Transurethral Resection (TUR) for Bladder Cancer
Transurethral resection (TUR) of the bladder is a surgical procedure that is used both to diagnose bladder cancer and to remove cancerous tissue from the bladder. This procedure is also called a TURBT (transurethral resection for bladder tumor). General anesthesia or spinal anesthesia is often used.
During TUR surgery, a cystoscope is passed into the bladder through the urethra. A tool called a resectoscope is used to remove the cancer for biopsy and to burn away any remaining cancer cells.
Bladder cancer can come back after this surgery, so repeat TURs are sometimes needed.
What To Expect After Surgery
Following surgery, a catheter may be placed in the urethra to help stop bleeding and to prevent blockage of the urethra. When the bleeding has stopped, the catheter is removed. You may need to stay in the hospital 1 to 4 days.
You may feel the need to urinate frequently for a while after the surgery, but this should improve over time. You may have blood in your urine for up to 2 to 3 weeks following surgery.
You may be instructed to avoid strenuous activity for about 3 weeks following TUR.
Why It Is Done
TUR can be used to diagnose, stage, and treat bladder cancer.
- Diagnosis. TUR is used to examine the inside of the bladder to see whether there are cancer cells in the bladder.
- Staging. TUR can determine whether cancers are growing into the bladder wall.
- Treatment. One or more small tumors can be removed from inside the bladder during TUR.
How Well It Works
TUR is the most common and effective treatment for early-stage bladder cancer. It may also be effective for more advanced cancer if all the cancer is removed and biopsies show that no cancer cells remain.
The risks of TUR include:
- Bladder infection (cystitis).
- Perforation of the wall of the bladder.
- Blood in the urine (hematuria).
- Blockage of the urethra by blood clots in the bladder.
What To Think About
Treatment with TUR may be followed by chemotherapy or immunotherapy.
Credit: By Healthwise Staff – WebMD
Holmium Laser Enucleation of the prostate (HoLEP) is a modern alternative to the standard Transurethral Resection of the Prostate (TURP) procedure for bladder outflow obstruction due to BPH. It requires a short period of hospitalisation and an anaesthetic. A catheter (a tube which drains the bladder) is also needed for 1-2 days until the urine clears. Patients are advised to take life quietly and to avoid straining or heavy lifting for four weeks after the surgery.
Who is it suitable for?
HoLEP can be performed on men of any age with urinary outflow obstruction caused by an enlarged prostate. It is particularly indicated in men with large prostates (over 60mls in size) and men on medications to thin the blood such as warfarin, aspirin or clopidogrel.
What are the advantages of HoLEP
There is no upper size limit of prostate that can be dis-obstructed – traditionally men with prostates over 100ml in size needed major open surgery
- There is often less bleeding than after a TURP
- Discharge is often quicker than after TURP at 1-2 days
- The chance of recurrence requiring further surgery is very low
- Unlike greenlight laser operations, large quantities of prostate tissue are sent for pathological analysis
- The PSA generally drops to very low levels after HoLEP operations
How does it work?
The aim of HoLEP is to relieve pressure on the tube through which the urine drains (urethra) by anatomically enucleating the majority of excess benign prostate tissue. This is done under a general anaesthetic with the help of a telescopic camera inserted through the penis. The three lobes of the prostate that are cored out intact are pushed into the bladder before being sucked up (morcellated) by a special instrument inserted through the telescopic camera. The pieces are sent for laboratory analysis just in case they might be found to be cancerous. A catheter is placed into the bladder to drain the urine while the raw surface heals, then left in place for around 24 hours before being removed on the day of discharge from hospital. Sterile saline fluid is also irrigated into the bladder through the catheter to dilute any blood in the urine and prevent clots from forming.
It is normal to have some blood in the urine after this operation, so it is advisable to drink plenty of water for a few days while it clears. Clots are sometimes passed 10-14 days afterwards; again, this is part of the healing process.
Apart from this and the risk of infection that accompanies any operation or invasive procedure, the only significant side-effect is the near certainty that normal ejaculation will cease. This is because the contraction that occurs during orgasm may not completely block the entrance to the bladder once some tissue has been removed, and the semen will flow back into the bladder (“retrograde” or “dry” ejaculation) rather than out through the penis. This is not harmful, but it does mean that future fertility is greatly reduced. The procedure does not generally affect erectile function or continence, although the urinary symptoms may take a few weeks to settle down afterwards.
