Bladder tumor

Author: Huang Guohua et al. / Country:
Publisher:
Publish Date: 2002-11-01
Features: If the anterior wall of the bladder is resected for a tumor, the obturator nerve may be stimulated, resulting in sudden severe adduction of the ipsilateral lower limb. This severe movement may lead to bladder perforation. Several methods can be used to reduce the obturator nerve reactivity, including reducing the power of the electrocutting current or injecting local anesthetic into the obturator nerve. In special cases, general anesthesia with paralytic agents may be required to prevent this reaction. Regardless of the location, complete bladder tumor resection is the principle to prevent recurrence of bladder tumors. In addition to resecting the initial macroscopically visible tumor, we prefer to perform a deep resection down to the detrusor muscle. Deep tissue specimens help determine the depth of bladder tumor invasion. We also resect a 1 cm area around the tumor base and enhance cauterization of the tumor bed. The deep tissue specimen is sent separately for pathological examination. Transitional cell carcinoma invading the muscle layer can achieve good treatment outcomes after thorough transurethral resection. Barnes et al. noted that patients with B-stage (T2-T3a) tumors had a 31% 5-year survival rate with transurethral resection alone. They believed that many patients with invasive tumors who underwent extensive surgery could be controlled solely through transurethral resection. Herr et al. also found that patients with T2 and T3a stage tumors had similar 5-year survival rates after larger TURBT procedures compared to those who underwent more extensive surgeries.
Section 3: Complications and Postoperative Care
Bladder perforation and bleeding are two complications associated with TURBT. Other intraoperative complications include injury to the ureteral orifice, urethra, and glans penis. Postoperative complications include hyponatremia, hypovolemia, and hemolysis. Late complications include urethral stricture formation, vesicoureteral reflux, and bladder neck contracture.
Bladder perforation is one of the most important complications of TURBT. If fat is observed at the base of the resection site, perforation should be suspected. Other manifestations include abdominal pain and distension. If the inflow of irrigation fluid is less than the outflow, perforation must be considered. If a large perforation is detected, the surgeon should switch the irrigation fluid to mannitol solution, stop bleeding, and terminate the surgery. Bladder imaging will help determine the extent of bladder damage and differentiate between intraperitoneal and extraperitoneal perforation. Intraperitoneal perforation results in contrast extravasation, revealing the contours of intestinal loops, while extraperitoneal perforation produces a sunburst contrast image in the retroperitoneal cavity. Large intraperitoneal perforations typically require exploration, debridement, and initial suture. Small intraperitoneal perforations can be managed by placing an intraperitoneal drain and a large urethral catheter for several days, followed by non-gastrointestinal antimicrobial therapy postoperatively. If the perforation is extraperitoneal, the patient should undergo continuous bladder drainage without suprapubic drainage. Antimicrobial therapy is required postoperatively, typically for 7–10 days to allow for healing of extraperitoneal perforation.
The following measures can help prevent bladder perforation during TURBT:
① Avoid excessive bladder distension during surgery, as the bladder wall is thickest when nearly empty.
② Layered tumor resection, meticulous hemostasis, and clear visualization are essential for surgical safety.
③ Tumors located on the lateral wall may cause obturator nerve reflex. Reducing the power of the electrocutting current and avoiding excessive bladder distension can minimize the risk of this reflex. If these measures fail, general anesthesia with paralytic agents may be required for safe tumor resection.
Invasive, highly vascular tumors may cause troublesome bleeding. Layered tumor resection with meticulous hemostasis during surgery usually prevents significant bleeding. A rollerball electrode can be used to cauterize the base of the resected tumor and assist in hemostasis. Bladder distension or hypotension may give the surgeon a false sense of the bleeding having stopped, so final inspection and hemostasis of the resection site should be performed when the bladder is relatively empty and the patient's blood pressure is close to pre-anesthesia levels. If irrigation is required, placing a large catheter at the end of the surgery can be helpful.
After surgery, residual tissue fragments must be flushed from the bladder. This can be done by placing the resectoscope tip at the bladder base to allow debris to drain or by using suction through the sheath. The bladder is full, so this procedure may need to be repeated. Under direct visualization, the resectoscope's cutting loop can grasp and remove residual tissue. Alternatively, a Toomey syringe or Ellick evacuator can be used to clear residual tissue fragments. A 22F or 24F catheter is placed in the bladder and connected to a gravity drainage system. When the catheter is properly positioned, we prefer manual irrigation on demand rather than continuous bladder irrigation.
Small papillary tumors can be resected according to outpatient procedures, with catheter drainage placed only during the post-anesthesia recovery period. However, if a large portion of the bladder wall is resected, catheter drainage should be left in place overnight. For simple bladder tumor resection, we prefer continuous intravenous antimicrobial therapy for 24 hours, followed by oral medication for 3–5 days. If bladder perforation occurs during resection, we typically continue non-gastrointestinal antimicrobial therapy for 5–7 days. After catheter placement, anticholinergic drugs can help if the patient experiences bladder spasms. Postoperative use of laxatives is recommended to prevent postoperative bleeding caused by constipation.
Regular follow-up is essential for treating bladder tumors. Our standard protocol is for patients to undergo cystoscopy and urine cytology every 3 months for the first 2 years after surgery. If no recurrence is detected, follow-up cystoscopy and urine cytology can be extended to every 6 months. If recurrence remains absent after another 2 years, annual cystoscopy and urine cytology checks are recommended. Follow-up frequency can be reduced for single, well-differentiated papillary tumors.
Upper urinary tract imaging should also be performed regularly, as transitional cell carcinoma can recur in the upper tract. Our practice is to perform an intravenous pyelogram annually for the first 2 years after surgery, followed by every other year if no recurrence occurs.
Section 4: Intravesical Chemotherapy
Intravesical instillation of chemical or immunological agents is used for the prevention and treatment of transitional cell carcinoma of the bladder. The three most commonly used agents are BCG, thiotepa, and mitomycin C. Long-term randomized comparisons of these three agents show that BCG is most effective in preventing tumor recurrence. Patients with a high risk of recurrence after transurethral surgery, especially those with progressive lesions, should receive intravesical chemotherapy. Patients with low-grade, solitary papillary tumors have a low risk of recurrence (less than 5%). However, those with multiple tumors, carcinoma in situ, or high-grade superficial tumors with a high recurrence risk should be considered for intravesical chemotherapy.
Intravesical chemotherapy plays a role in both preventing recurrence and adjuvant treatment after transurethral surgery. It is used for tumors that are too large or numerous to be resected completely, unresectable tumors, and carcinoma in situ. Intravesical chemotherapy also provides prophylaxis for recurrent tumors after transurethral surgery or for patients with a high likelihood of recurrence.
Chemical or immunological agents for intravesical treatment are suitable for cases where transurethral surgery is incomplete or the disease is confirmed. Herr conducted extensive clinical trials using thiotepa, adriamycin, mitomycin C, and BCG for intravesical chemotherapy. The effectiveness he considered as completely successful was defined as no tumor manifestations observed through cystoscopy, biopsy, or cytology. The complete effectiveness rate for BCG was 71%, significantly higher than that of other chemotherapeutic agents.