Trans-Urethral Resection of Bladder Tumor 
Emma Bryant, Gabrielle Yankelevich 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Transurethral resection of bladder tumor is a 
minimally invasive strategy to remove lesions of the 
bladder wall. It is both a therapeutic and diagnostic 
tool. A resectoscope is utilized to complete the 
resection; this tool uses electricity to both coagulate 
tissue and resect it. It consists of a sheath, lens, and 
working element (monopolar or bipolar electrode) as 
explained further below. Conventionally, bladder 
tumor resection is performed using a monopolar 
resectoscope. The current, generated by the 
diathermy machine, passes from the electrode 
through the patient’s body to terminate at an 
electrode on the skin (grounding pad). This approach 
requires non-ionizing conduction fluid, such as 
glycine or sorbitol.  
Ideally the irrigation solution is iso-osmotic, 
but by design it will contain less sodium and chloride 
ions than the patient’s bloodstream does. This leads 
to a risk of post-operative Trans- Urethral Resection 
(TUR) syndrome. This is a serious complication due 
to excessive absorption of irrigation solution, 
causing hyponatremia which can lead seizures and 
death. To prevent TUR syndrome, limit resections to 
1 hour. Water can also be used for irrigation, but it is 
both hypotonic and hypo-osmotic, so the patient’s 
serum sodium and osmolality will drop rapidly.  
In 
high-resource 
settings, 
bipolar 
resectoscopes are more commonly utilized to 
mitigate this risk. A bipolar working element uses 
both efferent and afferent currents, so an external 
electrode (grounding pad) is not necessary. Saline 
irrigation is used for bipolar resections.  
 
Monopolar resectoscope and its attachments: camera (within 
plastic sheath), fiber-optic light cable (Gray), electrical cable 
(Black) and handpiece for manipulating the electrode. 
 
 
A surgeon loading the resectoscope’s electrode. It is imperative 
that you understand and can troubleshoot all components of the 
resectoscope, to allow the operation to progress smoothly and 
to prevent harm to the patient.  
 
 
Detail of the resectoscope’s electrode, at full extension 
advancing beyond the lens of the scope.  
 
Risks of trans-urethral bladder 
tumor 
resection include transient postoperative bleeding 
and urinary retention. Post-operative urinary tract 
infection 
risk 
is 
significantly 
reduced 
with 
prophylactic antibiotics and pre-operative antibiotics. 
Additionally, both intra- and extraperitoneal bladder 
perforations can occur. The most common iatrogenic 
cause of perforation is “obturator jerk,” which is a 
spasm of the leg in response to electrostimulation of 
the obturator nerve by the resectoscope. Further, 
perforations can also result from thin bladder walls 
in female patients, advanced age, and those who have 
had previous resections. 
Trans-Urethral Resection of Bladder Tumor 
Emma Bryant, Gabrielle Yankelevich 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Proper staging of a bladder tumor includes CT scan of the chest, 
abdomen and pelvis, with the bladder distended with saline to 
show the size and location of the tumor. In this case, the surgeon 
should be aware that a portion of the tumor involves the intra-
peritoneal bladder; perforation here would require surgical 
repair.  
 
Trans-urethral resection of bladder tumor 
proceeds in the following steps: 
• Administration of general anesthetic with 
paralysis (can consider spinal anesthesia) 
• Insert either a bipolar or monopolar resectoscope 
• Resect the tumor and obtain hemostasis.  
• Collect tumor chips and send them for 
pathological analysis. 
 
