Transurethral resection of tumors of the bladder (TURBT) using endoscopic equipment remains a critical step in the diagnosis and management of patients with bladder cancer. When properly completed it provides important information for decision making and is therapeutic in a large percentage of patients. Instruction to new trainees on the importance and performance of the TURBT remains an important part of their training, should be instituted early and has gained in importance as transurethral resection experience has decreased as medical management of benign prostatic hyperplasia has been adopted. Limited experience with the loop resectoscope for benign prostatic hyperplasia has put an increased focus on training proper technique for resection during the treatment of bladder cancer.

Table 1. Parts of the TURBT procedure training program

Table 2. Tumor characteristics that should be documented

There are several aspects of the TURBT that should be emphasized during training aside from the actual technique of cutting and retrieving tissue (table 1). Proper positioning of the patient should not be overlooked. Placing the perineum at the table’s edge is important to allow for full mobility of the resectoscope to reach all quadrants of the bladder, particularly the distal anterior wall. Leg positioning in the stirrups to eliminate pressure over the common peroneal nerve or restrict venous flow should be carefully adjusted. Importantly we need to teach the trainee to pay attention to avoiding any pressure being put on the patient’s legs by operating room assistants or scrub personnel during the procedure to avoid changes in leg position or injury.

The proper technique and goals of the examination under anesthesia (EUA) should be taught to every trainee. The goals of the EUA include determining the extent of disease to aid in staging and assessment of surgical resectability. This is not a prostate examination. The bimanual starts at the level of the umbilicus and a blotting technique is used to examine the entire pelvis for palpable masses, asymmetrical thickening of the bladder and fixation or involvement of adjacent organs or the pelvic sidewall. At the end of the EUA a rotation of the examiner’s finger will complete the evaluation of the rectal wall so that lesions within finger reach will not be missed. Encourage this be done on all cases of TURBT as the more experience gained during training, the more likely abnormal findings will be recognized.

Figure 1. White light (A) and narrow band imaging (B) views demonstrating region of carcinoma in situ seen with narrow band imaging only.

Trainees need to become familiar with the various pieces of equipment needed for the TURBT. Continuous and noncontinuous flow should be presented and the importance of proper bladder distension during the resection should be highlighted. Biopsy forceps, including when they are helpful, the techniques used to obtain tissues and their dangers, need to be demonstrated. The use of the various angled lenses should be discussed to demonstrate how best to completely visualize the bladder, particularly at the bladder neck region. Familiarize the trainee of the existence, availability and use of the extended equipment, including the circumstances when they will likely be needed. Differences in monopolar and bipolar technologies should be discussed, including differences in the irrigation fluids needed, and the technical variations in the use of the loop and roller ball.

Figure 2. Margin of resection during TURBT and relationship to submucosal bladder tumor growth.

The different types of anesthesia available for use during the TURBT should also be taught. Monitored anesthesia care, laryngeal mask airway or endotracheal tube intubation with or without paralysis should all be discussed, including the expected depth of sedation, differences in patient breathing patterns during each of these types of anesthesia (which will affect bladder wall movement) and when one may be preferred over another. Selection of the proper type and depth of sedation is an important key to ensure optimal resection is completed safely.

Careful and thorough observation of the location, configuration, number of tumors present and associated mucosal abnormalities is an important part of the TURBT. All should be taught how best to routinely record these findings (table 2). While white light is always used during the initial endoscopic evaluation, detailed instruction on the use of the different forms of white light enhanced technology (narrow band imaging or blue light) should be included in the training program (fig. 1). Increased experience with these newer technologies will facilitate their usefulness as training progresses. Strategies for the resection must be taught. For example, how to approach single vs multiple tumors, smaller vs larger tumors, lateral wall lesions and the possible obturator reflex that may be elicited, dome tumors and the expected movement of the bladder wall during resection, tumors around or involving the ureteral orifices, distal anterior bladder wall tumors and the need for manual compression of the lower abdominal wall. The actual resection technique, including how to properly engage the tumor with the loop, the use of different angled loops to provide optimal angles for resection, initiating the bladder wall incision 1–2 cm away from the tumor base to ensure complete resection of tentacular submucosal tumor growth (fig. 2), proper depth of resection, and knowing how to identify the perivesical fat and overt perforations (fig. 3) are all critical for proper and safe completion. Finally, how to manage complications, when to terminate the procedure and when to recommend restaging resection are all important components that require instruction.

Figure 3. View of perivesical fatty tissues during TURBT.

Like most surgical procedures hands-on experience is an important part of the learning process. Proper instruction, however, is equally if not more important. Simulation models for the TURBT have been limited in the past but I feel can be very useful. More recently, the development of useful models has been made available and should be supported for further development and distribution. Ultimately, real-life experience during residency and fellowship training will provide the needed technical skills to allow the next generation of urologists to successfully master this procedure and provide high quality care for bladder cancer patients in the future.