A bladder cancer TUR-T (Transurethral resection of tumor) operation is a minimally invasive surgical procedure used to diagnose, treat, and manage bladder cancer. TUR is often the first step in bladder cancer treatment, helping to determine the stage and grade of the cancer, and in some cases, it may remove the tumor entirely if it is superficial. This procedure typically requires a short hospital stay and is crucial in both diagnosis and initial cancer management.

What is TUR-T operation?

A TUR or TUR-T operation for bladder cancer is a key procedure used to both diagnose and treat bladder cancer. This is an endoscopic surgery. In this operation, a surgeon removes abnormal tissue or tumors from the bladder by using a thin, tube-like instrument called a resectoscope, which is inserted through the urethra.

It is generally used for non-muscle invasive bladder cancer (early-stage cancers that haven’t penetrated the bladder’s deeper layers). It may serve as the primary treatment for small, superficial tumors or as a diagnostic step before further treatments, like chemotherapy or bladder removal surgery, depending on the cancer’s severity.

What are the indications?

The TUR operation for bladder cancer is indicated in the following scenarios:

• Diagnosis of Bladder Cancer: TUR is often performed to confirm the presence of bladder cancer. It allows for the collection of tissue samples for biopsy, helping to determine the type, stage, and grade of cancer.
• Non-Muscle Invasive Bladder Cancer: This is the primary treatment for superficial (non-muscle invasive) bladder tumors.
• Tumor Removal: In cases where the tumor is small and localized, TUR may be performed to completely remove the tumor. This can sometimes be curative for early-stage cancers.
• Staging of Bladder Cancer: For bladder cancers that may have progressed, TUR is used to assess the depth of invasion into the bladder wall, helping in staging and planning further treatment.
• Treatment of Recurrences: TUR-T can be used to remove recurrent bladder tumors, especially for patients with a history of non-muscle invasive bladder cancer that reappears after initial treatment.
• Management of Symptoms: It may also be indicated to relieve urinary symptoms caused by bladder tumors, such as hematuria (blood in urine), urinary frequency, or painful urination.
• Evaluation After Intravesical Therapy: After treatments like intravesical chemotherapy or immunotherapy, It may be performed to evaluate the response and check for residual or recurrent cancer.

Preoperative preparation

Since the procedure will be performed under anesthesia, patients are prepared similarly to other surgical procedures. Blood tests, an ECG, and a chest X-ray are requested. For elderly patients or those with other systemic diseases, consultations from relevant departments are obtained. If the patient is using aspirin or similar blood thinners, these are discontinued one week before the surgery, and if necessary, other medications with a lower bleeding risk are prescribed. The patient fasts for 6 hours beforehand and does not eat or drink anything. For elderly patients, compression stockings are applied to the legs to prevent blood clots from traveling to other parts of the body. Preventive (prophylactic) antibiotics are administered to protect against infection before surgery. Patients are given a consent form (patient information form) prepared for the TUR surgery to read, and their signature is obtained.

How to do operation?

TUR-T is an endoscopic surgical procedure performed with the patient lying on their back, with their legs bent and spread at the knees, and elevated. During this procedure, a cystoscopy is also performed. Under sterile conditions, a resectoscope (an instrument with an optical system projecting images onto a screen) is inserted through the urethra into the bladder. The urethra, especially the prostatic urethra, and the bladder are evaluated through the cystoscopy. The location, number, size of the tumor, the orifices (the entry points of the urine tubes from the kidneys into the bladder), and the tumor’s relation to the bladder neck are assessed. The tumor is then cut and removed using special endoscopic instruments called resectoscopes, and bleeding areas are cauterized to stop the bleeding.

The procedure is completed by inserting a urinary catheter (urethral catheter). Small and few tumors can be completely removed with this method. However, if the tumor is large or has multiple sites, it may not be fully removed, and a partial TUR is performed, with the removed tissue sent to pathology. Based on the pathology results, further necessary treatments are applied. The procedure typically lasts 30 minutes to 1 hour, depending on the size and number of tumors.

Type of anesthesia

Typically, spinal anesthesia (numbing from the waist down) is applied for TUR surgery. Sometimes, general anesthesia is used. It is best to administer the type of  anesthesia that the anesthesiologist deems appropriate.