Credit: The Prostate Centre
What is a transurethral resection of the prostate or TURP?
A transurethral resection of the prostate (TURP) is a surgical procedure that removes portions of the prostate gland through the penis. A TURP requires no external incision.
The surgeon reaches the prostate by inserting an instrument through the urethra (the narrow channel through which urine passes from the bladder out of the body). This instrument, called a resectoscope, is about 12 inches long and one-half inch in diameter. It contains a light, valves that control irrigating fluid, and an electrical loop that cuts tissue and seals blood vessels. It’s inserted through the penis and the wire loop is guided by the surgeon so it can remove the obstructing tissue one piece at a time. The pieces of tissue are carried by fluid into the bladder and flushed out at the end of the procedure.
Many common problems are associated with the prostate gland. These problems may occur in men of all ages and include:
- Benign prostatic hyperplasia (BPH). An age-related enlargement of the prostate that isn’t malignant. BPH is the most common noncancerous prostate problem, occurring in most men by the time they reach their 60s. Symptoms are slow, interrupted, or weak urinary stream; urgency with leaking or dribbling; and frequent urination, especially at night. Although it isn’t cancer, BPH symptoms are often similar to those of prostate cancer.
- Prostatism. This involves decreased urinary force due to obstruction of flow through the prostate gland. The most common cause of prostatism is BPH.
- Prostatitis. Prostatitis is inflammation or infection of the prostate gland characterized by discomfort, pain, frequent or infrequent urination, and sometimes fever.
- Prostatalgia. This involves pain in the prostate gland, also called prostatodynia. It’s frequently a symptom of prostatitis.
Cancer of the prostate is a common and serious health concern. According to the American Cancer Society, prostate cancer is the most common form of cancer in men older than age 50, and the third leading cause of death from cancer.
There are different ways to achieve the goal of removing the prostate gland. Methods of performing prostatectomy include:
- Surgical removal includes a radical prostatectomy (RP), with either a retropubic or perineal approach. This is used to treat cancer. Radical prostatectomy is the removal of the entire prostate gland. Nerve-sparing surgical removal is important to preserve as much function as possible.
- Transurethral resection of the prostate, or TURP, which also involves removal of part of the prostate gland, is an approach performed through the penis with an endoscope (small, flexible tube with a light and a lens on the end).
- Cryosurgery is a less invasive procedure than surgical removal of the prostate gland. Treatment is administered using probe-like needles that are inserted in the skin between the scrotum and anus. The urologist can also use microwaves.
- Laparoscopic surgery, done manually or by robot, is another method of removal of the prostate gland.
Credit : Hopkins Medicine
Where and what is the Prostate Gland?
The Prostate gland is at the base of the Bladder and surrounds the urinary passage (urethra). The normal function of the gland is to produce some of the seminal fluid, which is expressed with ejaculation.
How does the gland cause trouble?
With increasing age, the prostate gland enlarges slowly due to the stimulation by the male sex hormone (testosterone). Testosterone is produced by the testicles and therefore the first enlargement of the prostate gland begins at puberty. Slow growth continues in most men as they get older but only causes trouble if it narrows the urinary passage.
What does a prostate operation do?
The latest technique is the removal of the Prostate Gland is with Bi Polar resection and vapourisation in saline. The operation removes the gland and thus allows free passage of urine from the bladder.
The operation is done under anesthesia using a special instrument called a Resectoscope and the Bi Polar button and loop electrode which is passed down the urinary passage. Because there is no cut in the skin, healing after the operation is quicker. It may still be necessary however, to leave a catheter to drain the bladder for 1-2 days. The procedure is done as a Day Case or overnight stay in Hospital unless other concomitant ailments dictate a longer stay.
If the prostate gland is very large, it may be necessary to remove the gland by a cutting operation in the lower abdomen. If this method is preferred, our surgeon will explain the details.
What is TURIS?
The word TURIS emanates from Trans Urethral Resection in Saline. Here the resection of thr obstructing part of the prostate gland is removed by Bi-Polar current using cutting and vapourisation in Saline.
What are the advantages of Laser over Standard TURP Operation?
TURIS affords the following advantages:
- Greatly reduced bleeding in most cases resulting in less strain physiologically on your body, reduction in transfusion rate and early discharge from the hospital.
- The irrigation fluid used is Normal Saline and not Glycine which is 10 times more expensive volume for volume.
- This in turn results in diminishing the complication of the TUR Syndrome or Water intoxication and a reduction in cost.
