[Transurethral resection of bladder cancer: a simple and diffusely-performed technique but with controversial...

Nowadays TUR is considered the golden standard for the diagnosis and treatment of NMIBC. However, TUR should be adequate: all bladder lesions should be resected and muscle must be present in the specimen in order to correctly stage the tumor. No bladder perforation should be performed and CIS diagnosed.

Bimanual palpation pre- and post-TUR should be encouraged, especially in teaching institutions. Urethroscopy should always precede the visualization of the bladder. All the visible tumors should be resected preferably with bipolar resectoscope, to avoid tissue charring and to facilitate the pathological diagnosis. The exophytic part of the tumor should be first resected and the fragment collected in a separate bottle. Tumor base must be biopsied with cold cup. Muscle must be present in the specimen. Fulguration of the tumor base and 1-2 cm around is of paramount importance.

One of the most important parameters for evaluating the quality of TUR is tumor recurrence after 3 months. The EORTC GU Group showed that the 3-month recurrence varied from 0 to 46% between the European institutions participating in randomized prospective EORTC studies. This variability was not explained by the tumor characteristics nor by the adjuvant therapy administered, but by the poor quality of the TUR. The surgeon’s performance and poor TUR quality were therefore suggested as being responsible for the results. A second EORTC study confirmed in fact that using a bladder diagram at the moment of diagnosis (signing the areas where the lesions are) and the presence of an experienced surgeon performing TUR were the two significant factors that could reduce the recurrence after 3 months.

A complete, adequate first TUR is of paramount importance for the outcome of patients with NMIBC. It could be more important than any further adjuvant therapy administered.