Steps: 
1. Place patient in modified dorsal lithotomy 
position and have anesthesia administer general 
anesthetic with paralytic or spinal anesthesia. 
Spinal anesthesia allows monitoring of the 
patient for confusion, which may herald the onset 
of TUR syndrome.  
2. For monopolar resectoscopes, remember to place 
a grounding pad and utilize 10% dextrose or 
glycine irrigation. For bipolar resectoscopes, 
utilize saline irrigation. A large refillable sterile 
container for the irrigation allows the operation 
to continue without having to stop to refill.  
3. The 
patient 
should 
receive 
single-dose 
antimicrobial prophylaxis prior to the procedure. 
Prepare and drape the genitals using betadine or 
chlorhexidine. 
The 
American 
Urological 
Association 
guidelines 
for 
antimicrobial 
prophylaxis according to patient sex and surgical 
history can be found here.  
4. Visually inspect the lower abdomen and urethra. 
Perform a bimanual examination to assess for 
pelvic masses.  
5. If you have a smaller cystoscope, perform a 
cystoscopy using a 30 and 70-degree cystoscope 
lens if possible to maximize visualization of 
traditionally difficult areas of the bladder, such as 
the bladder neck and anterior bladder wall. 
6. Dilate the distal urethra using a urethral sound if 
necessary to insert the resectoscope. Note the size 
of the resectoscope sheath (usually 26F) and 
serially dilate only the meatus and most distal 
urethra, from 18F up to the size required, using 
lubrication. 
 
A urethral dilator with a curved tip being used to dilate only the 
urethral meatus to allow the resectoscope sheath to pass.  
 
7. Insert the resectoscope sheath in the bladder with 
either a blind or visual obturator. Removal of the 
obturator should cause return of fluid. This 
indicates proper placement of the sheath within 
the bladder. If the scope does not pass through 
the penile or bulbar urethra, the patient may have 
a urethral stricture. Insert the scope to visualize 
the area of blockage.  
 
Trans-Urethral Resection of Bladder Tumor 
Emma Bryant, Gabrielle Yankelevich 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Resectoscope sheath with a blind obturator, attached to the 
irrigation tubing.  
 
 
Insert the sheath and obturator into the urethral meatus, 
maintaining traction on the penis to keep the urethra straight. 
Keep your thumb on the obturator so there is no chance it will 
be dislodged, to prevent the unprotected edges of the sheath 
from damaging the urethral mucosa.  
 
 
The sheath and obturator should pass without resistance into 
the bladder. When the tip of the sheath is within the bladder, it 
should move inwards and outwards with gentle pressure, and 
urine or irrigation fluid from the bladder should flow freely out.  
 
8. Exchange the obturator for a resectoscope with 
monopolar or bipolar working element. Visualize 
the trigone, ureteral orifices, and tumors. 
 
Small bladder tumor and extensive bladder trabeculation 
(hypertrophy of the detrusor muscles due to obstruction.) 
 
9. Resect any small tumors at the base. 
 
The electrode is used at a controlled depth to resect the bladder 
tissue at the base of the tumor. 
Source: doi: 10.3389/frai.2024.1375482 
 
10. Divide large tumors into sectors and begin to 
resect the first section in layers. Start at the 
periphery of the tumor and swipe until the base is 
Trans-Urethral Resection of Bladder Tumor 
Emma Bryant, Gabrielle Yankelevich 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
reached. At this point, make a swipe at the edge 
of the tumor. This marks the depth to which all 
subsequent sections should be limited. The 
extracted tissue from the swipe should include 
the muscularis propria, but take special care to 
avoid 
extending 
through 
it 
entirely.  
TIP: This maneuver can be modified with tumor 
location. For example, lesions on the anterior 
wall of the bladder may require minimal bladder 
filling with increased suprapubic pressure for 
extraction. The lower abdomen should be 
compressed with the nondominant hand in this 
case. Additionally, the resection loop should be 
parallel to the mucosa for tumors located on the 
lateral wall to minimize risk of obturator spasm. 
 
Here, the scope is inverted so that its angled tip can view the 
anterior bladder. Overfilling the bladder pushes its anterior 
part away from the scope, so minimal bladder filling and 
frequent emptying are useful for accessing this area. 
Suprapubic pressure with the nondominant hand brings the 
anterior bladder closer to the resectoscope as well.  
 
11. If operating without continuous irrigation flow, 
empty the bladder every five swipes to ensure 
proper volume and thickness.  
12. Maintain hemostasis at each segment site before 
advancing. To verify hemostasis, empty the 
bladder and ensure that no active bleeding is 
appreciated.  
 