- Post-operative irrigation is not required.
- Retrograde Ejaculation, which is very common after a standard TURP, is almost non-existent in TURIS.
- All the above factors result in cost savings without any compromise whatsoever in the results of surgery!
Further, the cost savings are transmitted to you as we are not charging you more for this procedure. It is estimated that you will on average save Ksh. 40,000 – 60,000.
What are the disadvantages of TURIS?
The disadvantage is that it takes slightly longer to perform the surgery.
After the operation
There is usually some bleeding from the prostate cavity and this causes a red discoloration of the fluid coming from the catheter. This usually stops after a day or two. It helps to drink plenty of fluids after the operation to get a good wash-through of the bladder.
A common fear is that there will be leakage of urine after the operation, but serious leakage is rare. There may be minor leakage for a day or two after the catheter is removed, but this soon stops. There may also be feeling of urgency resulting in the need to pass urine frequently. Both the minor leakage and the urgency occur because there is a raw area inside which has to heal up. If there has been long-standing blockage of the bladder, the bladder itself may be damaged and the need to pass urine frequently may continue for several weeks.
Sometimes blood may appear again in the urine some 10-14 days after the operation. This is caused by the internal healing process and may be aggravated by constipation. This bleeding usually clears up quickly and it helps to drink plenty. In order to minimize this bleeding, we recommend that constipation should be avoided, and it may be necessary to take a mild laxative.
How soon will the urinary stream Improve?
Following the operation there is usually an immediate improvement in the urinary stream and further improvement may continue for up to 6 months. You may find that the frequency of urination does not completely settle down for 2-3 months.
Will the operation affect my sex life?
Sexual intercourse often becomes less frequent with increasing age but there is no reason for the prostate operation to end sex life. Removing the prostate gland does not alter erections of the penis or the sensation of orgasm. Once the operation has healed having sex will not cause damage, but it is best to wait 3-4 weeks.
How long before I can go back to work and become fully active?
This depends on how fit you were before the operation. However most of our patients are advised to go back to work even for half days in a couple of days.
Credit: Laserstone Surgery
What should I do if I think I have a urinary infection?
If you have pain in the bladder area (pictured below), pain when passing urine, a need to urinate frequently or urine that is dark or strong-smelling, especially if you have a fever of 38ºC or more, you should contact your GP for further advice.
These symptoms are all non-specific. They can be caused by many other conditions such as sexually-transmitted infection, vaginal thrush (in women), chemical irritants (soap & deodorants), stones (in the kidney, ureter or bladder), interstitial cystitis, bladder cancer or inflammation in the prostate gland (prostatitis).
It is, therefore, important that you see your GP to arrange appropriate investigations to establish the exact cause of your symptoms. Failure to treat a bladder infection promptly can cause infection to spread to the kidneys. In severe cases, this may result in blood poisoning (septicaemia).
What are the facts about urinary infection?
- Most urine infections are caused by bacteria (such as E coli, pictured above the right-hand links column) which come from your bowel
- In women, the urethra (water pipe) is very close to the anus making it easy for bacteria to reach the bladder and cause infection
- Most women have at least one attack of urinary infection during their lifetime and 20% of women suffer repeated attacks. This is more likely in women who are pregnant, sexually-active or postmenopausal
- Cystitis in men and children is more serious because it is often caused by underlying problems such as an enlarged prostate, prostatitis or inherited abnormalities
- Mild urinary infections usually clear within a few days and may not always require treatment with antibiotics
- Untreated, more severe infections can involve the kidneys and may even spread into the bloodstream
- Recurrent urinary infections in women can often be managed by simple, “self-help” measures
What should I expect when I visit my GP?
Your GP should work through a recommended scheme of assessment for suspected urinary infection. This will normally include one or all of the following:
1. A full history
Your GP will take a full urological history with special attention to previous urinary infections, periods of dehydration, your sexual activity, any intake of acidic or spicy foods and any relevant past medical problems.
2. A physical examination
A general physical examination, including rectal examination (in men) and vaginal examination (in women) will normally be performed. Your blood pressure will be measured as part of this assessment.
3. Additional tests
The usual tests performed are:
a. General blood tests
The actual tests performed will be left to your GP’s discretion. It is usual to measure kidney function and to check the blood cells for anaemia or other problems.
b. Urine Tests
A simple dipstick test of the urine may confirm that an infection. It is likely that urine will also be sent to the laboratory for culture to confirm any infection and to find out which antibiotics need to be used (culture & sensitivity assessment).
c. Other specific tests
If you have any discharge (from the penis or vagina), swabs may be taken for culture.