Hospital stay

Patients begin to regain oral intake once the effects of anesthesia wear off (5-6 hours after general anesthesia) or immediately after surgery if spinal anesthesia was administered. The duration of the hospital stay varies depending on the patient’s age, general condition, and the size of the tumor. Patients with small tumors and no postoperative bleeding are typically discharged the next day. If the tumor is large and a deep, wide area has been resected, the stay may be 2, and sometimes 3 days. In cases with bleeding, the duration may extend for several more days based on the situation.

Are there any differences between men and women?

The surgery does not differ between men and women; the procedure is entirely the same. However, since the urethra (the urine channel leading to the bladder) is shorter in women, reaching the bladder and performing the resection is generally easier and more comfortable compared to men.

Is a catheter placed, and how long does it remain?

A catheter is placed after surgery. The duration it stays in depends on the size of the tumor. In cases of very small tumors without bleeding, it may be removed within 1-2 days. However, if a large and deep resection has been performed, particularly in patients with prostate issues, the catheter may remain for up to a week.

Is this surgery a definitive solution?

In early-stage tumors, a definitive solution is achieved through the complete removal of the tumor (complete TUR). However, in some cases, the tumor cannot be completely excised, but the pathological examination of the removed tissue guides further surgical and treatment options.

Can TUR be repeated (re-TUR) and when?

In some situations, the TUR procedure is repeated 2-6 weeks later, which we call re-TUR. This is done if the tumor was not fully removed, if there is no muscle tissue in the removed specimen, or in cases of high-grade tumors.

Treatment options based on the pathology

If the cancer in the bladder is less than 3 cm, newly detected, and low-grade, a single dose of chemotherapy is administered into the bladder within the first 24 hours (preferably within the first 6 hours), and the patient is placed under regular follow-up. If the pathology result indicates Stage 2 cancer, a radical cystectomy is performed. If there is no muscle tissue in the specimen, a re-TUR is performed 2-6 weeks later, as the presence of muscle tissue in the pathology is crucial for treatment decisions. If muscle tissue is present and the cancer has not spread to the body, a radical cystectomy is performed. In cases where patients are too old to withstand the surgery or if there is ongoing bleeding related to the tumor, and if the tumor is too large to be removed during the first surgery, a second operation is also performed. In this case, maximum resection is attempted in the second surgery, which helps prevent bleeding and enhances the effectiveness of other treatments like radiotherapy and chemotherapy if they are to be applied. This procedure is referred to as palliative TUR.

Is chemotherapy given to the bladder during or after?

In some patients, chemotherapy drugs are administered to the bladder in the early postoperative period (within the first 6 hours) following TUR. The purpose of administering chemotherapy after surgery is to prevent tumor recurrence in later periods. Scientific studies have shown that these chemotherapeutics, given early after surgery, help prevent cancer recurrence. However, specific criteria must be met: the tumor must be newly detected, less than 3 cm in diameter, in a single focus, low-grade, and completely resected. In such cases, a single dose of chemotherapy is administered within the first 6 hours after surgery.Formun Altı

Complications

This operation for bladder cancer is generally safe, but like any surgical procedure, it carries certain risks and potential complications. Below are the common and less frequent complications associated with the this operation:

Common Complications:

• Bleeding and clot retention.
  • Urinary tract infections (UTIs).
  • Pain, bladder spasms, or discomfort.
  • Temporary difficulty urinating.

Less Common or Serious Complications:

• Bladder perforation.
  • Persistent hematuria.
  • Bladder scarring or contracture.
  • Recurrent bladder cancer.
  • Sepsis (rare but serious).

Summary

A TUR-T operation is a minimally invasive procedure used to diagnose and treat bladder cancer. During the surgery, a resectoscope is inserted through the urethra into the bladder, where a wire loop with an electrical current is used to remove tumors from the bladder lining. The procedure requires no external incisions and allows for tissue sampling to determine the cancer’s stage and grade. This is often the primary treatment for non-muscle-invasive bladder cancer and may also help relieve symptoms like blood in the urine. Postoperative follow-up is essential to monitor for complications and detect potential cancer recurrence.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul- TURKIYE