
Consider CT / MRI before TURBT if MIBC suspected
Mitomycin at first TURBT when appropriate
Repeat TURBT within 6 weeks if no detrusor muscle

FRCS studies +

Mariappan — detrusor muscle as a TURBT quality marker & early-recurrence predictor
Brausi — institution-level variation in early recurrence after TURBT
Sylvester / EORTC — recurrence & progression risk tables
Herr & Donat — quality control and restaging TURBT
BC2001 — chemoradiotherapy evidence for bladder preservation
NIAGARA — modern perioperative systemic therapy update for MIBC