Your GP may also arrange an ultrasound scan of your kidneys and bladder. This is not needed for a first infection in a woman but is usually performed for:
- recurrent infections in women (more than 3 attacks per year)
- all infections in men
- infections which have spread to the kidneys
- pregnant women
- patients with known neurological problems
- patients with known abnormalities of the urinary tract
- patients taking drugs which suppress the immune syste
If you fall into any of these groups, your GP will then arrange a formal referral to a urologist for further investigation. This may involve examination of the bladder as well as the investigations mentioned above.
What treatments are available for this problem?
Mild urinary infections can sometimes be cured by drinking plenty (6-8 glasses) of water daily and relieving any discomfort with simple painkillers (aspirin, paracetamol). It is, however, best to see your GP for advice especially if this is your first urinary infection.
If your symptoms are clearly caused by sexual intercourse (so-called “honeymoon cystitis”), you should refrain from sex until your infection has cleared completely.
If your symptoms worsen despite these measures, you should contact your GP immediately.
More severe infections usually require treatment with antibiotics. Your GP will normally prescribe an antibiotic (pictured) on a “best guess” policy, taking into account any allergies you may have. The drug given initially may need to be changed. This will depend on the results of laboratory culture and on the sensitivity of any bacteria to the antibiotic already prescribed. Even if no bacteria are grown from your urine sample, there is good evidence that antibiotics can be helpful in curing your symptoms. You will normally be asked to provide a further urine specimen 7-14 days after you have completed your course of antibiotics. This is important to ensure that there is no infection remaining and that any abnormal white cells or red cells in the urine have been eliminated. If they have not, further investigations may be needed to exclude problems such as stones, bladder cancer or tuberculosis.
Surgery is rarely indicated for urinary infection unless there is an underlying causative condition which requires surgical relief.
- In patients (especially children) shown to have reflux of infected urine back from the bladder to the kidneys, surgery may be recommended to stop the reflux.
- In some women after the menopause, ultrasound shows poor bladder emptying with a large residual urine and inspection of the bladder with stretching of the neck of the bladder under a brief general anaesthetic may be helpful. Hormone replacement therapy (HRT) using tablets, creams or pessaries may be prescribed after the procedure, to prevent the problem from recurring.
How can I prevent further attacks of infection?
If you suffer from repeated attacks of urinary infection, especially in women, your GP or urologist may recommend that you take low-dose antibiotics for 3-6 months
As an alternative to long-term antibiotics, you may find it helpful to take cranberry juice or tablets. Cranberry preparations have been shown, scientifically, to reduce recurrent infections. Some patients find tablets more palatable than juice. There are also a number of measures you can do for yourself to prevent further infections.
What causes a urinary infection?
Urinary infection occurs when bacteria enter the the urinary tract via the bladder and multiply to cause an infection. In children, bacteria may move from the bladder to the kidney(s), as a result of ureterovesical reflux.
Is a urinary infection important or serious in children?
- Urinary infections can make children feel very ill with non-specific symptoms such as vomiting, abdominal pain and a high temperature
- Renal scarIf infection enters the kidney(s) by reflux, the infection may cause a scar to form in the kidney(s)
- Scarring of the kidney (pictured) due to infection is permanent. This can cause problems with kidney function and may cause high blood pressure in later life
- Urinary infections in children must be treated without delay to prevent scarring
- Urinary infections may be an indicator of problems (abnormalities) within the urinary tract. These abnormalities may be a risk factor for future problems, including further infections
How will I know if my child has a urinary infection?
Symptoms of urinary infection may vary considerably with age. Infection may occur without the “fishy” smell and burning pain which adults often experience. In babies and young infants, urinary infection often has very non-specific features. If your child has a temperature without any obvious reason (such as a cold or cough), you should try to collect a urine specimen so that infection can be ruled out.
Symptoms in infancy:
- High temperature (fever)
- Poor feeding
- Smelly nappies
- Abdominal pain (“tummy ache”)
Symptoms in childhood:
- High temperature (fever)
- Increased frequency of passing urine
- Vomiting and / or diarrhoea
- Being “off their food”
- Abdominal pain (“tummy ache”)
- Back pain
- Bed wetting (when previously dry)
- Smelly or bloody urine
- Pain when passing urine
How will a urinary infection be confirmed?
