Transurethral resection of bladder tumours (TURBT) using a wire loop remains the gold-standard treatment for bladder tumours, but it is associated with unacceptably high early recurrence rates after first resection. Improvements to standard resection techniques and a range of optical and technological advances offer exciting possibilities for improving outcomes. Early second resection has been shown to reduce recurrence rates, and increase response to intravesical chemotherapy and/or immunotherapy. It should be considered in most high-risk non-muscle invasive cancers (T1; G3; multifocal) being managed by bladder conservation. Newer energy sources, such as laser, may facilitate day case management of bladder tumours using local anaesthesia in select groups of patients. The novel technique of photodynamic diagnosis improves tumour detection, and quality of resection, and is likely to become the standard for initial tumour management. The traditional 'incise and scatter' resection technique goes against all oncological surgical principles. En-bloc resection of tumours would be far preferable and demands further development and evaluation. The technique of TURBT needs to evolve to allow first-time clearance of disease and low recurrence rates.
Urinary incontinence remains an important clinical problem worldwide, having a significant socio-economic, psychological, and medical burden. Maintaining urinary continence and coordinating micturition are complex processes relying on interaction between somatic and visceral elements, moderated by learned behavior. Urinary viscera and pelvic floor must interact with higher centers to ensure a functionally competent system. This article aims to describe the relevant anatomy and neuronal pathways involved in the maintenance of urinary continence and micturition. Review of relevant literature focusing on pelvic floor and urinary sphincters anatomy, and neuroanatomy of urinary continence and micturition. Data obtained from both live and cadaveric human studies are included. The stretch during bladder filling is believed to cause release of urothelial chemical mediators, which in turn activates afferent nerves and myofibroblasts in the muscosal and submucosal layers respectively, thereby relaying sensation of bladder fullness. The internal urethral sphincter is continuous with detrusor muscle, but its arrangement is variable. The external urethral sphincter blends with fibers of levator ani muscle. Executive decisions about micturition in humans rely on a complex mechanism involving communication between several cerebral centers and primitive sacral spinal reflexes. The pudendal nerve is most commonly damaged in females at the level of sacrospinous ligament. We describe the pelvic anatomy and relevant neuroanatomy involved in maintaining urinary continence and during micturition, subsequently highlighting the anatomical basis of urinary incontinence. Comprehensive anatomical understanding is vital for appropriate medical and surgical management of affected patients, and helps guide development of future therapies.
Objectives: A retrospective study was conducted to examine the feasibility and safety of performing trans-urethral resection of bladder tumour (TURBT) in newly diagnosed patients as a day case operation. Patients and methods: All patients who underwent a primary TURBT over a 12 month period were included. Data were collected on patient demographics, tumour characteristics, day case vs. inpatient admission, indications for inpatient admission, re-admission rates within 28 days, and surrogate markers for quality of resection including recurrence rates. Results: A total of 172 patients were included. TURBT was performed as a day case procedure on 138 patients (80.2%). Rates of re-admission within 28 days were 7.2% and 5.9% in the day case and inpatient cohorts respectively. One hundred and thirty (75.6%) patients had non-muscle invasive bladder cancer (NMIBC). Of these, 84 (64.6%) were found to have detrusor muscle in their specimens, and 86 (66.2%) received peri-operative mitomycin C. Twelve month recurrence rates were 12%, 27% and 33% for low, intermediate and high-risk NMIBC respectively. Conclusion: This study shows that day case surgery for TURBT is feasible in the majority of patients, with a low rate of re-admission. Our data suggest that day case TURBT is suitable as standard practice in our institution and should be considered by others. Level of evidence: 2b.
Bladder cancer is the second most common urological malignancy with a one in 28 lifetime risk. Three-quarters of tumors are non-muscle-invasive (formerly termed superficial) at the time of presentation. Approximately half of all non-muscle-invasive bladder cancer (NMIBC) will recur and, depending on certain prognostic factors including grade, stage and presence of carcinoma in situ, a number will progress to muscle invasion. The standard of care for NMIBC is transurethral resection of bladder tumor (TURBT) to remove the mass lesion(s). Intravesical therapy of NMIBC post-TURBT therefore aims to delay/prevent recurrence and/or progression to muscle-invasive bladder cancer. While intravesical chemotherapy, such as mitomycin C, and immunotherapy, such as bacillus Calmette-Guérin are well established, there is current interest in novel therapies based on improved molecular understanding of bladder cancer. These novel therapies include gene therapy, using viral and non-viral vectors for transfer, monoclonal antibodies and direct tumoricidal viruses. While there is a sound theoretical basis for these therapies based on molecular targeting, there is little evidence in human studies that these therapies have clinical impact on NMIBC. However, it is certain that their use will be investigated further and they provide great hope for the future of NMIBC adjuvant therapy.
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