PRE-SURGICAL ASSESSMENT
Before surgery, your overall health status will be carefully evaluated and, in general, the following examinations will be performed or ordered:
- Laboratory blood tests
- Electrocardiogram and cardiological examination
- Anesthesiologic assessment, during which:
- The suitability for surgery is ascertained
- Additional exams or other physician evaluations may be ordered
- Any changes in, or suspensions of, chronic therapies are agreed upon
- Chest x-ray (if the patient has not recently undergone a chest CT scan)
We are glad to inform you that the need for blood transfusions is extremely low for this type of surgery.
Yet, it is extremely important to inform us whether you are taking any anti-platelet or anti-coagulant (“blood thinners”) medication. The suspension and/or replacement with other medications must be determined by your physician or by the anesthesiologist before surgery. These medications might increase the risk of intraoperative bleeding and their suspension or titration have to be carefully examined before surgery.
In some cases, it may be necessary to replace oral anti-coagulants (“blood thinners”) with low molecular weight heparin (injections). The anesthesiologist or coagulation specialist from our hospital will advise you in this regard.
If you do not inform us on time about these medications and they are subsequently not interrupted on time, the surgical procedure will have to be postponed, thus wasting precious time for your health!
A cardiological evaluation, in the 30 days prior to surgery is required.
BLADDER ANATOMY AND BLADDER TUMOR
The bladder
The urinary bladder is a hollow organ located in the pelvis, responsible for the collection of urine produced by the kidneys. The urine reaches the bladder through the ureters. From the bladder, urine is periodically expelled externally through the urethra (Fig. 1)
Fig 1. Urinary tract anatmy
The muscle that forms the bladder wall is called the “detrusor muscle”, a smooth muscle whose activity is regulated by nerve fibres, which perceive the bladder filling up and communicate this information to the central nervous system.
The urethra runs through the urogenital diaphragm, which consists of a striated muscle subjected to voluntary control, called the external sphincter. Micturition leads to the periodic emptying of the urinary bladder by an automatic reflex of the spinal cord, mediated by the central nervous system (Fig.2).
Fig. 2 Urinary tract structures involved in urination
Bladder cancer
Bladder cancer is the world’s ninth most common cancer. Currently, there are about 430,000 new cases per year. Bladder cancer is also characterized by a high mortality rate, ranking thirteenth among the causes of death for cancer. This tumour affects men more often than women, with a ratio ranging from 6:1 to 2:1, depending on the geographical areas. However, mortality is higher in women due to a more aggressive biology, along with a more frequent diagnostic delay. The risk of developing bladder cancer generally increases with age and more frequently affects people over 50 years old.
Cigarette smoking is undoubtedly the most important risk factor associated with bladder cancer, linked to approximately 50% of bladder cancer cases. In addition to smoking, some occupational agents are responsible for an increased risk of bladder cancer. These include aromatic amines and nitrosamine (frequent in workers in the textile, dyes, rubber, and leather industries), toluene, polyaromatic hydrocarbons, chloro-ethylene, dichloromethane, diesel and fuels derivatives. Some classes of workers, such as those in the industries of tobacco, chemical dyes and metals, are at a higher risk of developing bladder cancer because of their exposure to the chemical agents mentioned above.
If you fall into one of these risk classes, you MUST ABSOLUTELY INFORM US AT THE TIME OF THE UROLOGICAL VISIT!!! In fact, exposure to these agents must be stopped immediately as it could favour the development of a second tumour in a different location, such as the kidneys or ureters.
Bladder cancer can occur in several histological forms. The most common type of bladder cancer is the transitional cell carcinoma or urothelial carcinoma, that is, the tumour that originates from the transitional epithelium. These tumours represent about 90% of all bladder neoplasms. The remaining 10% consists of squamous cell carcinomas (squamous cells), adenocarcinomas, small cell carcinomas, sarcomas, and mixed forms where multiple histology patterns are present.
Tumours are usually located on the lateral walls of the bladder (Fig. 3): in most cases (75%) they have a papillary shape (i.e. like a small growth) or a flat or nodular shape (carcinoma in situ, CIS).
Fig. 3 Ultrasound allows the physician to identify a suspected bladder cancer
Bladder cancer symptoms are common to other diseases that affect the urinary tract: presence of blood in the urine and clot formation, a burning sensation in the bladder when compressing the abdomen, difficulty in and pain while urinating, greater susceptibility in getting infections. These symptoms become more and more prevalent as the disease progresses.
There are currently no reliable screening programs or early diagnostic methods, so it is necessary to take preventative measures regarding lifestyle such as quitting smoking and eating healthy and balanced meals.
Indications for trans-urethral resection of bladder tumour (TURBT)
Trans-urethral endoscopic removal of bladder cancer (TURBT) is recommended when the presence of a neoplastic lesion inside the bladder is discovered or even strongly suspected.
Surgery is the only method to make a definite diagnosis of bladder cancer, and it allows us to evaluate its extension (local staging).
GETTING READY FOR SURGERY
Anaesthesia
Epidural (spinal) anaesthesia is commonly used for endoscopic removal of bladder cancer. It is painless and characterized by an excellent postoperative pain control, less blood loss during surgery and lower frequency of thrombosis of the lower limbs or pulmonary embolism. For these reasons, spinal anaesthesia is the standard approach for this type of surgery.
However, if the anaesthesiologist considers the use of general anaesthesia safer according to your case, the latter approach will be used.
Before surgery, an antibiotic prophylaxis is administered (to prevent infections) and, depending on the anaesthesiologist’s evaluation, a pre-anaesthesia anxiolytic drug may be given.
At the same time, intravenous drugs for nausea and vomiting, gastro-protection and pain therapy (preventive analgesia) are administered. Pain killers are continued through the post-operative period. The pain control is thus optimal, allowing the patient to overcome the surgery trauma faster. Some muscle and joint pain due to the position on the operating table may appear after surgery, but this usually responds well to analgesic drugs and early mobilization. The minimal invasiveness of this surgical technique allows for a rapid recovery. In fact, the patient is encouraged to immediately resume normal feeding and to mobilize from the day following surgery.
The prevention of thrombotic and thromboembolic phenomena is implemented by placing elastic stockings on the lower limbs before surgery, as well as by the early mobilization of the patient.
(Further clarifications will be provided during the preoperative evaluation with the Anaesthesiologist specialist).