A sample of your child’s urine will need to be collected to look for signs of infection & dehydration. How the urine sample is collected will depend on your child’s age and how ill he/she is
The following headings describe the common ways in which urine can be collected from a child:
1. The older child who is toilet trained
a. Mid-stream urine (MSU) collection
- The child’s genitalia are cleaned with warm, soapy water
- The child begins to pass urine into the toilet
- Part way through passing urine, a specimen is collected into a sterile container
- The last part of the urine is then passed into the toilet again
2. The non-toilet trained child
a. “Clean catch collection” (preferred because of the low risk of contamination from skin or bowel motions)
- The child’s genitalia are cleaned with warm, soapy water
- Part way through passing urine, the collection is made in a container held under the child, without touching the child’s skin
b. Urine collection bagUrine collecton bag
- The child’s genitalia are cleaned with warm, soapy water and dried
- A special collection bag is stuck over the child’s urethral opening (“water passage”)
- As soon as urine enters the bag, the bag is promptly removed & the urine transferred into a sterile container
- If the collection is contaminated by bowel motions, the whole process must be started again
3. Very ill children (or those in whom it is difficult to catch a urine sample)
a. Specimen collection from a urinary catheter
- The child’s genitalia are cleaned with saline (salt solution)
- A small catheter is inserted into the bladder, through the urethra, by a doctor or nurse
- A specimen of the drained urine is collected in a sterile container
- The catheter is removed
b. Specimen collection from a suprapubic aspirateSuprapubic aspiration
- The skin in the lower part of the child’s abdomen (“tummy”) is cleaned with an antiseptic solution
- A fine needle is passed through the skin directly into the child’s bladder
- The aspirated urine is placed into a sterile container and the needle is removed
Collecting a urine sample from a child who is not toilet trained can be difficult and frustrating. Whilst using a collection bag may seem simple, this specimen is easily contaminated and the results are not as accurate as midstream or clean catch samples. Your Specialist Nurse, GP or Health Visitor can help you learn more about this.
How will my child’s urine infection be treated?
In babies and infants who are unwell, your doctor will not normally wait for the laboratory results to become available (this can take up to 48 hours) but will start treatment immediately with antibiotics. It may be necessary to change the antibiotic if your child is showing no improvement or if the laboratory results show that a different antibiotic would be better.
To clear the infection, it is very important that your child takes all the antibiotic medicine exactly as prescribed.
In most children, the fact that the child has improved is sufficient to say that the infection has cleared. In a few children (especially those with known abnormalities in the urinary tract), it is important that a further urine sample is collected and sent to the laboratory after the antibiotics have finished. This will confirm that the infection has been completely cleared. In these cases, it is best sent three days after the antibiotic course has been completed. If any traces of infection are found, the infection can come back again.
Will my child need further tests?
In a child over one year of age, additional investigations are not necessary unless the infections keep recurring or the bacteria found are unusual
It is normally recommended that children who have had a urinary infection before their first birthday should have an ultrasound scan of their kidneys, ureters and bladder. This is because a urinary infection can be the first clue to the presence of an underlying physical problem within the urinary tract. If any abnormality on the ultrasound is found, or if the infecting bacteria are unusual in any way, other tests and investigations may be needed
How can my child & I prevent further urinary infections?
- Ensure your child drinks plenty of fluids throughout the day so that he/she actually need to pass urine more frequently and the urine is lighter in colour (more dilute). Drinks should be water or water-based (e.g, squash) rather than tea/coffee/fizzy drinks
- Include a glass of cranberry juice in your child’s diet every day
- Ensure that your child goes to the toilet to empty his/her bladder regularly (e.g. on waking, mid-morning, lunch, mid-afternoon, teatime & before bed)
- Change nappies regularly
- Teach girls to wipe from front to back after passing urine so that germs from the anus do not enter the urethra
- Avoid scented soaps, bubble baths and hair washing with shampoo in the bath
- Encourage your child to wear only cotton underwear
- Ensure your child has a healthy diet
- Bio-yogurt may help by increasing “good bacteria”
- Constipation should be avoided. Ensure that your doctors are aware of any problems with constipation so that it can be treated immediately
- Follow the advice given to you about antibiotic treatment
Your doctors may decide that, to help prevent further infection, your child needs “prophylactic” antibiotics. This is a smaller dose than is used to treat an actual infection. It is intended to prevent infection from becoming established. Prophylactic antibiotics are best taken at bedtime.