Tips for Office-Based Transurethral Biopsy and Fulguration as a Treatment of Tiny Bladder Tumors

doi:10.4236/oju.2013.36047

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Open Journal of Urology, 2013, 3, 253-255

http://dx.doi.org/10.4236/oju.2013.36047 Published Online October 2013 (http://www.scirp.org/journal/oju)

Tips for Office-Based Transurethral Biopsy and

Fulguration as a Treatment of Tiny Bladder Tumors*

Teiichiro Aoyagi1#, Isao Kuroda1, Masaaki Tachibana2

1Tokyo Medical University, Ibaraki Medical Center, Inashiki, Japan

2Toky o Medical University, T o kyo, Japan

Email: #[email protected]

Received August 8, 2013; revised September 6, 2013; accepted September 14, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Among the patients who underwent outpatient cystoscopy as a follow up of bladder cancer, quite a few patients are ob-

served tiny papillary lesions suspicious for tumor recurrence. Tran surethral biop sy and/or resection under spinal or gen-

eral anesthesia in a hospitalized setting are the usual procedures for th is kind of patients, even thou gh these procedures

are simple and brief. We tried transurethral biopsy and fulguration as a treatment for very small bladder tumor in an

outpatient setting and here describe tips for these procedures. Olympus CYF-VA flexible cystoscope, a 3 Fr. diathermy

probe, monopolar electrosurgical unit were used. No additional anesthetics except for 10 ml of 2% Xylocaine gel ap-

plied to (male patient’s) urethra as an initial flexible cystoscopic procedure, was required for tumor treatment. Distilled

water was used as an irrigation fluid. Experienced tips of the procedures to avoid tumor recurrence are as follows: tu-

mor should be one location, size of the tumor should be less than 5 mm, bladder should be washed several times after

the fulguration with hundreds ml of distilled water. We conclud e that outpatient biopsy and fulguration for tiny bladder

tumor is effective and less invasive procedure as a treatment of bladder cancer patients.

Keywords: Transurethral Surgery; Bladder Cancer; Office Urology; Fulguration; Biopsy

1. Introduction

Office-based cystoscopic examination is a usual estab-

lished method as an initial and postoperative surveillance

of bladder tumor [1]. During the follow up period, small,

low grade and superficial bladder tumor recurs in quite a

few patients [2]. Although experience and efficacy of

office-based fulguration for low grade papillary lesions

has been reported previously, this procedure does not

performed routinely in the clinical practice, presumably

because there is no precise explanation on actual meth-

odology and safety [3-5]. However, considering increas-

ing comorbidities, use of anti-coagulation medication,

economic restriction and so on, ambulatory treatment for

these lesions should be beneficial both for patients and

surgeons [6]. Here, we present the tips of ambulatory

biopsy and fulguration treatment for tiny bladder papil-

lary lesions with some improvements after experiences of

failure cases.

2. Patients and Methods

Fourteen patients, 19 procedures were enrolled in this

report. The patient profiles are listed in the Table 1. All

the patients had the history of transurethral resection

(TUR) or nephroureterectomy surgery under spinal or

general anesthesia previously, and followed with repeat

surveillance flexible cystoscopy in an outpatient setting.

Safety to use diathermia for these patients was confirmed

by previous surgery, and informed consent on the treat-

ment of ambulatory procedures was made by patient’s

signature. This report does not violate ethical standards

of the Declaration of Helsinki and its revisions. No addi-

tional anesthetics except for 10 ml of 2% Xylocaine gel

applied to (male patient’s) urethra as an initial flexible

cystoscopic procedure, was required for tumor treatment.

Olympus (Tokyo, Japan) CYF-VA flexible cystoscope

and Versa Pro unit, Takei (Tokyo Japan) monopolar

electrosurgical unit B-1, Olympus flexible biopsy forceps

and 3 Fr. Takei Bugbee ureteroscope electrode were used.

Normal saline was used for observation, and distilled

water was used for treatment as irrigation fluid (Figure

1).

*The authors declare that they have no conflict of interests, no funds

and no grant on thi s project.

#Corresponding author.

T. AOYAGI ET AL.

254

Table 1. Patient profiles and results.

Pt Age Previous TUR Tumor Pathoogy Result Comment

1 71 6 m Dome 1 trigonum 3 UC G1 3 m relapse Treated with re-TUR

72 1 y Dome 1 UC G1 4 y free

2 82 Primary Trigonum 3 UC G1 4 m relapse Treated with office-based re-TUF

82 4 m Near left orifice 1 UC G1 4 y free

3 77 3 m Trigonum 1 UC G2 3 m relapse Treated with office-based re-TUF

78 3 m Bladder neck 1 9 m relapse Treated with re-TUR

79 7 m Trigonum 1 10 m relapse Treated with office-bas ed re-TUF

80 10 m Trigonum 1 6 m free Severe Alzheimer disease

4 60 8 y Dome 1cm × 2 UC G2 5 m relapse HD patient, Treated with re-TUR

5 83 6 m Left orifice 1 UC G2 2 m relapse Other location treated with re-TUR

6 80 6 m Left wall 1 UC G1 5 m relapse Other location tre ated with re-TUR

7 62 3 m Left wall 1 3 m relapse Other location treated with re- TUR

8 76 3 y Right wall 1 UC G1 4 y free

9 71 1 y Bladder neck 1 UC G1 > G2 4y free

10 66 2 y Anterior wall 1 2 y free

11 81 2 y Trigonum 1 2 y free

12 68 6 m Bladder neck 1 UC G2 7 m free

13 71 1 y Anterior wall 1 6 m free

14 69 16 m Bladder nec k 1 UC G1 2.5 y free Post nephroureterectomy

m: month, y: year, re-TUR: Transurethral resec ti on of bladder tumor after adm i s sion, HD: hemodialysis, UC: urothelial carcinoma.

Figure 1. Examples of biopsy and TUF (#2 patient, second procedure of biopsy and TUF, (a), (b), (c), (d). Cystoscopy after 12

months showed no recurrence, (e)).

3. Experiences

The first patient (Pt #1) had recurrent small tumor around

the fulgurated tiny tumors after 3 months, presumably

due to multiplicity of tumors and insufficient irrigation

after treatment. Second patient, had maintenance hemo-

dialysis (Pt #4), also recurred probably because the tumor

was too big (about 1 cm × 2) to treat in this setting. So in

treating the following case, we indicated this procedure

for a sole papillary lesion. In addition, after the fulgura-

tion, wash the bladder enough for several times until all

fulgurated white debris were completely cleaned out,

because living tumor cells might still exist in the debris.

As shown in the Table 1, although some patients re-

curred at other location, many of the treated patients

showed tumor free for more than 6 months in the treated

area. Patient #3 suffered severe Alzheimer disease, and

though tumor recurred several times, office-based treat-

ment was beneficial for both patient’s family and sur-

geon as much.

4. Conclusion and Tips

Office-based biopsy and fulguration for tiny bladder tu-

mor is thought to be effective and less invasive procedure

as a treatment of bladder cancer patients. Tips of the

successful transurethral biopsy and fulguration for tiny

bladder tumor are as follows: 1) sole lesion; 2) less than

5 mm in size; 3) wash bladder enough after the procedure

with distilled water.

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T. AOYAGI ET AL. 255

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