Operative note 09 Core CORE (added 2026)

TURBT

What it does: resect a bladder tumour through the resectoscope.

Examine with both hands, in and out. A fixed mass changes stage and plan.
Survey the whole bladder first, half full. Same order every time: trigone and both orifices, posterior wall, left wall, dome (bubble), right wall, front wall (70 degree lens, press above the pubis), neck.
Find both ureteric orifices before cutting near them.
Resect in order: tumour, then base, then edge. Base in its own pot.
Muscle must be in the specimen. No muscle = no stage. It is the quality standard. Deep enough: coarse muscle bundles. Yellow fat: too deep.
Small tumour: cold cup or loop, base included.
Lateral wall? Warn the anaesthetist. The obturator nerve fires a leg kick as you cut. Ask for a short paralysing dose. Fill less. Bipolar in saline, lowest current that cuts.
Avoid perforation: half fill. Loop placed beyond the tumour, drawn back towards you: cut on the return, sheath still. Short swipes. Never push the loop into a thin wall.
Suspect perforation (view deflates, fat, distension)? Stop. Catheter. Drain. Image.
Clear the chips through the sheath. Last look for a breach before any chemo goes in.
En-bloc (cut around, lift off) for small tumours.

Kit: 24-26 Fr continuous-flow resectoscope. 30 and 70 degree lenses. Bipolar loop in saline; rollerball or button. Cold-cup forceps. Suction on the outflow. Separate labelled pots: tumour, base, each biopsy. 3-way 20-22 Fr catheter for a big resection. Owner-specified.

2026 update: One dose of chemo in the bladder after resection. Within 2 h. Not if perforated or bleeding hard. Gemcitabine is now first choice in many units. (Mitomycin supply ran short.)

From the UroRef Operative Quick Guide.