Transurethral Resection of Bladder Tumors (TURBT)

• Standard treatment for non-muscle invasive bladder tumors (Ta, T1, Tis) and cTa low-grade tumors with the goal of removing all visible lesions
• Therapeutic option in patients with muscle invasive bladder tumor if tumor growth is limited to the superficial muscle layer and 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 the muscle
  • For large tumors and suspected muscle invasive bladder cancer, resection is done in parts, which include exophytic part of the tumor, the underlying bladder wall with the detrusor muscle and the edges of the resection area
    • Separate resection of larger tumors provides good information about the vertical and horizontal extent of the tumor and helps to improve resection completeness

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

• Selected mapping biopsies and 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 detrusor muscle in the specimen after initial resection, with the exception of TaG1
  • When a high-grade, primary CIS, T1 tumor and possibly a Ta has been detected at the initial TURBT

• A second TURBT can increase recurrence-free survival, improve outcomes after BCG treatment and provide prognostic information

Radical Cystectomy

• Indicated in patients with non-muscle invasive bladder cancer that have failed BCG treatment and in patients with highest risk of tumor progression
  • Also done in patients with residual high-grade cT1, variant histology, lymphovascular invasion, and concomitant CIS
• Standard curative treatment for patients with muscle invasive bladder cancer (cT2, cT3, cT4a, select cT4b)
  
  • Appropriate procedure in men involves cystoprostatectomy
  • While in women, a cystectomy and a hysterectomy may be done; in selected female patients, preservation of the uterus, vagina and/or ovaries should be done if possible
  • Followed by the formation of a urinary diversion either by ureterocutaneostomy, ileal conduit, continent cutaneous urinary diversion, ureterocolonic diversion, or orthotopic bladder

• Should include the essential pelvic lymph node dissection including common, internal iliac, external iliac and obturator nodes
• Done in combination with Cisplatin-based neoadjuvant chemotherapy for patients with cT2-cT4a disease
• Immediate radical cystectomy is suggested in patients with non-muscle invasive bladder cancer if:
  
  • TURBT staging accuracy for T1 tumors is low
  • Patients with non-muscle invasive bladder cancer experience disease progression to muscle invasive disease

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

Partial Cystectomy

• May be considered in small, solitary cT2 muscle invasive bladder cancer lesion 
  • Indicated if the lesions develop on the dome of the bladder and have no associated Tis in other areas of urothelium
• Done in combination with Cisplatin-based neoadjuvant chemotherapy 
• The procedure begins with a laparotomy (intraperitoneal) and 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 with 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 with a history of small, Ta LG/G1 tumors, fulguration of small papillary recurrences on an outpatient basis can reduce the therapeutic burden and can be a treatment option