Transurethral Resection of Bladder Tumors (TURBT)

• Standard treatment for non-muscle-invasive bladder tumors (Ta, T1, Tis) & cTa low-grade tumors w/ the goal of removing all visible lesions
• Therapeutic option in patients w/ muscle-invasive bladder tumor if tumor growth is limited to the superficial muscle layer & if re-staging biopsies are negative for invasive tumor
• The strategy of resection depends on the size of the lesion
  
  • In small tumors (<1 cm in diameter), en bloc resection can be done, where the specimen contains the complete tumor plus part of the underlying bladder wall including muscle
  • For large tumors, resection is done in parts, which include exophytic part of the tumor, the underlying bladder wall w/ the detrusor muscle & the edges of the resection area
  • Separate resection of larger tumors provides good information about the vertical & horizontal extent of the tumor & helps to improve resection completeness

• Complete & correct TURBT is essential to achieve a good prognosis
  
  • An absence of detrusor muscle in the specimen is associated w/ a significantly higher risk of residual disease, early recurrence & tumor understaging

• Selected mapping biopsies & transurethral biopsy of the prostate must be considered if sessile lesion or Tis or high-grade disease is suspected
• A second TURBT is performed:
  
  • After 2-3 weeks of incomplete initial TURBT
  • If there is no muscle in the specimen after initial resection, w/ the exception of TaG1
  • When a high-grade, primary CIS, T1 tumor & possibly a Ta has been detected at the initial TURBT

• A second TURBT can increase recurrence-free survival, improve outcomes after Bacillus Calmette-Guerin (BCG) treatment & provide prognostic information

Radical Cystectomy

• Indicated in patients w/ non-muscle-invasive bladder cancer that have failed BCG treatment & in patients w/ highest risk of tumor progression
• Standard curative treatment for patients w/ muscle-invasive bladder cancer
  
  • Appropriate procedure in men involves cystoprostatectomy
  • While in women a cystectomy & a hysterectomy
  • Followed by the formation of a urinary diversion

• Should include the essential pelvic lymph node dissection
• Immediate radical cystectomy is suggested in patients w/ non-muscle invasive bladder cancer if:
  
  • TURBT staging accuracy for T1 tumors is low
  • Patients w/ non-muscle invasive bladder cancer experience disease progression to muscle-invasive disease

• Delaying cystectomy for >3 months may increase the risk of progression & cancer-specific mortality

Partial Cystectomy

• Indicated if the lesions develop on the dome of the bladder & have no associated Tis in other areas of urothelium
• The procedure begins w/ a laparotomy (intraperitoneal) & resection of the pelvic lymph nodes
  
  • If the intraoperative findings preclude a partial cystectomy, a radical cystectomy is performed

Fulguration

• Fulguration without biopsy is considered in patients w/ recurrent non-muscle-invasive bladder cancer if all of the following are present:
  
  • No previous bladder cancer that was intermediate- or high-risk
  • A disease-free interval of at least 6 months
  • Solitary papillary recurrence
  • A tumor diameter of ≤3 mm

• In patients w/ a history of small, Ta LG/G1 tumors, fulguration of small papillary recurrences on an outpatient basis can reduce the therapeutic burden & can be a treatment option