Appropriate depth of resection. Note that the resectoscope is 
turned so that the electrode is parallel to the surface of the 
bladder being resected. 
Source: doi: 10.3389/frai.2024.1375482 
 
13. Resect the remaining segments. 
14. Use a bladder evacuator (Ellik or similar) or 60cc 
catheter-tip (Toomey) syringe to collect the 
tumor chips. If there are only a few chips, they 
can be retrieved with the resectoscope loop itself. 
The chips, as well as additional deep and 
marginal segments, should be sent for pathologic 
examination.  
 
 
Trans-Urethral Resection of Bladder Tumor 
Emma Bryant, Gabrielle Yankelevich 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
A bladder evacuator attaches to the resectoscope sheath after 
the resectoscope has been removed. It contains a one-way valve 
that allows you to squeeze, inserting fluid without returning 
collected specimens to the bladder, and release, drawing fluid 
into the reservoir. It will not work if the tip of the sheath is 
pressed against the bladder wall; the surgeon can reposition it, 
including inserting and withdrawing it as necessary, with the 
non-dominant hand. As shown here, the fluid is very bloody- if 
this situation persists, you should reinsert the resectoscope and 
try to find and control the bleeding.  
 
 
A 60mL catheter tip (Toomey) syringe, shown here with a cap 
over the tip, can be useful if you do not have a bladder 
evacuator, or if you need to remove clots. Source: Marmasphan, 
CC BY-SA 4.0  via Wikimedia Commons 
 
 
 
Pitfalls 
• For large-scale resections, place a 20- or 22-Fr 
catheter, which can be removed between 
postoperative day 1-7 depending on the 
depth/extent 
of 
the 
resection. 
For 
less 
experienced surgeons, or with extensive bleeding, 
a three-way catheter with continuous irrigation is 
appropriate. Smaller resections do not require a 
catheter and the patient can go home. If the 
patient is discharged without a catheter, the 
patient should void prior to discharge.  
 
A 3-way catheter, with irrigation entering through the top of the 
picture and drainage going out to the patient’s left. Source: 
Sarang, Public domain, via Wikimedia Commons 
 
• There is a significant risk for bladder perforation 
during this operation. Visible perivesical adipose 
tissue following resection, inadequate filling at 
maximum flow, and expanded abdomen are 
findings suspicious for perforation.  
• For minor damage: If discovered intraoperatively, 
the procedure can be completed quickly. Patients 
should recover with an indwelling catheter for 3-
5 days.  
• For severe damage: the procedure should be 
halted and an on table cystogram should 
immediately be performed to diagnose a 
perforation 
and 
differentiate 
between 
extraperitoneal and intraperitoneal injury. For 
extraperitoneal 
damage, 
resection 
should 
proceed under low pressure with minimal 
irrigation to reduce fluid extravasation and a 
foley should be placed. Surgical repair should be 
considered according to patient status and extent 
of 
injury; 
however, 
most 
extraperitoneal 
perforations will resolve with catheter drainage 
Trans-Urethral Resection of Bladder Tumor 
Emma Bryant, Gabrielle Yankelevich 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
only. In contrast, intraperitoneal injury requires 
immediately 
stopping 
the 
procedure 
and 
performing an exploratory laparotomy to fix the 
perforation.  
• Postoperative bleeding is possible and is 
especially important to consider in large 
resections. It can occur immediately following 
the operation, most likely due to incomplete 
hemostasis, or in the subsequent days. Patients 
with 
bleeding 
inadequately 
managed 
intraoperatively should be admitted overnight for 
observation. In either case, catheter drainage and 
continuous irrigation are indicated. 
• Urinary retention can occur for several days 
postoperatively 
and 
should 
resolve 
spontaneously. Persistence of retention may 
require administration of an alpha blocker and 
further work-up.  
 
Emma Bryant BS 
Medical University of South Carolina 
USA 
 
Gabrielle Yanklevich DO 
Medical University of South Carolina 
USA 
 
January 2025 
